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Perio Clinix
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Oral Surgery
Impacted Wisdom Teeth Extractions
What are "impacted wisdom teeth"?
In dental terminology "impacted" means that a tooth has failed to emerge fully into its expected position. This may occur either because there is not room enough in the jaw for the tooth, or else because the angulation of the tooth is improper.
How is the tooth removed?
Depending on the size shape and position of the tooth, removal can vary from a simple extraction to a more complex extraction.
A wisdom tooth that is fully erupted through the gum can be extracted as easily as any other tooth. However, a wisdom tooth that is underneath the gums and embedded in the jawbone will require an incision into the gums and then removal of the portion of bone that lies over the tooth. Oftentimes for a tooth in this situation, the tooth will be extracted in small sections rather than removed in one piece to minimize the amount of bone that needs to be removed to get the tooth out.
Impacted Canines Extractions
Buccally placed canines
If the canine is buccally placed and easily palpable a semilunar incision, at least 0.5cm above the gingival margin of the erupted teeth may be used.
Otherwise an incision is made around the gingival margins of the erupted teeth one tooth forwards and one tooth behind the position of the unerupted canine, with an anterior relieving incision carried up towards the buccal sulcus.
The bone is usually thin and may be removed with an elevator, or bur to uncover the crown. The tooth can then be elevated.
Palatally placed canines
Most canines are palatally placed.
Unilateral impaction the incision can be made on the palatal gingival margins from the first molar on the impacted side to the canine on the opposite side
Bilateral impaction the incision can be made from the first molar on the left to the gingival margin of the first molar on the right.
The flap is raised usually with a curved Warwick-James elevator to peel back the gingival margins. The Howarth’s can then be used to complete the raising of the palatal flap.
The incisive neurovascular bundle rising from the incisive foramen can be cut, and rarely gives rise to any clinically perceptible anaesthesia.
Bone can then be removed with a bur; to expose the whole of the crown, and the tooth elevated. Care must be taken to palpate and prevent movement of adjacent teeth.
The tooth may require decoronating, and further bone removed to allow its removal without damaging adjacent teeth.
Tie the suture knots so that they lie buccally to reduce irritation to the tongue.
Apicectomy with Retro Obturation
The definition of retrograde endodontic treatment, apexectomi, is removal of periapical pathology due to failure of root canal treatment. Non-healing periapical pathology associated with endodontically treated teeth is customarily managed by retreatment of the previous therapy. Root-end resection or retrograde endodontic treatment is less often the first optional treatment. The treatment might be the option after an unsuccessful retreatment or if retreatment is impossible.
Retrograde endodontic procedure involves laying of flaps and removal of tissues from outside the root canal space, including bone, periodontal membrane, and periosteum [3]. After root end is exposed and detected with microscope, there are possibilities to examine and recognize the pathology behind the periapical pathosis, and thereafter a proper treatment.
Retrograde endodontic surgery may induce postoperative pain, oedema and discoloration, which is all reversible.
Contraindication
Beside local contraindication there are general contraindications were the medical condition is complex and must be discussed with the patient's doctor.
The local contraindications are:
poor periodontal support
non-restorable tooth
poor access
Surgical procedure
A successful treatment of a periapical surgery is depended on the hemostasis among other factors. Hemostasis is essential for better visualization and good environment for replacing of the retrograde filling material. A good hemostasis-agent makes the hemostasis easy to achieve and manipulate, is biocompatible, does not impair healing, is reliable and is relatively inexpensive. There are different ways to achieve hemostasis; one is through pre-surgical local anesthetic with 2-3 carpules of epinephrine with multiple infiltration sites, the other is during surgery. Putting a sterile cotton pellet dipped in epinephrine into the bony crept after removal of granulation tissue.
When an optimum hemostasis is achieved the flap can be raised. There are three different incision-methods;
a) intrasulcular flap,
b)submarginal flap,
c) semilunar flap or vertical incision.
Intrasulcular
Intrasulucular flap extends along the gingival sulcus of the tooth being treated. There is a vertical incision at each end, which should give sufficient access to the root end these two cuts are united with a sulcus incision. This flap provides a good visualisation for the surgeon and the blood supply to the flap is being kept. The flap is elevated and access to the apex foramina is achieved with an elevating instrument (Norbergs Raspatorium). Postoperative pain and swelling are usually minimal. A possible disadvantage is gingival recession, this is normally a concern in the anterior region. Palatal flaps are only used for treatment of palatal roots of molars or premolars. The incision involves several teeth along their gingival sulcus. Here there is a need of carefulness to not damage the palatine neurovascular bundle.
Submarginal
The submarginal flap is made in the attached gingiva and follows its contours. This flap cannot be used in the mandible because of restricted width of the attached gingiva. The reason of choosing this flap is when the gingival tissue should be undisturbed, particulary adjacent to a crown. The flap should be minimized as possible to prevent ischemia of the remaining attached gingiva. The semilunar incision is entirely in the alveolar mucosa and is curved at its ends. This method is not widely used because of the small surgical access and the cause of ischemia .
Vertical incision
This is made vertically over the root and is reflected vertically over the apex. This does not cut the vessels off and could be used if the roots are long, but the surgical access is limited and the incision may directly lie over the blood clot in the bony cavity.
Root end resection
If any reverse filling is to be done, the root tip has to be prepared to receive the filling material. In the past, the preparation was made with burs, diamond stone and carbide burs. In the beginning of 1990s the ultrasonic devices became available, which has become more and more effective and relevant in the apical surgery.
The ultrasonic tip is smaller than the burs, that were usually used. This tips converse tooth structure and give more parallel preparation that makes the root end filling more precise and decrease the risk for microbacterial leakage. The ultrasonic tips allows the operator to make very precise preparations, because of the ease which it removes old gutta-percha and the way it cleans and widen canals narrowed by reparative dentine to make an excellent shape for the apical sealant.
Root-end filling materials
The purpose of a root-end-seal material is to prohibit bacterial invasion from the remaining intra-radicular pulp-tissue into the periradicular space and to prohibit intrusion of blood serum into the apical foramina. Other functions of an optimum apical seal are, insolubility in the tissue fluid and high dimensional stability. It should also adhere and adapt to the dentine walls of the preparated root end, prevent leakage of microorganism and be biocompatible.
A great variety of different materials have been suggested as apical sealants; amalgam, glass ionomer cement, gutta-percha, zinc oxide-eugenol based matrix, composite resin, MTA,cavit (eugenol-free temporary filling) .
Cysts elimination
Periodontology
Gingivitis Treatment
Periodontitis Treatment
Implant Dentistry
Single implant
If you are missing one tooth in a given area of your mouth, your dentist may recommend that you consider one dental implant to replace the root of the missing tooth and an implant crown to rebuild your tooth in a beautiful and natural looking manner. Compared to other treatment options to replace missing teeth, such as bridges and removable partials, an implant with an implant crown offers a long-lasting solution for a missing tooth and requires fewer follow-up office visits.
Multiple Implants
Implants for removable prostheses
Immediate loading procedures
Regenerative Procedures
Gum Grafting
When the gums are thin and weak due to a lack of tough attached tissues, recession can occur. Many feel that when this occurs the area may be more susceptible to bacterial penetration and trauma. When gum recession is a problem gum reconstruction using grafting techniques is an option.
When there is only minor recession, some healthy gingiva often remains and protects the tooth, so that no treatment other than modifying home care practices is necessary. However, when recession reaches the mucosa (loose, moveable tissue), the first line of defense against bacterial penetration is lost.
In addition, gum recession often results in root sensitivity to hot and cold foods as well as an "long in the tooth" appearance to the smile. Also, gum recession, when significant, can predispose the area to root decay and gouging as the root surface is softer than enamel.
A gingival graft is designed to solve these problems.
Free gingival epithelial graft
Tissue is taken from the roof of the mouth and placed over the exposed root extending it laterally onto adjacent soft tissue. Root coverage is predictable; however, the graft does not always blend in with adjacent gum. Its appearance is unnatural. This may not be a problem, if accomplished in the posterior regions or lower jaw, because the area will rarely be seen. Its shortcoming is the uncomfortable and sometimes painful nature of the healing process.
Subepithelial connective gum graft
Connective tissue is taken from under the gum on the palate (roof of the mouth). This tissue is placed under a flap in the area needing root coverage. Only the underlying connective tissue is removed from the palate; therefore, a painful open wound is not present as with the free gingival graft discussed previously. This technique offers better esthetics due to better color matches.
Bone Grafting
A bone graft is a surgical procedure that replaces missing bone with material from the patient's own body (autogenous bone) or an artificial, synthetic, or natural substitute. The graft not only replaces missing bone, but also helps your body to regrow its own lost bone. This new bone growth strengthens the grafted area by forming a bridge between your existing bone and the graft material. Over time your own newly formed bone will replace much of the grafted material.
Bone grafts are needed when part of your body is missing bone. This missing portion of bone is frequently called a “bony defect”. Examples of jawbone defects are: defects which occur following tooth extraction; generalized decrease in quantity of jawbone from trauma or long-term tooth loss; defects surrounding "old style" dental implants; defects resulting from cysts or tumor surgery.
Onlay Bone grafting
The solid slab graft consists as strong cortical bone which functions as a splint over the fracture site in addition to providing a stimulus for the formation of new bone. It is internally fixated.
Allografting
Allograft can come from many types of bones in many different forms. Allograft is usually removed from organ donors and placed in bone banks. Bone banks make sure the bone graft is sterile by testing it for diseases such as hepatitis and AIDS-just like testing done in a blood bank. Because it is not taken from the patient, it does not contain any living cells, and therefore has fewer chemicals to stimulate growth of new bone. The disadvantage of an allograft is that it may not always grow as well or as quickly as an autograft, but a bone-growing protein can be added to the area to make up for what the bone graft lacks. The advantage to using allograft is that the patient does not have to donate the bone graft. This makes the surgery shorter, and there may be less pain afterward. The allograft carries a very small risk of transferring infectious diseases even though it is rigidly tested.
membranes
A procedure in which a membrane is placed over the bone defect site. This membrane encourages new bone to grow and also prevents the in-growth of fibrous scar tissue into the grafted site.
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