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Karl Koerner, DDS, MS Easier, Faster, Less Stressful Extractions

for the General Dentist

Guilin, China – Dental Humanitarian Multiple Extractions and

Related Concerns

Alveoplasty

The surgical removal of a portion of the alveolar process.

Oral surgeon advertisement: An ill-fitting denture can cause: Mouth sores, Mouth ulcers, Mouth blisters, and Bone splinters. These things prevent people from eating, swallowing, and speaking properly.

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For the best healing, I can carefully trim away irritating bony irregularities.

Then the gums can be sutured for the best healing.

One month postop.

No alveoplasty performed. Severe pain.

No alveoplasty performed. Severe pain.

We used to have to increase the height of the ridge by lowering the floor of the mouth by the tongue or by doing a vestibuloplasty on the cheek/lip side so the denture stayed in better, but now those surgeries have largely been replaced by the use of implants.

Alveoplasty procedure:

1. Incise from socket to socket across the interseptal crests. 2. In lifting the full-thickness mucoperiosteum, do not reflect past the mucogingival line if possible. 3. With a rongeur or large bone bur (like an acrylic bur), smooth sharpness and protuberances, usually mostly on the labial-occlusal.

Guidelines, cont.

• Smooth bony points and sharp edges.

– Ronguer or

– Bur

– Bone file (last)

Ronguer

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5.5 mm 4.0 mm H73 OS.HP .055 H73 OS.HP .040

4. Small bleeders are controlled by crushing adjacent bone into the bleeding orifice with a periosteal elevator in the bleeding orifice or by burnishing bone graft material or bone wax into the bleeding site. 5. Use a bone file (such as a Hu-Friedy 2X file) to do additional smoothing after the ronguer or bone bur. 6. Replace the gingiva and feel bone with your finger through this soft tissue to see if it still feels sharp. 7. Carefully irrigate all loose bone particles from under the flap.

Guidelines, cont.

• Smooth bony points and sharp edges

– Rongeurs

– Bur

– Bone file (last)

Guidelines, cont.

• Smooth bony points and sharp edges

– Ronguer

– Bur

– Bone file (last)

Bone file

From Hupp, et al. Contemp. Oral and Maxillofac. Surgery. 5th ed. Mosby.

Many clinicians view this as “excessive” bone removal.

Many clinicians view this as “excessive” bone removal.

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Feel bone through the soft tissue. If

still sharp, smooth a little more. 8. The end result should a fairly smooth ridge, flatter than it was before. 9. Sockets are debrided of any infection and any granulation tissue is removed from the flaps. Papillae can be retained and even be interdigitated during suturing -- but in some cases of severe infection they may be excised. 10. Suturing can be with interrupted or continuous-lock sutures without tension.

Guidelines, cont.

• Remove pathology

– Granulomatous (cyanotic) tissue

– Infection

• Remove

– Exostoses

– Gross undercuts

– Frenae

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Guidelines, cont.

• Remove pathology

– Granulomatous (cyanotic) tissue

– Infection

• Remove

– Exostoses

– Gross undercuts

– Frenae

Exostosis removal and fibrous tuberosity reduction.

Types of Frenectomies • One hemostat • Two hemostats • Elipical incisions • “V” excision • “Z” plasty • Single pedicle and bilateral pedicle

flap techniques • Electrosurgery excision • Laser incision or ablation, no

sutures • Pediatric: No anesthetic except

topical, scissors on ventral surface of the tongue, no sutures….

• Adult • Pediatric • Labial • Lingual / tongue-tie

• For considertion: • 1. Scoring the bone at

the vestibular depth with scalpel or bur to cause scaring and prevent relapse.

• 2. Anterior nasal spine reduction.

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Spring loaded. Spring

loaded. Trigger. Trigger.

Gently lift up the lip for visibility and access.

Cut on both sides of the frenum.

Forms a “V”-shape.

Cuts extend upwards to the depth of the mucobuccal fold.

Cuts begin at same place -- at the bottom or “tip” of the frenum, near the teeth.

Cuts are down to bone (even though no bone will be exposed).

With a diastema, the “V” can extend to the lingual papilla.

• If needed (palatal blanching), make a wedge excision between the incisors, not to include the lingual papilla which could cause excessive bleeding.

Leonard, M. The maxillary frenum and surgical treatment. Gen Dent. Nov.-Dec. 1998.

Silverstein H, Kurtzman D, and Shatz PC. Soft Tissue Surgery. Aegis Communications.. 2007.

While grasping the frenum with tissue pickups, lift it up and slide the blade underneath from the side (one side to the center, followed by the other side to the center) to completely undermine the frenum. Leave the apical portion attached to the lip for now.

Do not denude the bone.

Leave a thin layer of bleeding connective tissue on the bone (which is the periosteum).

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Your assistant holds the lip. With the pickups, you gently pull the frenum up and forward. Using the blade, cut to join one side of the “V” to the other. If needed, you can cut up and around some remaining frenum that is higher than the mucobuccal fold.

Using a scissor (can be a Mitzenbaum such as this one) you can undermine some of the frenum, especially if very broad. Go under, open the beaks and then pull back.

Place the first suture at the depth of the mucobuccal fold where it should engage the periosteum that you left on the bone. This is the “anchor” suture. (Anchors the healing at this point to help prevent relapse.) Additional sutures if needed, generally above the “anchor”.

Exposed periosteum

heals as attached gingiva.

Exposed periosteum

heals as attached gingiva.

About 1/3 of individuals have muscle fibers within the frenum. Leonard, M. The maxillary frenum and surgical treatment. Gen Dent. Nov.-Dec. 1998.

Leonard, M. The maxillary frenum and surgical treatment. Gen Dent. Nov.-Dec. 1998.

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• Suture: 4.0 or 3.0 chromic gut.

• Anchor suture.

• Do frenums cause the diastema? – Heavy maxillary frenums can exist without a

diastema

– A diastema can exist without a frenum

– Genetic proclivity

can play a role in

having the frenum

Other reasons for a diastema: • Mesiodens between the centrals

• Tooth/arch size discrepancy – lower incisors touching palatal gingiva

• Missing teeth

• Macroglossia

• Tongue thrust

• Flaccid lip muscles

• Pernicious habits

American Academy of Pediatric Dentistry 2014

Diastema and the frenectomy: “It is recommended that treatment be delayed until the permanent incisors and cuspids have erupted and the diastema has had an opportunity to close naturally. If orthodontic treatment is indicated, the frenectomy (complete excision) should be performed only after the diastema is closed as much as possible to achieve stable results.

Maxillary Frenum and the Diastema

• Two studies measured that:

–≈ 45% of children at 6 years had a diastema

–≈ only 6% at 15 years had a diastema

Diastema – Frenum Evaluation

• Blanching test

– Lift the upper lip and pull it forward

– Does the frenum cause blanching of the palatal papilla?

– If yes, it is unlikely the diastema can successfully be resolved without removing the frenum.

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Lingual Frenectomy

• Cattails2.jpg

Salem, UT