Luis Bruzual Oral Surgery Day for CESRC
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www.centralenglandreferrals.co.uk Sharing knowledge and stimulating conversation between dental professionals. Follow Central England Specialist Referral Centre online and join in the conversation. Mr. Luis M Bruzual, B Odont(Ven) Cert(OMFS) BLACIBU Specialist in Oral Surgery Welcome to CESRC’S Oral Surgery day June 7, 14 and 28, 2017 The Pavilions Shirley BRUZUAL CESRC
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Transcript of Luis Bruzual Oral Surgery Day for CESRC
www.centralenglandreferrals.co.uk
Sharing knowledge and stimulating conversation
between dental professionals.
Follow Central England Specialist Referral Centre
online and join in the conversation.Mr.LuisMBruzual,BOdont(Ven)Cert(OMFS)BLACIBU
SpecialistinOralSurgery
WelcometoCESRC’S
OralSurgeryday
June7,14and28,2017ThePavilionsShirley
BRUZUAL CESRC
www.centralenglandreferrals.co.uk
Sharing knowledge and stimulating conversation
between dental professionals.
Follow Central England Specialist Referral Centre
online and join in the conversation.Mr.LuisMBruzual,BOdont(Ven)Cert(OMFS)BLACIBU
SpecialistinOralSurgery
UpdateonOralSurgeryforthe
GeneralPractitioner
June7,14and28,2017ThePavilionsShirley
BRUZUAL CESRC
www.centralenglandreferrals.co.uk <presentationtitle-date>©2016
Basic surgical needs
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1.Visibility
2.Control of haemostasis
3.Appropriate assistance
Basic surgical needs
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Basic surgical needs
1.Visibility• Adequate lighting
• Improve visualisation of surgical field
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2.Controlofhaemostasis
• Good Local Anaesthesia (vaso constrictor)
• Patient comfort (anaesthesia < anxiety)
• Suction (surgical suction)
• Instruments - exposure to structures
• Diathermy (bipolar or monopolar)
Basic surgical needs
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3. Appropriate assistance
• Assistants have to be familiarised with surgical instruments and surgical procedures
• Circulating nurse - trained in oral surgery to assist outside of sterile field
Basic surgical needs
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HandpiecesforOS
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Instruments
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Forceps
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Elevators
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Surgical retractors
Minnesota retractor
Rake retractor
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Minnesota retractor
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Minnesota retractor
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Periosteal elevators
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Suturing instruments
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Suturing instruments
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Surgical blades
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Surgical blades
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Surgical technique
• Provide minimal sufficient exposure of surgical field
• Preserve biological structures (Periosteum, Keratinised tissues, vascular and nerve structures)
• Allow appropriate closure of surgical wound
Flapproperties
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Surgical technique
• Use of appropriate instruments
• Avoid over-stretching, over-pressure and use care handling
• Preserve blood supply
TissueManagement
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Surgical technique
FlapdesignLocal flap
• Outlined by a surgical incision
• Carries its own blood supply
• Allows surgical access to underlying tissues
• Can be replaced in its original position
• Can be maintained with sutures and is expected to heal
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Surgical technique
Flapdesign
Properties
• Base > free margin
• Preserve an adequate blood supply
• Unless there is a large artery in the base
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Surgical technique
Flapdesign
Properties
• Axial blood supply in the base
• Flap must be held with retractor resting on intact bone to prevent tension
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Surgical technique
Flapdesign
Preventing complications
• Incision must be made over intact bone
• If a defect exists in the underlying bone, incision must be made at least 8 mm away on top of intact bone and 6 mm if the defect is created by surgery
• Always treat flap gently
• Don't stretch flap or place excessive pressure on itBRUZUAL CESRC
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Surgical technique
Flapdesign
Incision must be made away (6 mm) away from the expected created surgical defect
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Surgical technique
Width of Base always > Length of flapBRUZUAL CESRC
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Surgical technique
Envelope / sulcular flap
Envelope flap with one releasing incision
(Three corner flap)
Envelope flap with two releasing incision
(four corner flap)
3
21
1
23
4
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Surgical technique
Envelope / sulcular flap no releasing incisions
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Surgical technique
Envelope flap with one releasing incision
(Three corner flap)
2
3
1
2
1
3
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Surgical technique
Envelope flap with two releasing incision (four corner flap)
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Surgical technique
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Surgical technique
Semilunar flap
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Surgical technique
Semilunar flap
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Surgical technique
Semilunar flap
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Surgical technique
Semilunar flap
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Surgical technique
Semilunar flap
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Surgical technique
• Flap dehiscence
• Flap tearing
• Injury to local structures
• Flap necrosis
Flapcomplications
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Alternative surgical technique to conventional surgical extraction of impacted third molars
(other impacted teeth)
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Coronectomies
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Coronectomies
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CBCT planning
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Coronectomies
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Coronectomy + enucleation of cyst
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Coronectomies
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Coronectomies
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Coronectomies
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Coronectomy + enucleation of cyst
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Coronectomies
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Coronectomies
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Coronectomies
Preop 3 months postBRUZUAL CESRC
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Coronectomies
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Coronectomies
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Simple SuturesSuturing needles
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Suturing needles
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Simple SuturesSuturing needles
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Simple SuturesSuturing needles
Tear created by normal cutting
needle
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Suturing techniques
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Simple sutures
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Horizontal continuous mattress sutures Simple sutures
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Horizontal continuous mattress sutures Simple sutures
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Simple sutures
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Continuous simple sutures
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8 shaped suture
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Continous blocked suture
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Horizontal individual mattress sutures
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Horizontal individual mattress sutures
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Horizontal continuous mattress sutures
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Removing Sutures
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• What constitutes the ideal suture?
• Easy to handle
• Easy to knot
• Minimal tissue reaction
• Maintain tensile strength until tissue has healed
• Narrow diameter to minimise tissue damage and scarring
• Unfavourable surface for bacterial colonisation
• Cost
Sutures
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Learning outcomes: • Understand the different complications that
can arise from dental extractions• Preventing and anticipating complications
related to dental extractions• Manage complications related to dental
extractions• Management of patients taking NOAC
other blood thinning drugs
Complications related to dental extractions
BRUZUAL CESRC
•Haemorrhage•Dry Socket (Local alveolar osteitis)•Oro-antral communications (OAC) / Oro-antral fistulas (OAF)
Other conditions •MRONJs - ORNJs•Temporo-Mandibular Joint (TMJ)•Displaced tooth or tooth segment to other anatomical spaced•Tooth deglution and bronco aspiration
Complications related to dental extractions
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Aspirin Clopidrogel
WarfarinNovel anticoagulants - NOACs
Heparins
Atrial Fibrillation - other arrhythmiaSeptal defects
Pulmonary embolismDeep vein thrombosis
Cerebro-vascular accidentsRecent Myocardial infarction
Post extraction haemorrhage secondary to anticoagulation
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•Preventable •Most common of complications•Immediate or delayed•Alarming •Related to traumatic procedure (poor technique)•Related to anti platelet, anticoagulation meds or systemic conditions •Anticipated
Haemorrhage
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Post extraction haemorrhage secondary to anticoagulation
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Traumatic extractionTuberosity fracture
Lingual plate fractureDental fusionAge - Race
Post extraction haemorrhage secondary to traumatic extraction
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Post extraction haemorrhage secondary to traumatic extraction
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Post extraction haemorrhage secondary to traumatic extraction
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1. Irrigate the area with isotonic solution and remove excessive clots 2. Patient is then instructed to bite on the gauze pack until the general condition has
been evaluated.3. Patient’s blood pressure and pulse rate should be checked.4. Administer local anaesthetic just enough to achieve anaesthesia in desired area.
(Lidocaine 2% 1:80.000 adrenaline) Avoid giving large amounts of LA that will temporarily stop the bleeding but then will result in bleeding later on.
5. Once anaesthesia is obtained, the extraction wound is examined to determine the source of bleeding. Determine whether the bleeding is from the soft tissues (gingiva), the alveolus’ bone or both.
6. Bone bleeding: pack local haemostat into socket7. Secure haemostat with sutures8. Soft tissue bleeding - local haemostasis - diathermy or silver nitrate
Management of post extraction haemorrhage
BRUZUAL CESRC
In addition to serving as a mechanical obstruction to bleeding, these materials affect the coagulation process. In contact with blood, collagen causes aggregation of platelets, which bind in large numbers to the collagen fibrils. The aggregated platelets degranulate, releasing factors such as thromboxane A2 that assist in the formation of a clot. The sponge also provides a 3-D matrix for strengthening the blood clot.
Haemostatic Collagen These products (eg, CollaPlug, CollaTape, and Helistat [Integra LifeSciences]) are soft, white, pliable, nonfriable, coherent, sponge-like structures.
Management of post extraction haemorrhage
BRUZUAL CESRC
Cellulose (eg, Surgicel, ActCel)Surgicel (Johnson & Johnson) is a resorbable oxidized cellulose material.
Expensive but useful option in oral surgery. It is prepared as a sterile fabric meshwork.
Management of post extraction haemorrhage
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Management of post extraction haemorrhage
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Secure haemostat
Management of post extraction haemorrhage
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Soft tissue bleeding
Management of post extraction haemorrhage
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Patient that can be treated in practice
Management of patients in anticoagulation
Warfarin - INR < 3.0 (4.0) not more than 72 hours
Aspirin and Clopidogrel - Can be discontinued 4-7 days before the
procedure
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Novel Anticoagulants (NOAC)
• Praxada® Dabigatran • Xarelto® Rivaroxaban • Eliquis® Apixaban
Advantages - do not require regular blood test
Disadvantages - Effect cannot be easily quantified
Management of patients in anticoagulation
Praxada® - Stop drug 24 hrs prior to an invasive surgical procedure in patient with normal renal function I.e. creatinine clearance >80ml/min
If creatinine clearance 50-80ml/min -increase time to 48 hours If creatinine clearance 30-50ml/min -increase time to 72 hours
Xarelto® and Eliquis® - Stop drug 24 hrs prior to an invasive surgical procedure Both drugs should be started asap after haemostasis is achieved Risk vs benefit (discuss with the prescribing doctor) BRUZUAL C
ESRC
NICE - for extraction of up to 3 teeth, periodontal surgery and implant placement:
• Procedure should be done just before the next dose or 18-24 hours after the last dose given
• 5% Tranexamic acid mouthwash 5 days post-operative
Management of patients in anticoagulation
Novel Anticoagulants (NOAC)
* As long as no earlier than 4 hours after haemostasis has been achieved
Simplified dose schedule - Scottish Dental Clinical Effectiveness Programme
BRUZUAL CESRC
Management of patients in anticoagulation
Novel Anticoagulants (NOAC)
NOAC Usual drug scheduledMorning dose
(pre-treatment) Post-treatment dose
Apixanban or Dabigatran
Twice a day Miss morning dose Usual time in evening *
Rivaroxaban Once a day; Morning Delay morning dose4 hours after
haemostasis has been achieved
Once a day; Evening Not aplicable Usual time of the evening*
* As long as no earlier than 4 hours after haemostasis has been achieved
Simplified dose schedule - Scottish Dental Clinical Effectiveness Programme
BRUZUAL CESRC
•Associated with extraction of postero-superior teeth: second premolars and molars (Tuberosity fractures)
ORO-ANTRAL COMMUNICATION (OAC)ORO-ANTRAL FISTULA
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ORO-ANTRAL COMMUNICATION (OAC)
Immediate after extraction
Signs: Trans-alveolar visualisation of maxillary sinus membrane tearor communication
Symptoms: • Passage of air from the maxillary sinus to the oral cavity• Passage of fluid from the oral cavity to the maxillary sinus• Post extraction epistaxis
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ORO-ANTRAL COMMUNICATION (OAC)
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Management of oro-antral communication
<5 mm Communication • Never probe the defect• Never test by nose blowing• The gingival margins around the socket should be approximated as close as possible• Gently pack physical agents placed in the socket to stop excess bleeding, (Surgicel,
Spongostan or Haemocollagene)• Antibiotics should be prescribe Amoxicillin, Metronidazole or Clyndamicin)• Nasal decongestants can be beneficial (Ephedrine nasal drops, Oxymetazoline)• Antiseptic mouth-wash should be used (Chlorhexidine) after 24 hours• Consider use of a cover plate (extra precaution should be taken if taking an impression)• Carefully follow the patient 1, 2, 3 and 4 weeks and advise to avoid straining the area (no
holding back sneezes, no smoking, no use of straws, no pressure on the sinus). BRUZUAL CESRC
Management of oro-antral communication
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>5 mm Communication Do not attempt to pack haemostats (gelatine sponges, etc)
Surgical management
• Immediate surgical repair• Antibiotics, nasal decongestants• Carefully follow the patient after 2 and 4 weeks and advise to avoid straining the area (no
holding back sneezes, no smoking, no use of straws, no pressure on the sinus).
Management of oro-antral communication
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Surgical management of oro-antral communication
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Delayed
Signs: Delayed healing in previous extraction siteIntra oral visual communication to maxillary sinus cavityAssociated or not with maxillary sinus discharge
Symptoms: Passage of fluid from the oral cavity to the maxillary sinusSinusitis symptoms - Infection
ORO-ANTRAL FISTULA (OAF)
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ORO-ANTRAL FISTULA (OAF)
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Diagnostic imaging:•OPG•Periapicals•OM views•CT or CBCT
ORO-ANTRAL FISTULA (OAF)
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ORO-ANTRAL FISTULA (OAF)
Diagnostic imaging:•OPG•Periapicals•OM views•CT or CBCT
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ORO-ANTRAL FISTULA (OAF)
Diagnostic imaging:•OPG•Periapicals•OM views•CT or CBCT
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ORO-ANTRAL FISTULA (OAF)
Diagnostic imaging:•OPG•Periapicals•OM views•CT or CBCT
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ORO-ANTRAL FISTULA (OAF)
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ORO-ANTRAL FISTULA (OAF)
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ORO-ANTRAL FISTULA (OAF)
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Surgical management of oro-antral fistula
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Surgical management of oro-antral fistula
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Synonyms: •Alveolitis sicca dolorosa•Localised alveolar osteitis•Fibrinolytic osteitis
DRY SOCKET
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Pathophysiology: Blood clot disintegration - no granulation tissue
Incidence: For routine dental extractions, 0.5% to 5% After extraction of mandibular third molars 1% to 37.5%
Surgical extractions result in about 10 times higher incidence of AO
DRY SOCKET
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• Onset after 1 - 3 days of extraction• Severe pain inside and around the extraction
site - radiate to ear• Disintegration of the blood clot• Foul smell (Necrotic Odour) • Not an infection (No suppuration)
• Higher incidence • Smokers• Female : Male Ratio 3:2 • Oral Contraceptive• Physical dislodgment of clot
DRY SOCKET
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DRY SOCKET
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DRY SOCKET
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Emergencies
DRY SOCKET
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Clinical features - Pain
Alveolar Osteitis (AO) (DRY SOCKET)
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ALVOGYL
100 g the following active ingredients : 25.70 g of butamben, 15.80 g of iodoform 13.70 g of eugenol
TREATMENT Localised Alveolar Osteitis (LAO) (DRY SOCKET)
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Treatment: •LA (Avoid Lidocaine)•Wash area•Stimulate bleeding•Treat symptoms (pain) Recommendations•Rinses•Chlorhexidine MW•Review visit - advise that might need several visits
TREATMENT Localised Alveolar Osteitis (LAO) (DRY SOCKET)
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I. Temporo-mandibular joint I. Prolonged extractions
I. Trismus (masseter muscle) II. Dental anaesthetic injection - ID Block
I. Mandibular hypo-mobility < than 2 cm III. TMJ subluxation or true luxation
Temporo-Mandibular Joint complications
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Temporo-Mandibular Joint complications
TMJ true luxation
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Temporo-Mandibular Joint complications
TMJ true luxation
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TMJ true luxation
Temporo-Mandibular Joint complications
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Temporo-Mandibular Joint complications
TMJ true luxation
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Temporo-Mandibular Joint complications
TMJ true luxation
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BisphosphonatesInhibit osteoclastic function - essential enzymes
RANKL Inhibitors (Receptor Activator Nuclear Factor kB Ligant)
Inhibit osteoclastic function - humanised monoclonal antibody
Anti-angionegic drugsTarget the process of new blood vessel formation - restrict tumour vascularisation
Medically related osteonecrosis of the jaws (MRONJ)
AAOMS position paper, on medication related osteonecrosis of the jaw, 2014BRUZUAL CESRC
Patients may be considered to have MRONJ if all of the following characteristics are present:
1. Current or previous treatment with anti-resorptive or antiangiogenic agents
2. Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region that has persisted for more than eight weeks
3. No history of radiation therapy to the jaws or obvious metastatic disease to the jaws.
Medically related osteonecrosis of the jaws (MRONJ)
AAOMS position paper, on medication related osteonecrosis of the jaw, 2014BRUZUAL CESRC
MRONJ is comparatively uncommon following dental extractions
• 0.04 - 0.5% incidence in patients on ORAL BP
• 1.15% - 14.8% incidence in patient on IV BP
• There are an estimated 8.2-12.8 cases / million / year or 508 - 793 patients newly diagnosed each year in the UK
Medically related osteonecrosis of the jaws (MRONJ)
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Clinical features: • Exposed bone• Pain• Persistent fistula• Osteonecrosis• Infection
Medically related osteonecrosis of the jaws (MRONJ)
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Medically related osteonecrosis of the jaws (MRONJ)
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Medically related osteonecrosis of the jaws (MRONJ)
Low Risk High Risk
If any of the following is present If any of the following is present
• Patients being treated for osteoporosis or other non-malignant disease of bone (e.g. Paget’s disease) with oral bisphosphonates for less than 5 years who are not currently being treated with systemic steroids
• Patients being treated for osteoporosis or other non-malignant disease of bone (e.g. Paget’s disease) with oral bisphosphonates or quarterly or yearly infusions of intravenous bisphosphonates for more than 5 years
• Patients being treated for osteoporosis or other non-malignant disease of bone with quarterly or yearly infusions of intravenous bisphosphonates for less than 5 years who are not currently being treated with systemic steroids
• Patients being treated for osteoporosis or other non-malignant disease of bone with bisphosphonates or denosumab for any length of time who are currently being treated with systemic steroids
• Patients being treated for osteoporosis or other non-malignant disease of bone with denosumab who are not being treated with systemic steroids
• Patients being treated with anti-resorptive or anti-angiogenic drugs (or both) as part of the management of cancer
• Patients with a previous diagnosis of MRONJ
BRUZUAL CESRC
Has the pat had previous dx MRONJ
Is the patient being treated with anti-resorptive or anti-angiogenic drugs for the management of cancer?
Is the patient currently taking a bisphosphonate drug or have taken them in the past?
Yes
Is the patient currently taking denosumab or have taken it in the last 9 months
Yes
No
No
No Yes
How long have they taken/did they take the bisphosphonate drug for?
YesNo
Is the patient being currently treated with systemic steroids
< 5 years > 5 years
NO RISK LOW RISK HIGH RISK
No YesBRUZUAL CESRC
Medically related osteonecrosis of the jaws (MRONJ)
Bisphosphonate > 4 years OralSuspend medication for 2 months prior
to extractions
Bisphosphonate + other risk factors (Smoking, Steroids, anti-cancer drugs)
> 4 years OralSuspend medication for 2 months prior
to extractions
Anti-RANKL Denosumab
Given every 6 months
Sub Cutaneous
Suspend medication 3 months prior to extractions
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Medically related osteonecrosis of the jaws (MRONJ)
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Medically related osteonecrosis of the jaws (MRONJ)
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www.centralenglandreferrals.co.uk <presentationtitle-date>©2016
Medically related osteonecrosis of the jaws (MRONJ)
Recommendations
• Healthy diet and reducing sugary snacks and drinks • Maintain excellent oral hygiene • Use of fluoride tooth paste • Stop smoking • Limiting alcohol intake • Reporting any symptoms such as: loose teeth, numbness or altered sensation,
pain or swelling ASAP • Monitoring:
• Regular clinical check up • Consider imaging if suspected changes or symptoms • If any surgical procedure has been done monitor area until it has completely
healed (minimum 8 weeks or until area has healed)
If patient develops MRONJ - refer to specialistBRUZUAL CESRC
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Medically related osteonecrosis of the jaws (MRONJ) Antibiotics therapy for high risk patients
Recommended antibiotic prophylaxis (patients with high risk of MROJN) - (IV bisphosophonates)
• 1g Amoxicillin TDS starting 3 days prior to surgery • 1g Amoxicillin + Clavulanic Acid starting TDS 2 days prior to surgery • If allergic to penicillin
• Clindamycin 600 mg TDS 2 days prior to surgery • Metronidazole 400 mg TDS 2 days prior to surgery
BRUZUAL CESRC
PRGF Platelet Rich Growth Factors
PRF / L-PRF/ AL-PRF
Luis M Bruzual, B Odont(Ven), Cert (OMFS)
BRUZUAL CESRC
Platelets produce growth factors for > 7 days
• PDGF-AB /Platelet derived growth factor
• TGF β-1 / Transforming growth factor β
• VEGF / Vascular endothelial growth factor
• TSP-1 / Thrombospondin - 1
What are PRGF benefits?
BRUZUAL CESRC
Applications in Dental/Oral and Maxillofacial Surgery
• Bone defects (congenital, post cystic, post-traumatic, etc.)
• Alveolar preservation for implant placement
• Sinus and alveolar ridge augmentation
• Implant placement
• Periodontal defects
• Prevention of MRONJ and ORN
• Treatment of MRONJ and ORNBRUZUAL CESRC
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PRGF PreparationPRGF Preparation
Blood collection Centrifugation Preparations
BRUZUAL CESRC
What are PRGF benefits?
BRUZUAL CESRC
PRGF Preparation
BRUZUAL CESRC
PRGF Preparation
BRUZUAL CESRC
What are PRGF benefits?
BRUZUAL CESRC
BRUZUAL CESRC
What are PRGF benefits?
BRUZUAL CESRC
What are PRGF benefits?
BRUZUAL CESRC
What are PRGF benefits?
BRUZUAL CESRC
Why Leukocytes • Cytokines production
• Anti-inflamatory effects
• Anti-infectious effects
• Promote angiogenesis VEGF
PRF is also rich in Leukocytes
Leukocytes produce cytokines**
• 3 pro-inflamatory cytokines
• IL-6 / Interleukin 6
• IL-1β / Interleukin 1B
• TNF - α / Tissue Necrotic Factor alpha
• 1 retro-inflammatory Cytokine
• IL-4 / Interleukin 4
PRF is also rich in Leukocytes
One of the most powerful promoter of the VEGF
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