Sunday, 7 December 2014

A Guide to Oral Surgery

A couple of weeks ago I attended a study day led by Dr Parimal Patel about oral surgery, where we got to practice minor oral surgery and suture techniques on pig's heads (gross I know). Here I will summarise the main learning points from the day.



When encountering extractions in practice, general practitioners should be able to deal with most situations, but assessment is key!

Things that may ring some alarm bells when it comes to difficulty include:
  • Close proximity to vital structures e.g. antrum, ID canal
  • Long, curved or unusual root morphology
  • Buried roots which are root treated
  • Severely impacted teeth
  • Difficult to manage patient e.g. anxious, trismus, complex medical history
  • Decoronated molars

When it comes to lower wisdom tooth impactions, mesio-angular impactions tend to look more difficult radiographically (on DPTs), and disto-angular impactions look easier than they turn out to be!

There are some assessment scales out there to help categorise difficulty of the impaction for example Pell and Gregory.

Principles of Flap Design


1. Good Access
2. Broad base in order to allow for a good blood supply
3. On sound bone
4. Avoids vital structures e.g. mental foramen



There may be an increased risk of oro-antral communication (OAC) if there is a:
  1. Large antrum
  2. Lone standing tooth in an atrophic maxilla
  3. Molar tooth with large, splayed roots close to antral floor
There is thought to be a 10% incidence of OAC in upper molars, with 0.5% of oro-antral fistulas (OAF). 

OAFs are epithelialised OACs and are more difficult to treat than OACs.


The floor of the Antrum highlighted with the arrows


Sometimes, it may be acceptable to leave a root fragment in place when a fracture occurs mid-extraction. Criteria for leaving root fragments in place include:
  • No periapical infection around the root
  • Fragment is less than an apical third
  • The root is not mobile
  • The root is close to vital structure e.g. antrum
If you think you have perforated the antrum, if you see is a dark grey lining evident that moves in a out as the patient breathes, you haven't, you can just see the lining!

Management of an OAC:

  1. 3 sided broad based flap with periosteal relief (90% success rate)
  2. OR Partial thickness palatal rotational flap
  3. Record fully and explain what has happpened to patient
  4. Advise the patient to avoid blowing their nose for 10-14 days
  5. 7 day course of broad spectrum antibiotics
  6. Nasal spray/drops (ephedrine 0.5%)
  7. CHX mouthwash
  8. Review after 1 week

Complicated Medical Histories


Bisphosphonates

Patients may be taking these to manage disorders such as rheumatoid arthritis, but these will mostly be oral preparations. 
Evidence shows that IV bisphosphonates pose the most risk for osteonecrosis

Some patients who present with a history or are currently on courses of chemotherapy for some cancers are often being or have been treated with IV bisphosphonates. Guidelines recommend that these patients be referred to a secondary setting for extractions and may need antibiotic cover e.g. metronidazole for 3 days prior to the extraction.

Warfarin

An anticoagulant taken for many conditions to help thing a patient's blood. The measure of its effect on a patient is measured with the International Normalised Ratio (INR).

The target INR should be between 2 and 4, anything above 4 you would not attempt an extraction in primary care without liaising with their GMP.

INR should be taken at most 3 days before the extraction and if it fluctuates a lot, the INR should be taken on the day. 

You should also treat these patients as early on in the day as possible so that you don't disturb their medication regime (similar to how you would manage diabetics). 

Complications of Extractions


Intra-operative:
  • Failure of anaesthetic
  • Decoronation
  • Damage to adjacent teeth/restorations
  • Displacement of root or tooth
  • Oral-antral communication (OAC)
  • Tuberosity fracture
  • Soft tissue damage/tears
  • Alveolar fracture
  • Bleeding
  • Dislocation
Post-operative:
  • Dry Socket
  • Infection
  • Pain
  • Inflammation
  • Secondary Bleeding
  • Paraesthesia/anaesthesia/disthesthesia
  • Trismus
  • Haematoma

There is a recent school of thought when extracting teeth, it is really important to help preserve as much tissue as possible in order to support implants. Some tips to help do this include:
  1. Do not raise a flap
  2. No bone removal
  3. Minimal trauma during extraction
  4. Preserve soft tissue architecture 
  5. Forced orthodontic extrusion in order to create soft tissue/bone?

A lot of patients I see in practice ask about implants and consider having them to replace teeth, so minimising trauma and loss of the bone or soft tissue structure during extractions is something I try my best at, even though I've been experiencing some really difficult cases at the moment such as fractured roots which are root filled which had a previously were post crowned.

My heart used to sink whenever this type of patient presented to me, as I knew getting that tooth out would be difficult. But the tips I learnt from this day have helped to build up my confidence and in the end, it is ok to refer these sort of cases if you cannot do them yourself and you have properly assessed them.  

And nowadays with the increasing threat of litigation, it is important, as the GDC would say, to work within your remit skill set.

Please see a previous post about ridge preservation for implants here.


Why not take a look at my other Clinical Guide posts?


Have you had some difficult extraction cases? Please leave your experiences and any other tips for young dentists in the comment section below!



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