Oral Surgery 4 PDF

ORAL SURGERY II MATERIAL
TOPIC NO. 1
PRINCIPLES OF SURGERY
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Principles of Incision
1. Use a sharp blade with proper shape and
size.
2. Long firm continuous stroke
3. Avoid cutting vital structures when incising
4. Blade should be held perpendicular to the
epithelial surface
5. Placed incision lines on areas with sound
bone support
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Surgical Flap
“Surgical flaps are made to gain
access to an area or to move
tissue from one place to
another.”
A section of soft tissue that:

1. Outlined by a surgical Incision
2. Adequate Blood supply
3. Allow Access to underlying tissue
4. can be Repositioned
5. Can be maintained by Sutures
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Complications of Flap
Surgery
necrosis
dehiscence
tearing
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Prevention of Flap Necrosis
1. Wider base than free margin. Free margin can be
wider if a major artery is present in the base.
► Flap should have sides that either run parallel to each
other or converge from the base to the apex.
2. The length of the flap should be no more than twice
the width of the base.
► In the oral cavity the length of the flap should never
exceed the width
3. An axial blood supply should be included in the base
of the flap.
4. The base of the flap should not be excessively
twisted, stretched or grasped with anything that might
damage vessels. REPRODUCE
Flap Dehiscence
Prevention:
1. Approximate the edges of the flap over healthy bone
2. Gentle handling of flap edges
3. No tension flaps
“Dehiscence exposes the underlying bone, producing pain,

bone loss and increased scarring.”
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Prevention of Flap Tearing
1. Create a flap that is large
enough to allow sufficient access
on the area of surgery
► Common mistake: creating a
conservatively small flap thinking
it would be less traumatic
► a properly cut long incision heals
as quickly as a short one.
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Tissue Handling
1. NO excessive pulling or crushing, YES
extremes of temperature, 1. Delicately hold tissue
desiccation 2. Moistened and cover with damp
2. NO use of unphysiologic chemicals sponge
which can easily damage tissue.
3. NO tight pinching by tissue forcep
4. NO aggressively retraction to gain
greater surgical access.
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BLEEDING HEMATOMA
• Decreases oxygen carrying • Creates pressure on wound
capacity of the patient • Decreases vascularity
• Decreases visibility • Increase tension on wound edges
• Creates hematoma • Act as culture media potentiating
infection
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BLEEDING CONTROL
1. ASSIST NATURAL HEMOSTATIC
MECHANISM
Pressure pack
• small blood vessels - 2. CAUTERY MACHINE
pressure 20-30 seconds
• heat is applied directly to the bleeding
• larger vessels - 5 to 10
site or to the bleeding vessel
minutes continuous pressure
• a metal instrument such as a hemostat
• Dab rather than wipe the touches the bleeding site and the
wound with gauze. cautery tip touching the instrument
• Wiping would reopen vessels • Patient is grounded to allow current to
that are already plugged by enter the body
clotted bloo d • blood and other fluid are removed on
the
TOPRANK-HISUBIDOJR site to be cauterized
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BLEEDING CONTROL
4. PRESSURE DRESSING OVER
3. SUTURE LIGATION THE WOUND
• Creates pressure on the small
• Applicable in larger blood vessels vessels that were cut thus
• Grasp the end of the severed blood promoting coagulation.
vessel with a hemostat and non- • Too much pressure would
absorbable sutures tied on the compromise wound vascularity
vessel
• The hemostat is removed once
suture has been tied and
satisfactory control of the bleeding
observed
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BLEEDING CONTROL
5. USE OF VASOCONSTRICTOR 6. USE OF MATERIALS TO AID IN
SUBSTANCES THE COAGULATION PROCESS
• epinephrine (vasconstrictor) • Thrombin and collagen
• Epinephrine is effective when (procoagulants
placed on the site of desired • Gelfoam, expands in the presence
vasoconstriction at least 7 minutes of moisture and act as a plug as
before surgery begins well as frawework for blood clot to
adhere
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Management:
Dead Space 1. Suture tissue planes together to minimize
post-operative void
2. Pressure dressing over the repaired wound
- to allow fibrin to bind them or pressed
• any area devoid of tissue after together by surgical edema
closure of the wound - pressure dressing left for 12 -18 hours
• created by: .3. Place packing into the void until bleeding
1. removing tissue in the depths of the has stopped and then remove the packing.
wound - the packing is usually impregnated with
2. not reapproximating all tissue an antibacterial medication
planes during closure. 4. Use of drains
– Continually remove blood that accumulate within
• Dead spaces usually fills with the wound
blood, which creates a hematoma Suction drains (presence of negative
which has a high potential for pressure)
infection. Non-suction drains (drain by natural flow)
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DECONTAMINATION AND
DEBRIDEMENT
DEBRIDEMENT IRRIGATION
► Bacterial contamination is • Forcing large volumes of fluid on
unavoidable hence to lessen the the wound under pressure
chances of infection it is necessary • Repeated irrigation dislodges
to decrease bacterial count bacteria and foreign material and
► Wound debridement is the careful rinses them out of the wound
removal from injured tissue of • sterile saline or sterile water is used
necrotic, foreign, and severely but solutions containing antibiotics
ischemic material that would can be an option
impede wound healing
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EDEMA CONTROL
FACTORS AFFECTING DEGREE
DEFINITION 1. Amount of Tissue Injury
it is the accumulation of fluid in the – The greater the amount of tissue
interstitial space because of injury, the greater the amount of
transudation from damaged vessels edema.”
and lymphatic obstruction by fibrin 2. Amount of connective tissue in
surgical site
– The more loose connective tissue that
is contained in the injured region, the
more edema is present.
– Less connective tissue : attached
gingiva
– More connective tissue : lips, floor of
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EDEMA CONTROL
DEFINITION MANAGEMENT
it is the accumulation of fluid in the 1. Ice Pack : decreases vascularity and
interstitial space because of therefore decreases transudation
transudation from damaged vessels 2. Keep head elevated above the rest of
and lymphatic obstruction by fibrin the body as much as possible during
the first few postoperative days.
3. Short-term high dose systemic
corticosteroid administered to the
patient have an impressive ability to
lessen inflammation and transudation.
– corticosteroid should be started
before tissue damage takes place
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PATIENT’S GENERAL HEALTH AND NUTRITION
CONDITIONS WITH LOW BODY
RESISTANCE
► Proper wound healing depends on 1. Diseases with catabolic state of metabolism.
– IDDM
the patient’s ability to resist
– end stage renal or hepatic disease,
infection, to provide essential
– malignancies
nutrients for use as building 2. Conditions that impede oxygen or nutrient delivery
materials, and to carry out to tissues
reparative cellular processes. – COPD
► Numerous medical conditions – CHF
– drug addiction
impair a patient’s ability to resist
3. Patients taking drugs or physical agents that
infection and heal wounds. interfere with immunologic or wound-healing cells.
– autoimmune diseases needing long term
steroid therapy
TOPRANK-HISUBIDOJR –
DOpatients
NOT under chemotherapy and radiotherapy
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ORAL SURGERY II MATERIAL
TOPIC NO. 2
COMPLICATED EXTRACTION
OPEN EXTRACTION
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CLOSE EXTRACTION OPEN EXTRACTION
• no requirement of reflection of soft • Surgical extraction
tissue flaps and bone removal • method of removing teeth fractured during
routine extraction or removal of teeth in
where close extraction had failed
• In a some situation an open extraction
technique maybe more conservative and
causes less operative morbidity than a
close extraction
• Too great force on forcep extraction may
cause more injury like fracture of adjacent
bone or the floor of the maxillary sinus or
even fracture of the mandible.
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Basic principles of flap design
1. Wider base than free margin 2. Rest on sound bone
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Basic principles of flap design
3. Incision should not cross bony
prominence
• crossing bony prominences like the
canine eminence would result to
dehiscence and delayed healing
• Incision through interdental papillae (1)
results to unnecessary damage
• Incision should not cross attached
gingiva directly over the most
prominent of the facial aspect(2) of
tooth which will result to defect and
periodontal deformity
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Types of Flap
Envelop flap Three cornered flap Four-cornered

Trapezoidal
Flap
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Semilunar flap Y incision
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Surgical Extraction
INDICATIONS: ESSENTIALS:
1. If there is a need for excessive 1. Excellent light
force to extract a tooth 2. Excellent suction (small diameter tip)
Irrigation syringe
2. Highly dense bone
3. Surgical bur (round and tapering)
4. Widely divergent roots 4. Elevators (straight/ angular/cryer/crane)
5. If the roots of the teeth 5. Luxators
encroaches or in near proximity to 6. Root tip picks
the floor of the maxillary sinus
6. Teeth with crowns with extensive
caries or have large amalgam
restoration
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Technique for
Surgical Extraction
Options:
1. Flap and use forcep or elevator as area is
more visible
2. Flap and bit of buccal bone grasped by
forcep and removed with the tooth
3. Flap + bone reduction and use forcep of
elevator
4. Flap + bone reduction + 3m purchase
point with surgical bur + elevator / crane
pick /cryer
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Technique for
Surgical Extraction
Options:
5. Flap + bone reduction + tooth sectioning
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Technique for
Surgical Extraction: Root Fragments
Important:
1. Use the appropriate instruments. Root tip
picks for smaller fragment, elevator for
larger root
2. Be cautious on the direction of force and
avoid excessive apical force
3. Open window approach is an option
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IMPACTED
TEETH
Oral Surgery II Material
Topic 3
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Definition
• A condition wherein a tooth is
completely or partially unerupted
and is positioned against another
tooth, bone or soft tissue so that its
further eruption is unlikely - Henry
Archer
• A tooth that fails to erupt into the
dental arch within the expected
time. - Larry Peterson
• unerupted, malposed, embedded
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Etiologies
Local Systemic
1. adjacent tooth: irregularity in 1. Cleidocranial dysostosis
position and pressure 2. Achondroplasia
2. surrounding bone: dense 3. Progeria
3. mucous membrane: dense 4. Oxycephaly
4. jaws: underdeveloped
5. Primary teeth: premature loss
6. Primary teeth: over retention
7. Clefts
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Etiologies
Cleidocranial dysostosis Achondroplasia
Rare congenital condition • Dwarfism: Hereditary congenital
characterized by: disturbance othe skeleton
1. defective ossification of the cranial • cartilages fail to develop f properly
bones
2. complete or partial absence of the
clavicles
3. delayed exfoliation of the primary
teeth
4. unerupted permanent teeth
5. rudimentary supernumerary teeth
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Etiologies
Progeria Oxycephaly
• Infantilism • Aka “steeple head”
• Premature old age
1. small stature
2. absence of facial and pubic hair
3. wrinkled skin
4. gray hair
5. facial appearance, attitude and manners
of old age
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Incidence of Impacted Teeth (in
descending order of frequency)
1. Mandibular 3rd molars 5. Mandibular cuspids
2. Maxillary 3rd molars 6. Maxillary premolars
3. Maxillary canines (higher 7. Maxillary central incisors
incidence in the palatal than 8. Maxillary lateral incisors
the buccal) 9. 1st molars
4. Mandibular premolars
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Indication for therapeutic removal of
impacted teeth:
7. Pain
1. Pericoronitis 8. Retention in
2. Periodontitis edentulous ridge
3. Caries 9. Crowding
4. Pathologic root 10. Involvement in a
Resorption fracture*
5. Cystic Formation
6. Neoplasm
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Operculitis Dentigerous cyst
• soft infection limited to the • As a general rule, if the follicular
overlying gingival flap sac around the crown of the tooth is
• Usual causative agents: greater than 3mm then it can be
streptococci, staphylococci, diagnosed as a dentigerous cyst.
Vincent’s spirochetes • It involves unerupted mandibular 3rd
molars and can progress into an
ameloblastoma and carcinomas.
• Ameloblastoma is the most
common odontogenic tumor
associated with impacted teeth
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Contraindication to removal of impacted teeth
1. Old patient with an asymptomatic 2. Poor systemic condition and an

impacted tooth asymptomatic impacted tooth.
• Patients over 40 years old with an 3. Possible excessive damage to
impacted tooth that shows NO sign adjacent structures if surgery
of disease and with 4mm or more of undertaken
overlaying bone should not be 4. When there is doubt on the future
removed status of the second molar
• Regular radiograph every 1 to 2
years to ensure that no adverse “As a general rule, all impacted teeth
sequelae occur. should be removed unless removal is
contraindicated”
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Odontectomy
Definition: Advantage of Early Removal
• “Removal of a partly erupted and 1. Younger patients tolerate the
unerupted teeth or retained roots procedure better
that cannot be extracted by the 2. Quicker recovery
forceps technique and therefore 3. Better healing with more complete
must be removed by surgical regeneration of bone and better
excision.” reattachment of gingival tissue to
adjacent tooth.
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Odontectomy
Definition: Ideal Time of Removal
• “Removal of a partly erupted and • one third of the roots are already
unerupted teeth or retained roots formed and before they are two
that cannot be extracted by the thirds formed
forceps technique and therefore • between 16 to 18 years old.”
must be removed by surgical
excision.”
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Preoperative Evaluation: Radiographs
Types of Exposure
1. Periapical*
2. Occlusal Exposure
• thickness of the cortical plate can be
assessed
3. Lateral exposure
• Extraoral, good for class III horizontal
impacted 3rd molars
4. Panoramic, rotational,
orthopantomogram
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Preoperative Evaluation: Radiographic Localization
Frank shift technique
• To localize the mandibular canal in relation
to the apices of the lower third molar.
• 1st intraoral film is taken in normal position
at the molar region.
• 2nd intraoral film is taken with a shift of the
tube vertically (downward) 25 degrees
from the first exposure.
• Clinical code: DLUB
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Preoperative Evaluation: Radiographic Localization
Clark shift technique

• To localize impacted teeth in relation to the
apices of well erupted adjacents
• 1st intraoral film is taken in normal position
• 2nd intraoral film is taken with a shift of the
tube horizontally (mesial or distal direction)
25 degrees from the first exposure.
• Clinical code: SLOB
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Classification of Impacted Teeth
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Classification of
lower third
molars
Classification based on relation to the second molar
• Class I Class II Class III

• Space between the ramus and Space between the ramus and All or most of the third molar
the distal side of the second the distal side of the second is in the ramus
molar is LESS than the
molar enough to accommodate
mesiodistal diameter of the
mesiodistal diameter of the crown of the third molar
crown of the third molar
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Classification based on relative depth on the bone:
Position A Position B Position C

Highest portion of the tooth Highest portion of the tooth is Highest portion of the tooth is
below the occlusal line and below the cervical line
is on level or above the
above the cervical line
occlusal line
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Classification based on the long axis of the second molar:
1. Vertical
2. Horizontal
3. Inverted
4. Mesioangular
5. Distoangular
6. Buccoangular
7. Linguoangular
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CLASSIFICATION OF UPPER THIRD
MOLARS
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Classification based on relative depth in bone
Class A Class B Class C
Highest portion of the Lowest portion of the Lowest portion of the
tooth is below the cervical crown of the impacted crown of the impacted thir
line of the second molar. maxillary third molar is molar is at or above the
between the occlusal plane cervical line of the second
of the second molar and molar
the cervical line.
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Classification based on the long axis of the
second molar:
1. Vertical
2. Horizontal
3. Inverted
4. Mesioangular
5. Distoangular
6. Buccoangular
7. Linguoangular
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Classification in relation to the maxillary sinus
Sinus Approximation (SA) No Sinus Appoximation (NSA)

• Less than 2mm of distance of apex • 2 mm or more between the
with the sinus impacted maxillary third molar and
the maxillary sinus
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Impacted Maxillary Canine
Class I : on the palate
Class II : on the buccal or labial aspect
Class III : located in both the palatal process and labial or maxillary bone.
Class IV : in the alveolar process, usually vertically positioned between

the incisor and the first bicuspid
Class V : in an edentulous maxilla
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Factors that may Complicate the Removal of
Impacted Teeth
1. Tooth: Depth 7. Soft tissue
2. Tooth: Angulation 8. Tumors
3. Tooth: Condition* 9. Access*
4. Periodontal ligament 10. Ramus
5. Bone density 11. Skeletal Disease
6. Adjacent Tooth: relation and 12. Follicular Sac
condition 13. Mandibular canal
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Principles in odontectomy
1. Direct vision
2. Careful technique instead
of speed
3. As minimal force as
possible
4. The second molar and its
periodontal structures
should remain uninjured
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Five Basic Steps In the Procedure
1. Incision and Flap Design

2. Bone Reduction & Removal
3. Tooth Sectioning
4. Use of elevators
5. Irrigation, debridement and Proper Closure
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Types of Flap Design
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1. Envelop flap
- incision begins lingual to the

oblique ridge and extends
approximately 15-20 mm to the
distolingual aspect of the
mandibular second molar.
- It continue buccally around
the neck of the second molar to
the interproximal space
between the first and second
molars
- The incision can be extended
for more access if necessary. REPRODUCE
2. Triangular Flap
- identical to the envelop but has an

additional vertical incision which
extends downward approximately
10mm towards the mucobuccal fold
 Blade used: Barb Parker No. 15
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 Envelop flap is most commonly
used flap for removal of maxillary
impacted teeth
 When soft tissue is reflected,
bone overlying 3rd molar is easily
visualized
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 If tooth is deeply impacted, a
releasing incision can be used to
gain greater access
 When 3-cornered flap is
reflected, the bones more apical
portions become more visible
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Principles of Flap Design:
1. sharp sterile blade

2. single stroke straight to bone
3. reverse bevel technique around the neck of the teeth
4. use molt no. 4 to reflect the flap
5. push stroke is used for further reflection of the flap
6. full thickness of the mucoperiosteum should be reflected
7. flap is held back by a Minnesota retractor placed lightly against the
bone with little pressure gainst the flap
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2. Bone Reduction / Removal
Principles:
1. Reduction with continuous flow of water
2. Intermittent reduction
3. Avoid hitting soft tissue or/and the flap
4. The less the bone reduction the less traumatic
5. Expose the greatest convexity of the tooth
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3. Tooth Sectioning
Rationale:
1. Be able to retrieve the impacted out through a small opening.
2. To minimize the amount of necessary bone reduction lessening post-
op pin and swelling
3. Less chance of damage to adjacent tooth.
4. Risk of fracture to the jaw is reduced.
4. Danger of injury to the inferior alveolar nerve is lessened
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4. Use of Elevators
 Use adjacent bone as fulcrum

 Only a considerate amount of force is used with the
elevators in an attempt to remove the impacted teeth.
 An excessive amount of force may lead to fracture of either
the impacted tooth, the adjacent or the mandible.
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5. Irrigation, debridement and proper closure
 Edges of the socket are smoothened either by rotary instrument, curette

or files.
 Bone fragments are lifted from the wound with a small curette.
 Soft tissue remnants in the socket are removed carefully by means of
sharp or blunt dissection.
 Avoid heavy curettage in the depths of the wound where the inferior
alveolar nerve and vessels lie.
 The wound is thoroughly cleansed with the irrigating solutions
 The mucoperiosteal flap is then re-approximated with sutures.
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Postoperative Instructions
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1. Rest
 Avoid strenuous activities for 12 hours. This provide the

least microtrauma. thereby minimizes bleeding
complications.
 On supine position the head should be elevated on
several pillows to lessen hydrostatic pressure which can
induce bleeding.
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2. Diet
 It is important to drink a large volume of fluid.

 Do not drink through a straw because it may induce
bleeding
 Eat regular meals as soon as possible after surgery.
 Cold, soft food maybe the most comfortable for the first
day
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3. Bleeding
 Bite firmly on a gauze pack that has been placed on the

surgical site for an hour or so and gently remove it
afterwards.
 Do not smoke for at least the first 12 hours because it will
promote bleeding and interfere with healing.
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4. Oral Hygine
 do not rinse the mouth or brush the teeth for the first 8
hours after surgery
 after the 1st 8 hours rinse gently with warm salt water (1/2
tsp. Salt in 8 oz of warm water) every 4 hours
 brush your teeth gently but avoid the area of surgery
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5. Swelling
 swelling after surgery is a normal body reaction. It

reaches its maximum about 48 hours after surgery and
usually last 4 – 6 days
 applying ice packs over the area of surgery for the first 12
hours help control swelling and may help allow the area
to be a little more comfortable
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6. Stiffness
 after surgery the patient would experience jaw muscle

stiffness and limited opening of the mouth. This is normal
and would improve in 5 – 10 days
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7. Bruising
 patient may experience some mild bruising in the area of

surgery. This is a normal response in some person and
should not be a cause for alarm. It will disappear in 7 – 14
days
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8. Medications
 Analgesic
- some discomfort is normal after surgery. Take the
analgesic with a whole glass of water and with a small
amount of food if the drug causes nausea
 Antibiotics
- not an SOP in odontectomy cases. To be given only when
necessary.
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Postoperative Follow-up
 Irrigation
- vigorous oral rinse to debride the operative site
 Suture removal
- should be removed 5 – 7 days after surgery
 too early removal = wound to open up again.
 delayed removal = may cause suture tract infection
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ODONTOGENIC DISEASES OF THE
MAXILLARY SINUS
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▪ Also known as antrum of Highmore in
honor of Nathaniel Highmore an English
anatomist who 1st describe it.
▪ Started development at the 3rd fetal month
▪ less than 1 cm in size at birth
▪ By age 12 or 13 the sinus would have
expanded to a point at which its floor will
be on the same horizontal level as the
floor of the nasal cavity
▪ Reaches maximum size around 18 yrs of
age
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• Capacity : 10 –15 ml
• Largest of the paranasal sinuses
(ethmoid, frontal, and sphenoid)
• Complete absence is rare
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Description...
• 4 sided pyramid
• Base on nasoantral wall
• apex at the root of the zygoma
Dimension….
• Antero-posterior X height X width
• 34mm X 33mm X 23mm
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Boundaries...
▪ superiorly : orbital plate of the maxilla
which contain a bony canal for the
infraorbital nerve and blood vessels
▪ inferiorly : alveolar process of the maxilla
▪ anteriorly & laterally : facial part of the
maxilla including the canine fossa
▪ posteriorly : sphenomaxillary wall
separating it from the infratemporal fossa
▪ medially : nasal wall separating it from the
nasal cavity
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Ostium maxillae
▪ communication of the maxillary sinus with the nasal cavity

▪ opens on its medial wall a distance 2/3 from the floor
▪ drains into the middle meatus of the nasal cavity between the
inferior and middle conchae
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Lining...
• respiratory epithelium which is a mucous secreting,
pseudostratified, ciliated, columnar epithelium
• mucosa is thin and is attached to the periosteum
• Thickness is not constant :
– roof : 2 – 5 mm
– floor : 2 – 3 mm
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▪ in infants the floor of the sinus is always
higher than the floor of the nose, in adults
it is reversed.
▪ Innervation : PSAN - supplying the lining
of the mucous membrane
▪ Blood supply : infraorbital artery a branch
of the maxillary artery
▪ collaterals come from anterosuperior
alveolar artery a branch of the maxillary
artery
▪ Lymphatic : abundant and terminates into
the submandibular nodes
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Function of the sinuses...
1. Resonance of voice
2. Reserve chambers to warm inspired air
3. Reduce skull’s weight
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Symptoms of Maxillary Sinusitis
1. pain 2. Nasal discharge 3. General toxemia
– May affect eyeball, – initially watery and – chills
cheek , and frontal serous – sweats
region – may become – elevation of
– pain on teeth on the purulent, dripping in temperature
area involved nasopharynx and – dizziness
– unusual motion or cause constant
irritation – nausea
jarring may
accentuate the – if from dental origin – difficult breathing
suffering secretion has foul
odor
– nasal voice
– feeling of stuffiness
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Diagnostic Tools for Maxillary Sinusitis:
1. signs and symptoms
2. Rhinoscopy/endoscopy*
3. Radiograph
4. Sinus lavage /irrigation
5. History of persistent colds or
sinus attack of a few weeks
or months duration
6. transillumination
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Causes of Chronic Maxillary Sinusitis:
1. Repeated attacks of acute antritis 7. Allergies
2. Single attack of acute antritis that 8. Low body resistance
has persisted to a chronic state 9. Endocrine imbalance
2. Neglected/ovelooked dental focus
3. Chronic infection in ethmoid and “Fundamental pathologic change in
frontal sinus chronic sinusitis is cellular
4. Altered metabolism proliferation resulting to a lining
5. Stress, physical and mental which is thick and irregular.”
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Specific causes of maxillary
sinusitis of dental origin:
1. accidental opening during extraction
2. displacement of tooth or root during
extraction
3. infection from abscessed teeth
4. agressive curettage after extraction
5. pathological entities of odontogenic
origin
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Clinical Manifestation of sinus
perforation:
1. nose bleeding
2. When patient instructed to
hold nose and blow… bubbles
comes out of the alveolus
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Management of Accidental Opening after extraction:
1. Small Opening 2. Large Patent Opening

 avoid: • immediate primary closure
a. Irrigation • rationale:
b. vigorous mouth washing a. reduce possibility of sinus
c. frequent and lusty blowing of the contamination by oral infections
nose and disease
 don’t pack socket with gauze, cotton b. prevents formation of oro-antral
or other materials
fistula
 don’t probe the opening
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Primary Closure Procedure
1. Flap
2. Reduction of height of
ridge
3. Relaxing incisions are
made
4. Edge of socket are
freshened so that raw
surfaces would be in
contact with each other
5. Suture with tension REPRODUCE

Pharmacologic Management:
1. Antibiotics
 Sinusitis of odontogenic origin can be given either penicillin,
erythromycin or clindaymcin.
 Recommended length of regimen: 10 to 14 days
2. Pain reliever
3. Decongestants can be given 7-10 days
postop
4. Nasal spray containing vasoconstrictors
5. Orally administered antihistamines
REPRODUCE
Closure of Oro-Antral Fistula
Techniques:
1. Palatal Pedicle Flap
2. Berger’s Technique
3. Placement of a cone-
shaped piece of preserved
cartilage into the defect
4. Use of gold disks or plates
5. Placement of autogenous
bonedisks
REPRODUCE
Palatal Pedicle Flap
• The greater palatine artery is
included in the flap
• Combination mattress and
interrupted sutures
• Prefabricated stent is placed on
the palate to protect donor site
• exposed bone on the donor site
of the palate may be covered by
surgical cement or a gauze
strip saturated with
compound tincture of benzoin
REPRODUCE
Berger’s Technique
• Berger is a dentist, 1939
• Closing of oro-antral opening
by obtaining tissue from the
buccal or cheek area
• Incision extended up to the
mucobuccal fold
• in the undersurface of the flap
the periosteum is incised
horizontally at different points
to lengthen the flap
REPRODUCE
REPRODUCE
Use of Gold Disks or Plates
• gold disks or 24-k, 36 gauge
gold plate
• involved sinus is thoroughly
cleaned and adequately
exposed
• bone prepared for the
reception of the metal
• metal placed over the opening
and maintained there by
suturing the soft tissue flaps
over it TOPRANK-HISUBIDOJR DO NOT
REPRODUCE
Use of Preserved Cartillage
• tooth socket prepared by
curettement
• wedge the cartilage into the
socket (should not be loose)
REPRODUCE
Causes of failure in closure of an oro-antral
fistula:
1. Persistent infection
2. Poor patients overall health condition / systemic
3. Improper technique
Flap placed directly over the opening in
bone
closure with too much tension
failure to provide a fresh raw surface
4. Poor drainage from the sinus
REPRODUCE
Intranasal Antrostomy
1. 2% tetracaine (pontocaine) in
ephedrine 1% solution is applied
to the inferior meatal wall and the
inferior turbinate
2. Wall is penetrated with a or
trocar which will make a
sufficiently large opening to admit
cutting forceps
3. Window enlarged in all directions
to obtain a diameter of at least
2cm
4. Nasoantral ridge is lowered to
the level of the nasal floor
REPRODUCE
In case of a tooth lodge on the
sinus:
patient should be informed
surgical approach for the removal of the
tooth from the sinus should not be made
through the alveolus.
no effort at recovery should be initiated
unless the exact location of the tooth is
determined by careful clinical and
radiographic examination
REPRODUCE
Caldwell-Luc Operation
INDICATIONS:
1. Removal of foreign materials from the
sinus which eliminate a blind procedure
2. Trauma of the maxilla when the walls
of the maxillary sinus are crushed or
the floor of the orbit has dropped
3. Hematomas of the antrum with active
bleeding through the nose
4. chronic maxillary sinusitis with polypoid
degeneration of the mucosa
5. Mass or lesions in the sinus
REPRODUCE
Caldwell-Luc Operation
PROCEDURE:
1. Flap.
2. The tissue is elevated from the
bone going superiorly as high as
the infraorbital canal.
3. opening is made into the facial
wall of the antrum above the
bicuspid roots and enlarged to
a size that permits inspection of
the cavity (approximately size
of an end of an average index
TOPRANK-HISUBIDOJR
REPRODUCE
DO NOT
Biopsy
REPRODUCE
BIOPSY
Definition Indications:
• Biopsy is the removal of tissue from • To confirm a clinical impression of a
a living individual for diagnostic lesion.
examination.” • Lesion does not respond to
• Biopsy is the removal and conservative therapy.
examination, usually microscopic, • For determination of a more
of tissue from the living body, definitive treatment of the lesion
performed to establish precise
diagnosis.” (Daniel Waite)
REPRODUCE
Early Warning Signs for Potential Cancer:
Early Warning Signs Late Signs
1. an ulceration that bleeds easily 1. Difficulty in chewing, swallowing or
and doesn’t heal within 10 to 14 moving the tongue or jaw
days 2. Unexpected weight loss or fever
2. A lump or thickening
3. a reddish or whitish patch that
persists
3. Difficulty in swallowing General Rule: “When in doubt, Biopsy!”
REPRODUCE
4 Types of Biopsy:
1. Cytology
2. aspiration biopsy
3. incisional biopsy
4. excisional biopsy
REPRODUCE
Cytology
Indication:
• For detection of uterine cervix • when large areas of mucosal
malignancy. change must be monitored for
• Not a substitute for biopsy but dysplastic change (post radiation
should only be used as an adjunct. changes, herpes, pemphigus,)
• Oral use is unreliable: it only allow
examination of individual cells but
not histologic architecture.
• A positive cytology report still has to
be confirmed by biopsy prior to any
definitive treatment.
REPRODUCE
Technique (cytology):
1. Lesion scrapped repeatedly and
firmly with a moistened tongue
depressor or cement spatula.
2. Cells obtained are smeared evenly
on a glass slide.
3. Slide immediately immersed in a
fixing solution (95% ethyl alcohol
and ether) or sprayed with a fixative
(hair spray works well)
4. Cells are stained and the cellular
characteristics examined under the
microscope
REPRODUCE
Aspirational Biopsy
• Use of a needle and a syringe to penetrate a
lesion for aspiration of its content Indication:
• Inability to aspirate fluid or air = mass probably • Lesions suspected to contain
solid fluid
• If pus is aspirated = infectious mass like an
abscess.
• Air on aspiration = traumatic bone cavity
• Blood on aspiration = vascular malformations
on the jaw, aneurysmal bone cyst , central
giant cell granulomas
• A radioluscent lesion in the jaw that yields
straw-colored fluid on aspiration = cyst
REPRODUCE
Technique:
1. Area is anesthetized.
2. Use 18-g needle in a 5 or 10 ml syringe and inject needle at
the approximate depth of the mass.
3. Tip of the needle may need to be repeatedly repositioned in
an effort to locate a fluid center.
4. For intraosseous lesions with expansion and thinning of
bone needle maybe firmly applied directly to the
mucoperiosteum and made to perforate the cortical plate.
5. If above fails then a mucoperiosteal flap maybe elevated
and bur used to penetrate the cortical plate.
REPRODUCE
Incisional vs Excisional Biopsy
Incisional Excisional
• Lesions larger than 1cm (extensive) • Lesions 1cm or less
• High suspicion of being malignant • Benign lesions
• only a particular or representative • The entire lesion is removed with
part of the lesion is removed some portion of normal tissue
• Located in hazardous areas included
• Any lesions that can be removed
completely without mutilating the
patient like pigmented and small
vascular lesions
REPRODUCE
Principles in incisional biopsy
1. Get tissue in an area that shows complete
tissue changes.
2. Necrotic tissue should be avoided because
they are useless in diagnosis.
3. Material taken from the edge of the lesion to
include some normal tissue
4. Representative area of the lesion is cut in a
wedge fashion.
5. Take deep and narrow biopsy rather than a
broad shallow one. Superficial changes are
quite different form deeper ones.
REPRODUCE
Principles in excisional:
• the entire lesion along with 2 –
5 mm of normal appearing
surrounding tissue is excised
REPRODUCE
Technique of excisional
1. Avoid distortion of the tissue with
local anesthetic infiltration.
2. Isolate the lesion and immobilize
tissue. A traction suture, hook or
forcep maybe used for
mobilization but avoid crushing the
specimen.
3. Elliptical incision around the
lesion. The margins should at
least be 5 mm from the lesion in
width and depth.
4. The biopsy site maybe sutured or
allowed to heal by secondary
intention TOPRANK-HISUBIDOJR DO NOT
REPRODUCE
Specimen Handling
1. The tissue submitted must be carefully
handled to avoid distortion which may
affect final evaluation.
Fixative
2. Utilize proper instrumentation
3. Carefully blot the specimen of any excess • Most common fixative: 10% formalin
blood
or 4% formaldehyde
4. Orient the specimen by identifying
appropriate margins. A suture is helpful to • Isotonic solution of saline or local
label a specific area of the specimen. anesthetic maybe used and the
5. Avoid dehydration secondary to delay in specimen refrigerated until the proper
fixation or improper fixation solution is available.
6. Placed the excised specimen in 10% • The volume of the fixative should be
formalin solution immediately. 20X relative to the size of the
7. Label the specimen clearly for easy specimen
identification and to avoid confusion.
REPRODUCE
Contents of Biopsy Request Form
1. Submitting doctor
2. Patients name and pertinent information
3. Pertinent facts about the lesion
a. history of growth rate, duration or previous
treatment
b. location of the lesion
c. Size
d. regional lymph node involvement
e. superficial vs. invasive character
f. clinical impression
REPRODUCE
Biopsy of Bone Lesions
• Principles similar with soft tissue biopsy
• Major difference is the time difference before the
laboratory request is processed
• Bone must be decalcified prior to cutting the tissue in
preparation for microscopic examination
REPRODUCE
Preprosthetic Surgery
TOPRANK-HISUBIDOJR DO NOT REPRODUCE

FACTS OBJECTIVE:
• Loss of natural teeth = gradually • To create proper supporting

decrease in alveolar ridge structures for subsequent
configuration placement of prosthesis
• Pattern of resorption is • To improve esthetics, denture
unpredictable stability and retention
• Resorption accelerated by
denture wearing
• Mandible resorb more severly
than the maxilla

Procedures
Hard Tissue Surgery Soft Tissue Surgery
1. Alveoloplasty or Alveolectomy 1. Maxillary tuberosity reduction

2. Maxillary tuberosity reduction 2. Mandibular retromolar pad reduction
3. Buccal exostosis and excessive 3. Lateral palatal soft tissue excess
undercuts 4. Unsupported hypermobile tissue
4. Lateral palatal exostosis 5. Inflammatory fibrous hyperplasia
5. Mylohyoid ridge reduction 6. Inflammatory hyperplasia of the palate
6. Genial tubercle reduction 7. Frenectomy
7. Torus removal

Simple Alveoloplasty
• The simplest form of
alveoloplasty consist of digital
compression of the lateral walls
of the extraction socket after
extraction
• Envelop flap or with releasing
incision if necessar

Methods of Bone Reduction
1. Rongeur and bone file
2. Chisel and mallet
3. Rotary instrument

Intraseptal Alveoloplasty
• Also known as “dean’s technique”
• Areas where ridge is of relatively
regular contour but present an
undercut to the depth of the labial
vestibule
• Right after extraction or in the early
initial postoperative healing period

Intraseptal Alveoloplasty
Advantages: Disadvantages:
• Labial undercut can be reduced 1. Decrease in ridge thickness
without affecting much the height
of the ridge
• Periosteal attachment to the
underlying bone is maintained
• Muscle attachment left
undisturbed

Maxillary Tuberosity Reduction
• Can be due to bone or soft tissue or both
• crestal incision extending to the posterior
aspect of the tuberosity
• Most posterior aspect incised using
number 12 blade
• Care in cutting to avoid perforating the
maxillary sinus

Exostosis and Excessive Undercuts
• More common in the maxilla
than in the mandible
• Crestal incision with 1-1.5mm
extension beyond the area
requiring recontouring
• Vertical-releasing incision
created if necessary to
improve access and prevent
trauma

Mylohyoid Ridge Reduction
• When this ridge is sharp, denture pressure may
produce significant pain on the area
• Mylohyoid muscle attachment is released by
sharply incising at the area of bone origin
• Remove the sharp prominence of the mylohyoid
ridge with a rotary instrument or bone file while
protecting soft tissue carefully.
• Immediate replacement of the denture to
facilitate a more inferior relocation of the muscle
attachment.

Genial Tubercle Reduction
• The area of attachment of the
genioglossus muscle in the anterior
portion of the mandible may
become increasingly prominent as
the mandible begins to undergo
resorption
• Dissect full thickness
mucoperiosteal flap lingually
exposing the genial tubercle
• Remove the attachment of the
genioglossus muscle by sharp
incision
• Smoothen prominence
Soft Tissue Abnormalities

Maxillary Tuberosity Reduction
(Soft Tissue)
• Primary objective is to provide adequate interarch space for proper
denture construction in the posterior area and a firm mucosal base
with consistent thickness
• Extent of tissue reduction needed can be evaluated by a preoperative
panoramic radiograph with good diagnostic value
• Or soft tissue thickness can be evaluated by probing with a sharp
instrument after anesthesia (ridge mapping)

Procedure:
1. Local infiltration
2. Elliptical incision around soft tissue
to be excised
3. Soft tissue excised
REPRODUCE
4. Undermining of buccal
and palatal flaps to
provide adequate soft
tissue contour and
tension free closure also
known as submucosal
resection of the soft
tissue
REPRODUCE
5. Coaptate tissue to
check for excess
REPRODUCE
5. Suture with
interrupted or
continuous
suture technique
REPRODUCE
Lateral Palatal Soft Tissue Excess
• Soft tissue excess in the lateral aspect
of the palatal vault often interferes with
proper denture construction
• It creates slight undercuts that narrows
the palatal vault
• Tangential incision to cut off the
superficial layers of mucosa and
underlying fibrous tissue to be remove
• Surgical splint lined with tissue
conditioner inserted 5 to 7 days

Inflammatory Fibrous Hyperplasia
• Also called epulis fissuratum or denture fibrosis
• Usually a result of ill-fitting denture
1. Hyperplastic soft tissue is excised superficial to
the periosteum from the alveolar ridge
2. The unaffected margin of the tissue excision is
sutured to the most superior aspect of the
vestibular periosteum with interrupted suture
3. Surgical splint or denture lined with soft tissue
conditioner is inserted and worn continuously
for the first 5 to 7 days

Inflammatory Papillary Hyperplasia of the Palate
• multiple nodular projections in the palate
• Due to : mechanical irritation
: seen in patients who wear prosthetic appliance
• Potentially contributing factors:
1. poor oral hygiene
2. fungal infection
3. inflammation
1. Removal by:
a. scalpel cutting superficial to the periosteum
b. electrocautery
c. Use of acrylic or bone bur or dermabraision brush to abrade
e. laser

Frenectomy
• Level of frenal attachment vary Techniques:

• Movement of the soft tissue adjacent to 1. Simple excision technique
the frenum may create discomfort and
ulceration and may interfere with the 2. Z-plasty
peripheral seal 3. Localized vestibuloplasty with
secondary epithelialization
• 1 & 2 are effective when the

mucosal and soft tissue band is
relatively narrow
• 3 when the frenal attachment
has a wide base

Localized vestibuloplasty
w/ secondary epithelialization
Simple Frenectomy Z-Plasty
• Wide frenal attachment

• Wide V type incision
• Incision through mucosal and
submucosal tissue without
perforating the periosteum
• Undermine mucosal and
• Do not inject exactly on the • Two oblique incisions are submucosal tissue
frenum
made in a Z fashion • Edges of the mucosal flap is
• Narrow eliptical incision sutured to the periosteum at the
• Fibrous frenum is dissected from • The two pointed flaps are
maximal depth of the vestibule
the underlying periosteum gently undermined and rotated
• Secondary epithelialization
• Margins of the wound are gently • Closure with interrupted
undermined and reapproximated • Surgical splint
sutures
• Vestibular height is DO
TOPRANK-HISUBIDOJR maintained
NOT
REPRODUCE
Lingual Frenectomy
• Lingual frenum attachment extending
to the tip of the tongue
• Affect speech and in the absence of
teeth can interfere with denture
stability
• Traction suture
• Hemostat placed across the frenal
attachment at the base of the tongue
for approximately 3 minutes providing
vasoconstriction and a nearly bloodless
field
• Transverse cut from the tip of tongue
downwards
• Lateral borders of the wound margins
are carefully undermined

Torus
• Has no pathological
significance
• Sometimes misdiagnosed as
tumor
• Denture can cause
impingement and pain that
can lead to infection
• Can be an etiological factor in
oral malignancy if constant
irritation occur
REPRODUCE
Indications for Torectomy
• it is large
• lobulated
• with a thin mucoperiosteal
cover extending posteriorly to
the vibrating line in the palate
that prevents seating of the
denture over the mass and
prevents posterior seal at the
palatine fovea
REPRODUCE
Procedure
1. Double Y incision extended the
incision beyond the part of the bone
to be reduced.
2. Traction sutures
3. Holes are drilled in equal distances to
sectionalize the torus.
4. Primary drill holes are interconnected
5. Maxillary torus not excised en mass
but by segments. Osteotome or
chisel with the bevel facing bone
each segment is excised.
6. Protruberances and sharp areas
smoothened
7. Palatal stent placed over the flap.
REPRODUCE
REPRODUCE
Palatal Stent
Functions: • Old denture can be used as a stent
• Made of clear acrylic
1. prevent hematoma
• fabricated prior to surgical
2. protection of the wound procedure.
3. To stabilize a dressing • Cast is scrapped and stent is
fabricated with shape consistent to
estimated amount of bone
reduction
• dressing of ZOE with gauze mesh
or a periodontal dressing which has
to be changed every 2 to 3 days
• patient instructed to remove stent
and clean site after meals
REPRODUCE
Mandibular Torus
✓ located on an area lingual to the bicuspids

✓ usually bulbar
✓ can be single or multiple
✓ occasionally coalesce to form a thick
lingual exostosis from the cuspid to the
second molar
REPRODUCE
Mandibular Torectomy
1. incision on top of the ridge in edentulous cases or on neck of teeth for proper closure
2. incision beyond the bone to be reduced to avoid tearing of the thin flap
3. a trough is cut around the torus to develop a plane from which the torus should split
4. a single beveled osteotome or chisel with the bevel directed away from the bone is used
and bone is split by a sharp blow with a mallet
5. bone smoothening
6. irrigate
7. sutures
8. splint
REPRODUCE

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ORAL SURGERY II MATERIAL

A section of soft tissue that:

“Dehiscence exposes the underlying bone, producing pain,

1. Wider base than free margin 2. Rest on sound bone

Envelop flap Three cornered flap Four-cornered

1. Old patient with an asymptomatic 2. Poor systemic condition and an

Clark shift technique

• Class I Class II Class III

Position A Position B Position C

Sinus Approximation (SA) No Sinus Appoximation (NSA)

Class II : on the buccal or labial aspect

Class IV : in the alveolar process, usually vertically positioned between

1. Incision and Flap Design

- incision begins lingual to the

- identical to the envelop but has an

 Blade used: Barb Parker No. 15

1. sharp sterile blade

 Use adjacent bone as fulcrum

 Edges of the socket are smoothened either by rotary instrument, curette

 Avoid strenuous activities for 12 hours. This provide the

 It is important to drink a large volume of fluid.

 Bite firmly on a gauze pack that has been placed on the

 swelling after surgery is a normal body reaction. It

 after surgery the patient would experience jaw muscle

 patient may experience some mild bruising in the area of

▪ communication of the maxillary sinus with the nasal cavity

1. Small Opening 2. Large Patent Opening

5. Suture with tension REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

• Loss of natural teeth = gradually • To create proper supporting

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

1. Alveoloplasty or Alveolectomy 1. Maxillary tuberosity reduction

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

• Level of frenal attachment vary Techniques:

• 1 & 2 are effective when the

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

• Wide frenal attachment

TOPRANK-HISUBIDOJR DO NOT REPRODUCE

✓ located on an area lingual to the bicuspids

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