Chapter 5: Oral Surgery Introduction


Surgical Technique Fundamentals Introduction



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Surgical Technique Fundamentals

Introduction


Careful treatment of soft tissue and bone results in minimal postoperative pain, swelling, bleeding, and disability. The following principles cannot be over-emphasized if the surgery is to be as atraumatic as possible. The surgeon must:

Access to the Operative Site


Access to the surgical field is accomplished by:

  • positioning the patient to allow for optimum exposure

  • using good lighting

  • having the assistant suction the field as necessary

  • controlling bleeding in the field

  • reflecting a flap/removing appropriate amounts of bone whenever necessary. (A properly developed flap will afford you maximum access to the field. A flap will heal much better and faster than a torn, traumatized area of tissue.) If developing a flap does not permit access to the operative site, then bone must be removed.

Note: You will be more likely and less hesitant to develop a flap if you have anesthetized a broad area around the surgical site and have the necessary instruments readily available on your surgical tray.

Unimpeded Path for Removal of Tooth


The path for removal of a tooth must be unimpeded. Malpositioned, impacted, and deeply carious teeth frequently do not have a clear path for removal. They may be blocked by an adjacent tooth and/or overlying bone. Multi-rooted teeth often have curves in the roots which may be blocked by bone, or the distance between the roots may be too wide for removal through the tooth socket.

Obtaining an unimpeded path of removal means removal of bone and/or surgical sectioning of teeth or roots. Controlled tooth division is an important phase of exodontia. Sectioning of teeth when indicated reduces trauma and prevents complications from the use of excessive force (e.g., sinus exposure, fracture of the maxillary tuberosity or mandible).


Controlled Force


The force used to remove a tooth must be under control at all times. The force used with rotary drills must also be carefully controlled. The surgeon has to develop a feel for the amount of bone removed by the drill, use of light pressure, and be careful to protect the adjacent tissues. Brute or uncontrolled force is unnecessary and must be avoided in exodontia.

Contraindications for Tooth Extraction

Introduction


Tooth extraction is often contraindicated. Contraindications include those local to the extraction or those systemic to the patient. These contraindications can be relative or absolute depending on the general condition of a patient. You must weigh these contraindications against the benefits of the extraction.

Local Contraindications


Local contraindications for tooth extraction include the following conditions:

  • presence of oral sepsis

  • When oral sepsis is present (e.g., acute necrotizing ulcerative gingivitis, herpetic lesions, gingival stomatitis, or acute generalized gross oral sepsis from any cause), you may choose to delay exodontia.

  • radiation therapy to maxilla/mandible. Previous radiation therapy to the maxilla/mandible is a relative contraindication for the removal of teeth. It is preferable to remove teeth with a poor prognosis before radiation therapy. However to retain an abscessed tooth in an irradiated maxilla/mandible may also be contraindicated. Endodontics is preferred to extractions when possible. An oral surgeon should be consulted before treatment.

  • acute dental infection

  • When an acute dental infection is present, you must consider the patient's general condition before extracting a tooth. A patient in a toxic condition with a fever should be treated differently from an afebrile, but otherwise well patient, although both have a dental infection with local or spreading inflammation. The primary objective is to limit the spread of infection and return the patient to good health. Your choices include:




    • administer antibiotics, drain the abscess if indicated, and then reschedule the patient for removal of the tooth.



    • immediately remove the tooth to eliminate the source of the infection, establish drainage, and limit the spread of the infection.

Good judgment is the key as to whether to proceed with the extraction or postpone it if there will be considerable cutting or bone removal. You must also consider the difficulty of the extraction.

Antibiotics are especially indicated when there are systemic symptoms (e.g., elevated temperature, lymphadenopathy, trismus, and pain when swallowing) or when the patient is compromised by systemic disease.


Systemic Contraindications


Systemic contraindications for tooth extraction may include the following conditions:

  • uncontrolled medical disease

  • Any uncontrolled medical disease may be considered a contraindication to tooth extraction. Such conditions include severe hypertension (diastolic pressure 115 mm Hg), uncontrolled diabetes (blood glucose >250), severe anemia, leukemia, severe liver disease, or patient with alcohol withdrawal syndrome. Certain blood dyscrasias such as hemophilia require proper medical management before extractions can be performed.

  • pregnancy

  • Elective surgery should be postponed until after the pregnancy. If extraction is necessary, generally the second trimester of pregnancy is the preferred time for dental procedures. With proper obstetric consultation, extractions can often be done at any stage of pregnancy. Care should be taken to position the patient properly (not lying flat on back) and to avoid extremely stressful situations.


Warning: Local anesthesia should be used. Nitrous oxide is contraindicated.



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