OS Final lectures only

• 1. Sharp blade
• 2. Firm, continuous stroke
• 3. avoid vital structures
• 4. blade held perpendicular =squared wound edge
• 5. placed on attached gingiva and over healthy bone
•  Incision for extraction  incision on gingival sulcus

• 1) Flap necrosis
• 2) Dehiscence
• 3) Tearing

• 1. Apex (tip) of flap is never wider than the base, unless major artery is present in the base
• 2. Length of flap should be no more than 2X the width of base
•  Less critical in oral cavity but still the length of flap never exceed the width
• 3. Axial blood supply should be included in base of flap whenever possible
• 4. Base of flaps should not be excessively twisted, stretched, or grasped with anything that might damage vessels
• which will  feeding and draining of pulp.

• 1. Prevented by approximating the edges of flap over healthy bone (gentle handling of flap’s edges)
• 2. Expose underlying bone  pain, bone loss and  scarring

1. Flap tearing occurs frequently in surgeons trying to create flap without tearing/interrupting surgery

• 1. Assisting natural hemostatic mechanisms: either fabric sponge for pressure OR hemostat on a vessel  stasis of
• blood in vessels  promote coagulation (small: 20-30 sec & large: 5-10minutes)
• NOTE: dab (not wipe) the wound!
• 2. Use of heat to cuase the ends of cut vessels to fuse closed (thermal coagulation) via electrical current
• 1) Pt must be grounded  current entering the body
• 2) Cautery tip can ONLY touch pt at the bleeding site
• 3) Removal of blood or fluid accumulated around the vessel to be cauterized
• 3. Suture ligation: grasped with hemostat and ties a nonresorbable suture around the vessel
• 4. Placing pressure dressing over the wound  pressure on small vessels that were cut promoting coagulation
• NOTE: MOST DENTOALVEOLAR CAN BE CONTROLLED BY PRESSURE!
• 5. Vasocontrictive substances (ex. Epinephrine) OR procoagulatns (ex. commercial thrombin or collagen)

• 1) Suturing tissue planes together to minimize post-operative wound
• 2) Pressure over the repaired wound
• 3) Packing into void until bleeding stopped  then remove packing
• a. used when can’t tack tissue together ex. in bone cavity
• b. packing usually impregnated with antibacterial to  infection
• 4) Use of drains  no hematoma (may be with pressure drains)  either suction or non-suction drains

• ice
• positioning (head above heart)
• steroids

• Avoid releasing over bony prominences
• Avoid splitting papilla
• Anterior release tends to provide better visualization and access

• soft tissue.
• rounded and produce the smallest hole,
• minimizing trauma

• skin repair.
• triangular shaped
• puncturing tough tissue
• produce a larger
• hole than tapered tips.
• Regular cutting tips: edge is on the inner curvature.
• Reverse cutting tips: edge is on the outer curvature

3-0 black silk

• – Gut
• – Chromic gut
• – Vicryl (polyglactin)

• – Silk, braided
• – Nylon, monofilament

• Each stitch is tied separately.
• May be used in skin or underlying tissue layers.
• More exact approximation of wound edges can be achieved with this technique than with the running stitch.

• close tissue layers which require close approximation, such as the peritoneum.
• May also be used in skin or blood vessels.
• Advantages: speed of execution, and accommodation of edema during the wound healing process

• parallel (horizontal mattress)
• perpendicular (vertical mattress) to the wound edge. strength of closure;
• each stitch penetrates each side of the wound twice, and is inserted deep into the tissue.

• • % = grams/100 cc
• • 1% = 1 gram/100 cc
• • 1% = 1000 mg/100 cc
• • 1% = 10 mg/cc
• • 2% = 20 mg/cc

• • 1:1000 = 1 gram/ 1000 cc
• • 1:100,000 = 1 gram/ 100,000 cc
• • 1:100,000 = 1000 mg/ 100,000 cc
• • 1:100,000 = 0.01 mg/ cc
• • 1:200,000 = 0.005 mg/cc

• 1.8 cc
• • 2% lidocaine ( 20 mg/cc) = 36 mg
• • 1:100,000 epinephrine ( 0.01/cc) = 0.018 mg

• • Lidocaine- 5 mg/ kg or 300 mg total
• • Lidocaine with epinephrine- 7 mg/ kg
• • Healthy patients- 10 carpules
• • Cardiac patients- 2 carpules
• – epinephrine increases cardiac sensitivity to
• predispose to dysrhythmias

• • Severe uncontrolled metabolic disease
• – Diabetes, Leukemia, Lymphoma, Cardiac,
• recent MI, uncontrolled HTN
• • Pregnancy- first and last trimesters
• • Bleeding diatheses
• – Hemophilia, platelet disorders
• • Drugs
• – Steroids, chemo, immunosuppressives
• • Psychiatric

• • Radiation
• • Teeth in area of tumor
• • ? Severe pericoronitis
• – Antibiotics, extraction of impinging
• maxillary tooth, operculectomy
• • ? Acute dentoalveolar abscess
• – Antibiotics, incision and drainage, trismus,
• difficulty anesthetizing

• ž Type 1/dense bone
• ž Short clinical crowns (attrition)
• ž Hypercementosis & bulbous roots (older patients)
• ž Widely divergent or dilacerated roots
• ž Extensive caries (root caries)
• ž Large restorations
• ž Retained roots
• ž Close approximation of maxillary
• sinus/IAN
• ž Unsuccessful “closed” (forceps)
• delivery Not so easy

• —- extends 2 teeth anterior and 1 tooth posterior to the area of the surgery
• 3-cornered: 1 ant, 1 post

• — extends 1 tooth anterior and 1 tooth posterior to
• the area of the surgery
• envelope: 2 ant, 1 post

• both located in the mandible:
• — lingual nerve
• — mental nerve

• ž Solid bone is best
• ž 6-8 mm from bony defect
• ž Prevents wound dehiscence

• ž Reseat the forceps
• ž Subgingival grasp
• ž Use of straight elevator
• ž Buccal bone removal (trough)
• ž Split the tooth (divide and conquer)

• ž Envelope flap to expose crestal bone
• ž Teeth luxated with straight elevator
• ž Forceps delivery
• ž Buccal and lingual plate compression
• ž Removal of bone spicules & undercuts
• ž Irrigation
• ž Reposition soft tissue
• ž Suture

• žKeep tissue in place
• žApproximate wound edges
• žHemostasis
• Does not typically aid in maintaining a blood clot in socket

• acute/chronic hepatitis
• cirrhosis
• primary hepato-cellular carcinoma

HBeAg status

dry for 7 days

Heptavax (3 shot series)

• HCV
• acute/chronic hepatitis, cirrhosis, primary hepatocellular carcinoma
• No vaccine

• acute: syptoms, HCV RNA and ALT spike
• anti-HCV ab's increase both
• chronic: Alt inconsistent spikes, HCV RNA gaps
• 85% acute, 20-50% chronic
• chronic->cirrhosis
• cirrhosis -> 20% hepatic failure, 20% HCC (30 years)

HIV-1

Post exposure prophylaxis

• 30%
• IV drug users 50-90%

• exposure type
• pathogen
• amount of inoculum
• amt in pt blood at exposure

• HCV 1.8%
• HIV 0.3%
• HBV 37-62% HBsAg and HBeAg+ -> 22-31 clinical hepatits
• 23-27% HBsAg+ and HBeAg- (1-6% clinical hepatitis)

care/plan flaps, suture

direct pressure, leave open(secondary intention)

vaseline, ointment, scar mgt

antibiotic ointment (5-10 days)

palliative

• cause: excessive retration
• reposition/suture

• NO turbine drills, H2O2 rinses
• prevention: tight wound closure
• mgt: antibiotics, surgery if mediastinal involved

submandibular displacement: place finger over lingual plate when sectioning or removing tip, don't push apically. Try to manipulate root back into socket w finger

• turn pt head to side of delivery
• aspiratioin: O2, broncoscopy, check right main-stem bronchus
• swallowing: high cellulose diet (bananas, sauerkraut
• follow tooth movement

right main-stem bronchus

stabilize w/ wire/acrylic splint, plan endo

replace, stabilize, endo. consult ortho

• small: remove
• large: equilibrate tooth, splint, allow bone to heal

• plan: beware isolated super-erupted posterior tooth
• mgt: if bone attached to periosteum: do not lay flap, stop, splint and defer 6-8 weeks, extract open surgical tech
• bone separated: smooth jagged edges, position and suture soft tissue to cover exposed bones or antral openings.

mandibular molar areas, especially 3rds to reduce fracture risk

• non-epithelialized, 2mm or less: no closure, no suction, smoking, nose-blowing
• non-epithelialized, >2mm: surgical flap for primary closure , prescribe antibiotics. Recommend decongestant, nasal spray for involved side.
• epithelialized: refer

• soft diet, heat, analgesics
• dislocation: relocate, barrel bandage

• Blood vessels - clamp, tie or
• coagulate.
• Tissue - tight suture
• Nutrient canal/bone - gently
• burnish bone; insert oxidized
• cellulose into socket and suture wound

• Remove all granulation tissue.
• Do not tear or crush tissue.
• Avoid damaging major vessels.
• Have patient bite on gauze for 15 minutes following surgery before leaving the office.
• Apply pressure with gauze.
• Tie off bleeding vessels.
• Burnish bone where bleeding.
• Apply Gelfoam® or Surgicel® to socket.

observation, moist heat packs

• Warm saline rinses, antiinflammatory medication, rule out hematoma.
• - if it worsens after day 5, suspect infection and refer to OMF surgeon.

• ("Dry Socket")
• Inform patient of risk if removing mandibular 3rd
• molars (the incidence of osteitis following removal of mandibular 3rd molars is greater than 5%).
• Use nerve blocks.
• Carefully debride the wound.
• Minimize trauma.
• Irrigate the socket with warm sterile saline.
• Place medicated dressing.
• Repeat daily for 1-2 weeks.
• Administer strong analgesics for the first few days.
• Utilize long acting anesthetics.

• failed to fully erupt into the oral cavity within its expected developmental time period
• no longer reasonably be expected to do so
• eruption is prevented by adjacent teeth, dense overlying bone, or excessive soft tissue
• most often become impacted because of
• inadequate dental arch length and space in which
• to erupt
• retained for lifetime unless removed surgically
• proactive: removal should be considered as soon as
• diagnosis is made AND treatment can be safely performed

• 1. third molars (“wisdom teeth”)
• 2. maxillary canines
• 3. mandibular premolars

20 (-25yo)

• begins horizontal, mesioangular, vertical
• failure of rotation is mcc of impaction, then inadequate space anterior to anterior ramus

• fully erupted
• at occlusal plane
• in function
• adequate keratinized gingiva
• no evidence of cheek biting
• no periodontal pockets
• no caries
• extremes of age
• compromised medical status
• damage to adjacent structures
• “first do no harm”

• 1/3 -2/3 root formed
• late teenage (16-18), recover easier
• if root not formed, spins in bony socket->multiple sections

• Class 1 = 0% ramus coverage of impacted
• tooth
• Class 2 = 50% ramus coverage
• Class 3 = 100% ramus coverage
• Class A = impaction same as 2nd molar
• Class B = bet. occlusal plane & cervical line
• Class C = below cervical line of 2nd molar

• mesioangular (horizontal?)
• ¡ Class 1, A
• ¡ roots partially formed
• ¡ wide PDL
• ¡ wide follicular space
• ¡ elastic bone
• ¡ distance from 2nd & nerve
• ¡ soft tissue impaction
• ¡ young patient

•  B over maxillary C and molars (esp 1M)
•  Floor of maxillary sinus associated with maxillary molars
•  Maxillary tuberosity
•  Labial on mandibular incisors

• a. Located directly against the lingual aspect of mandible in retromolar pad region
• b. Lingual nerve rarely regenerates  make incision well buccal!

• 1)Mental nerve: esp during surgical removal of mandibular PM roots or impacted PM and periapical Sx
• a. Result in temporary/permanent anesthesia/paresthesia of lip and chin
• b. If 3-cornered flap in area of mental nerve: vertical releasing incision far anterior to avoid severing of
• mental nerve (NOT at interdental papilla between canine and 1PM)
• 2) Lingual nerve
• a. Located directly against the lingual aspect of mandible in retromolar pad region
• b. Lingual nerve rarely regenerates  make incision well buccal!
• 3) Buccal nerve
• 4) Nasopalatine nerve
• NOTE: Buccal and nasopalatine nerves: damage during flaps for removal of impacted teeth, but since the area of innervation is
• small and rapidly reinnervated  without sequelae or complications
• 5) Inferior alveolar nerve
• a. Most common place of injury: area of mandibular 3M during extraction
• b. Common enough that must inform pt of possibility

• International Normalized Ratio (INR): takes prothrombin time (TP) and control
•  Normal: 2-3
•  Okay to do extraction when INR of 2.5 or less without reducing anticoagulant dose

• internal oblique ridge after extraction of 1/2M
•  Lingual flap stretches over internal oblique
•  bone perforates
•  sharp projection of bone in area
•  Tx
• 1) Leave projection alone: exposed bone will slough off in 2-4 wks  method of choice if no sharp bone
• 2) Smooth it with bone file without flap (because flap will  amt of exposed bone)
•  Require anesthesia
•  Only for sharp bone!

• levels of fibrinolytic activity  lysis of blood clot and subsequent exposure
• of bone
•  fibrinolytic activity: maybe result of subclinical infection, inflammation of marrow space or others…
• 3. Incidence:
•  After routine extraction: 2%
•  Removal of impacted 3M: 20%
• 4. Prevention
•  Minimize trauma and bacterial contamination of area of surgery
•   with preoperative and postoperative rinses with antimicrobial mouth rinses (chlorhexidine)  up to 50%
• 5. Tx: relieving pain during healing
•  Gentle irrigation and insertion of medicated dressing

• ① Rapid epithelial turnover with desquamation
• ② Host immunologic factors (ex. IgA)
• ③ Dilution by salivary flow
• ④ Competition between oral organisms for available nutrients and attachment sites

• ① Ciliated respiratory epithelium
• ② Secretory immunoglobulins
• ③ Epithelial desquamation

• 1. Sepsis: breakdown of living tissue by action of microorganisms and is usually accompanied by inflammation
•  Not mere presence of microorganism!
• 2. Asepsis: avoidance of sepsis
• 3. Medical asepsis: attempt to keep pts, staff, objects as free as possible of agents that cause infection
• 4. Surgical asepsis: attempt to prevent microbes from access to traumatic surgically created wounds
• 5. Antiseptic: substance applied to living tissue that prevent multiplication of infectious microbe
• 6. Disinfectant: substance applied to inanimate object that prevent multiplication of infectious microbe
• 7. Sterility: NO/free of viable microbe
• 8. Sanitization: reduction of # of viable microbe to safe public health standards
• 9. Decontamination: reduction of # of viable microbe (not associated with public health standards)

•  Oldest method used by Pasteur and Koch
•  Monitor by endospore: Bacillus stearothermophilus (tests hospital and dental offices’ sterilization)
•  6 months after sterilization  possibility of organism entering sterilization bags  label with expiration date
•  Dry Heat:
• 1) Sterilize glassware and bulky items that can withstand heat but rusts!
• 2) Success by attaining temperature and sufficient duration of time!
• 3) Advantage: relative ease of use and unlikelihood of damaging heat-resistant instruments
• 4) Disadvantage: time and potential damage to heat-sensitive instruments
•  Moist Heat:
• 1) More efficient because require lower temperature  less time because
• a. Water is better at transferring heat than air
• b. Takes about 7X much heat to convert boiling water to steam than to turn room temp to boil   storage of
• heat in steam
• c. Saturated steam under pressure (autoclave) is more effective because  pressure   boiling point 
• superheated steam
•  NOTE: instruments must be bagged!
• 2) Advantage: effectiveness, speed and relative availability of equipment
• 3) Disadvantage: moisture dulls and rusts instruments & cost of autoclave!
• 2. Gaseous sterilization: destroys enzyme and vital biochemical structures
•  Examples:
• 1) ethylene oxide gas: most common
• 2) highly flammable gas with CO2 or nitrogen  safe
• 3) Advantage: effectiveness for sterilizing porous material, large equipment and material sensitive to heat/moisture
• 4) Disadvantage: need of special equipment and  time required for sterilization and aeration to  toxicity