{"id":10163,"date":"2016-04-08T15:40:30","date_gmt":"2016-04-08T13:40:30","guid":{"rendered":"https:\/\/www.zerodonto.com\/en\/?p=10163"},"modified":"2017-10-19T14:00:48","modified_gmt":"2017-10-19T12:00:48","slug":"new-challenge-dentistry-complex-oral-surgery-office","status":"publish","type":"post","link":"https:\/\/www.zerodonto.com\/en\/2016\/04\/new-challenge-dentistry-complex-oral-surgery-office\/","title":{"rendered":"A new challenge in dentistry &#8211; Complex Oral Surgery in the Office"},"content":{"rendered":"<p class=\"p1\"><span class=\"s1\">Root canal therapy of a molar tooth was a sophisticated treatment 50 years ago: the extraction was the rule.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Endodontics of a molar tooth is still a sophisticated treatment today, but it has become a normal dental procedure in any dental office.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">What has changed? Tools, techniques, mentality of the dentist and patient needs.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Dentists today are used to working in very narrow spaces.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Progress in some surgical disciplines, such as periodontology and implantology, has been extraordinary.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Oral surgery, however, was excluded: the tools and techniques for the extraction of wisdom teeth are the same as 50 years ago, even in the video clips we see today on the Internet.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">The contrast is even more striking when we consider that dentists safely perform sinus lift procedures in their offices, while referring cases of cysts to hospitals. Yet, the elevation of the sinus membrane requires greater skill than the detachment of a cyst wall.<\/span><!--more--><\/p>\n<p class=\"p1\"><span class=\"s1\">Elevation of the sinus mucosa after a micro-antrostomy. This delicate maneuver allows you to keep the sinus membrane intact before proceeding to the filling.<\/span><\/p>\n<p><iframe loading=\"lazy\" width=\"1170\" height=\"658\" src=\"https:\/\/www.youtube.com\/embed\/sAGcgdlluMc?feature=oembed\" frameborder=\"0\" allow=\"autoplay; encrypted-media\" allowfullscreen><\/iframe><\/p>\n<p class=\"p1\"><span class=\"s1\">A case of cystic lesion associated with the impacted wisdom tooth (surgery under local anesthesia)<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10164\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/CISTI_38_OPT_PRE-min-1024x493.jpg\" alt=\"CISTI_38_OPT_PRE-min\" width=\"940\" height=\"453\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/CISTI_38_OPT_PRE-min-1024x493.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/CISTI_38_OPT_PRE-min-300x144.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/CISTI_38_OPT_PRE-min-768x370.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/CISTI_38_OPT_PRE-min-750x361.jpg 750w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">The video clip starts where the impacted tooth has already been extracted. We remove the cyst by means of dissection with surgical curette and gentle traction with biopsy forceps, through the osteotomy used for extraction.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The dissection technique is similar to a micro-antrostomy.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The periodontal bone peaks of the second molar and the external oblique line were preserved. <\/span><\/p>\n<p><iframe loading=\"lazy\" width=\"1170\" height=\"658\" src=\"https:\/\/www.youtube.com\/embed\/tShxsmEE058?feature=oembed\" frameborder=\"0\" allow=\"autoplay; encrypted-media\" allowfullscreen><\/iframe><\/p>\n<p class=\"p1\"><span class=\"s1\">We believe the time has come to align oral surgery to today&#8217;s high dentistry standards to carry out even complex oral surgery in the office safely and without stress.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Surgery can become complex as a result of: <\/span><\/p>\n<ul>\n<li class=\"li1\"><span class=\"s1\">limited access (eg. target depth)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">risk of damage (eg. to the inferior alveolar nerve)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">unusual cases and aggressive diseases (eg. keratocysts)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">systemic conditions (eg. anti-coagulant therapy)<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">These factors often overlap and complicate each other.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Solving complex cases requires:<\/span><\/p>\n<ul>\n<li class=\"li1\"><span class=\"s4\">diagnostic competence<\/span><\/li>\n<li class=\"li1\"><span class=\"s4\">effective anesthesia<\/span><\/li>\n<li class=\"li1\"><span class=\"s4\">adequate instruments<\/span><\/li>\n<li class=\"li1\"><span class=\"s4\">rational method of operation<\/span><\/li>\n<\/ul>\n<p class=\"p4\"><span class=\"s1\">Prejudices are another source of complexity:<\/span><\/p>\n<p class=\"p4\"><span class=\"s1\">1. Cone beam (CB) is frequently used as a first-level examination for wisdom teeth.<br \/>\nHowever, the examination which identifies the risk is the panoramic radiograph (Rood &amp; Shehab, 1990).<br \/>\nThe CB is a second-level examination (SEDENTEXCT, 2016) which serves to identify the lingual or buccal location of the alveolar canal relative to the roots when the intersection between the two structures is at the height of the furcation or at the middle or coronal third of the roots.<\/span><\/p>\n<p class=\"p5\"><span class=\"s1\">2. Anesthesia without epinephrine. <\/span><\/p>\n<p class=\"p4\"><span class=\"s1\">Epinephrine (1: 100,000) is necessary to obtain a sufficient duration and depth of anesthesia and is indicated in most heart conditions (Brown &amp; Rhodus, 2005) because it prevents the incretion of norepinephrine.<\/span><\/p>\n<p class=\"p5\"><span class=\"s1\">3. The nerve block is dangerous. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">In studies with a large sample size (more than 10,000 cases) no neurological damage was observed (Arcuri et al, 2004).<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">4. High speed handpieces can produce emphysema and bone necrosis. <\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Emphysema is impossible because the 45\u00b0 surgical handpieces do not emit air into the operative field. The handpiece is obviously not indicated for implant surgery where the loss of vitality even of a few cell layers may compromise the osseointegration. The loss of some osteocytes does not cause clinically significant consequences in extractive surgery.<br \/>\n<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Good results depend on proper and neat surgical actions. <\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">No diagnostic test and no surgical instrument can prevent injury from poorly planned or poorly executed surgery.<\/span><\/p>\n<p class=\"p4\"><span class=\"s1\">Let\u2019s see three illustrative case reports.<\/span><\/p>\n<p class=\"p1\" style=\"text-align: center;\"><strong><span class=\"s1\">CASE 1<\/span><\/strong><\/p>\n<h4 class=\"p2\"><span class=\"s1\"><b>Pain and repeated abscesses in a 70 year-old male patient, with heart disease, taking anticoagulant therapy<\/b><\/span><\/h4>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10179\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-Claudio-OPT-min-1024x535.jpg\" alt=\"Screti Claudio OPT-min\" width=\"940\" height=\"491\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-Claudio-OPT-min-1024x535.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-Claudio-OPT-min-300x157.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-Claudio-OPT-min-768x401.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-Claudio-OPT-min-550x287.jpg 550w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">The left mandibular third molar is very deep, carious, with a radiolucent area around the crown. The anatomic relationship with the alveolar canal is at risk: the roots appear radiolucent where they cross the canal.<br \/>\n<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Medical history<\/b>: heart attack two years ago, currently taking anticoagulants and candidate for heart surgery for stent and subsequent dual antiplatelet therapy. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Rationale for surgery<\/b>: need to remove the infected tooth before heart surgery.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Complexity factors<\/b>: impairment of general health, anticoagulants, deep impaction associated with erosion of the lingual cortical plate and radiolucency of the middle third of the roots where they cross the alveolar canal (Rood &amp; Shehab, 1990).<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">A Cone Beam was requested.<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10183\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-C_TC7-1024x921.jpg\" alt=\"Screti C_TC7\" width=\"940\" height=\"845\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-C_TC7-1024x921.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-C_TC7-300x270.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-C_TC7-768x691.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-C_TC7-445x400.jpg 445w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Screti-C_TC7.jpg 1233w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\"> The impacted tooth is carious and the lingual cortical bone is eroded.<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10177\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.09.52-min-904x1024.jpg\" alt=\"Schermata 2016-04-07 alle 12.09.52-min\" width=\"904\" height=\"1024\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.09.52-min-904x1024.jpg 904w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.09.52-min-265x300.jpg 265w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.09.52-min-768x870.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.09.52-min-353x400.jpg 353w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.09.52-min-300x340.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.09.52-min.jpg 1206w\" sizes=\"auto, (max-width: 904px) 100vw, 904px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">The alveolar canal is buccal to the roots of the impacted tooth, the apexes are located in close proximity of the basal edge of the mandible and the lingual cortical plate is eroded in a deep portion.<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10171\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0462-min-1024x719.jpg\" alt=\"DSC_0462-min\" width=\"940\" height=\"660\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0462-min-1024x719.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0462-min-300x211.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0462-min-768x539.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0462-min-570x400.jpg 570w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">A periodontal probe penetrates into the fistula more than 15 mm, before reaching the impacted crown.<\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><b>Strategy to address the complexity factors<\/b><\/span><\/p>\n<ul>\n<li class=\"li3\"><span class=\"s1\">compromised general health:<br \/>\n<b>operating prior to cardiac surgery, local anesthesia with epinephrine <\/b>(Brown &amp; Rhodus, 2005)<\/span><\/li>\n<li class=\"li3\"><span class=\"s1\">anticoagulant therapy:<br \/>\n<b>assessing<\/b> <b>INR the day of surgery <\/b>(&lt; 2.5) (Weltman et al, 2015) <\/span><\/li>\n<li class=\"li3\"><span class=\"s1\">deep impaction and lingual erosion:<br \/>\n<b>45\u00b0 handpiece, long burs, Friedman elevators<\/b><\/span><\/li>\n<li class=\"li3\"><span class=\"s1\">proximity to the alveolar canal: <b><br \/>\nsonic tips<\/b><br \/>\n<\/span><\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10172\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0464-small-min-1024x680.jpg\" alt=\"DSC_0464-small-min\" width=\"940\" height=\"624\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0464-small-min-1024x680.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0464-small-min-300x199.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0464-small-min-768x510.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0464-small-min-602x400.jpg 602w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">An incision corresponding to the fistula, a releasing incision directed distally and buccally, and an incision in the sulcus of the first molar, delimit a triangular flap.<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10173\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0473-min-948x1024.jpg\" alt=\"DSC_0473-min\" width=\"940\" height=\"1015\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0473-min-948x1024.jpg 948w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0473-min-278x300.jpg 278w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0473-min-768x830.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0473-min-370x400.jpg 370w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0473-min-300x324.jpg 300w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">Bone resection with preservation of the external oblique line and the partial removal of the infected soft tissue allow the crown of the deeply impacted tooth to be visible.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Technical steps in the video clip<\/b><\/span><\/p>\n<ul>\n<li class=\"li1\"><span class=\"s1\">Removal of the soft tissue around the crown with a curette<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Incomplete division of the crown with a long drill, fracture with elevator and removal of fragments<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Profuse bleeding makes it difficult to see the roots near the alveolar nerve at the bottom of the wound<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">The sonic tip (Komet, SFS 90 M \/ D) and operating microscope optimize visibility and minimize the risk of neurological damage. The sonic vibration tips are shaped to create a space to insert a thin elevator between the bone and root<\/span><\/li>\n<\/ul>\n<p><iframe loading=\"lazy\" width=\"1170\" height=\"658\" src=\"https:\/\/www.youtube.com\/embed\/VwKGCJcghZ4?feature=oembed\" frameborder=\"0\" allow=\"autoplay; encrypted-media\" allowfullscreen><\/iframe><\/p>\n<div id=\"attachment_10174\" style=\"width: 950px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-10174\" class=\"size-large wp-image-10174\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0479-min-1024x860.jpg\" alt=\"The fragments of the extracted tooth. \" width=\"940\" height=\"789\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0479-min-1024x860.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0479-min-300x252.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0479-min-768x645.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0479-min-476x400.jpg 476w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><p id=\"caption-attachment-10174\" class=\"wp-caption-text\">The fragments of the extracted tooth.<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\">The wound is still healing by secondary intention, one month later. The postoperative period was uneventful.<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10170\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0340-min-918x1024.jpg\" alt=\"DSC_0340-min\" width=\"918\" height=\"1024\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0340-min-918x1024.jpg 918w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0340-min-269x300.jpg 269w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0340-min-768x856.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0340-min-359x400.jpg 359w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0340-min-300x334.jpg 300w\" sizes=\"auto, (max-width: 918px) 100vw, 918px\" \/><\/p>\n<p class=\"p1\" style=\"text-align: center;\"><strong><span class=\"s1\">CASE 2<\/span><\/strong><\/p>\n<h4 class=\"p2\"><span class=\"s1\"><b>Pain in a 73 year-old female patient<\/b><\/span><\/h4>\n<p class=\"p2\"><span class=\"s1\">Partially impacted mandibular left third molar, carious, with risk indicators for the inferior alveolar nerve: the intersection of alveolar canal and roots is unusually high.<\/span><\/p>\n<p class=\"p2\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10184\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-1024x488.png\" alt=\"Trapani V\" width=\"940\" height=\"448\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-1024x488.png 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-300x143.png 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-768x366.png 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-750x357.png 750w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p2\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10165\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-1024x1012.jpg\" alt=\"DSC_0009_21612-min\" width=\"940\" height=\"929\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-1024x1012.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-300x296.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-768x759.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-405x400.jpg 405w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-60x60.jpg 60w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-32x32.jpg 32w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-64x64.jpg 64w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-96x96.jpg 96w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0009_21612-min-128x128.jpg 128w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p2\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-10181\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-min.jpg\" alt=\"Trapani V copia-min\" width=\"935\" height=\"713\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-min.jpg 935w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-min-300x229.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-min-768x586.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-min-525x400.jpg 525w\" sizes=\"auto, (max-width: 935px) 100vw, 935px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">The risk of neurological damage depends on the relationship between the alveolar canal and roots of the impacted tooth and the patient&#8217;s age (Haug et al, 2005).<\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><b>Complexity factors<\/b>: age (atrophy of the residual ligament), extensive caries (lack of leverage points), alveolar nerve at the height of the furcation.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Despite the tooth being superficial, a CB is required to study the relationship between the roots and the alveolar canal: in particular, it is necessary to know if the canal is buccal, lingual or between the roots.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The CB shows the alveolar canal that passes through the roots.<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10182\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-2-min-1024x870.jpg\" alt=\"Trapani V-2-min\" width=\"940\" height=\"799\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-2-min-1024x870.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-2-min-300x255.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-2-min-768x653.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-2-min-471x400.jpg 471w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-10180\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-2-min.jpg\" alt=\"Trapani V copia 2-min\" width=\"633\" height=\"677\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-2-min.jpg 633w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-2-min-281x300.jpg 281w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-2-min-374x400.jpg 374w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Trapani-V-copia-2-min-300x321.jpg 300w\" sizes=\"auto, (max-width: 633px) 100vw, 633px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Strategy to address the complexity factors<\/b><\/span><\/p>\n<ul>\n<li class=\"li1\"><span class=\"s1\">atrophic ligament:<br \/>\n<b>use of sonic instruments<\/b><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">alveolar nerve between the roots:<br \/>\n<b>creating a cleavage with sonic tips and gentle luxating maneuvers using the microscope<\/b><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><b>Technical steps in the video clip<\/b><\/span><\/p>\n<ul>\n<li class=\"li1\"><span class=\"s1\">Elevation of a triangular flap with distal releasing incision<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Separation and removal of the crown<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">The roots are mobilized by thin elevators: the initial subluxation avoids the need to apply excessive force to the elevators in the proximity of the neurovascular bundle<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">A new cleavage is obtained using sonic tips or thin burs where the elevator cannot be inserted between the tooth and bone lever<\/span><\/li>\n<\/ul>\n<p><iframe loading=\"lazy\" width=\"1170\" height=\"658\" src=\"https:\/\/www.youtube.com\/embed\/BOyTe6m3zp0?feature=oembed\" frameborder=\"0\" allow=\"autoplay; encrypted-media\" allowfullscreen><\/iframe><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Technical steps in the video clip<\/b> <\/span><\/p>\n<ul>\n<li class=\"li1\"><span class=\"s1\">The roots are separated from the nervous vascular bundle, which is seen as a whitish cord<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">The sonic instrument (Komet, SFS90M \/ D) is used to create a clear cleavage plane where a small root elevator can be inserted<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Removal of the distal root<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">The mesial root can also be dislocated gently, using the surgical microscope<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">The root comes out by bypassing the nerve<\/span><\/li>\n<\/ul>\n<p class=\"p2\"><span class=\"s1\">The integrity of the neurovascular bundle that crosses the empty socket can be verified after the extraction.<\/span><\/p>\n<p><iframe loading=\"lazy\" width=\"1170\" height=\"658\" src=\"https:\/\/www.youtube.com\/embed\/KZLe85fF_FU?feature=oembed\" frameborder=\"0\" allow=\"autoplay; encrypted-media\" allowfullscreen><\/iframe><\/p>\n<p class=\"p1\"><span class=\"s1\">The patient had 5 days of impaired lip sensitivity which completely recovered 15 days after surgery.<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10168\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0161-min-942x1024.jpg\" alt=\"DSC_0161-min\" width=\"940\" height=\"1022\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0161-min-942x1024.jpg 942w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0161-min-276x300.jpg 276w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0161-min-768x835.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0161-min-368x400.jpg 368w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0161-min-300x326.jpg 300w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\" style=\"text-align: center;\"><strong><span class=\"s1\">CASE 3<\/span><\/strong><b> <\/b><\/p>\n<h4 class=\"p2\"><span class=\"s1\"><b>Recurrent keratocysts (Keratocystic Odontogenic Tumor) in a 16 year-old girl<\/b><\/span><\/h4>\n<p class=\"p3\"><span class=\"s1\">Radiolucent lesion around the root of the left mandibular lateral incisor.<\/span><\/p>\n<p class=\"p3\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10176\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/PRE-min-749x1024.jpg\" alt=\"PRE-min\" width=\"749\" height=\"1024\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/PRE-min-749x1024.jpg 749w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/PRE-min-220x300.jpg 220w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/PRE-min-768x1049.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/PRE-min-293x400.jpg 293w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/PRE-min-300x410.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/PRE-min.jpg 824w\" sizes=\"auto, (max-width: 749px) 100vw, 749px\" \/><\/p>\n<p class=\"p3\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10166\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0064_8806-min-1024x646.jpg\" alt=\"DSC_0064_8806-min\" width=\"940\" height=\"593\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0064_8806-min-1024x646.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0064_8806-min-300x189.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0064_8806-min-768x484.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0064_8806-min-634x400.jpg 634w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">The patient reported a previous surgery for cyst removal, which occurred one year earlier. The histopathologic diagnosis was: keratocyst.<\/span><\/p>\n<p class=\"p3\"><span class=\"s1\">Complexity factors<\/span><\/p>\n<ul>\n<li class=\"li3\"><span class=\"s1\">aggressive lesion with high risk of recurrence<\/span><\/li>\n<li class=\"li3\"><span class=\"s1\">involvement of the roots of adjacent teeth<\/span><\/li>\n<li class=\"li3\"><span class=\"s1\">thin periodontal biotype<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">The lateral incisor responded weakly to the vitality test and underwent endodontic treatment.\u00a0<\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10175\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/OP-min-717x1024.jpg\" alt=\"OP-min\" width=\"717\" height=\"1024\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/OP-min-717x1024.jpg 717w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/OP-min-210x300.jpg 210w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/OP-min-768x1097.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/OP-min-280x400.jpg 280w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/OP-min-300x428.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/OP-min.jpg 801w\" sizes=\"auto, (max-width: 717px) 100vw, 717px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Strategy to address the complexity factors<\/b><\/span><\/p>\n<ul>\n<li class=\"li1\"><span class=\"s1\">high risk of recurrence:<br \/>\n<b>complete removal of the lesion and treatment of bone walls with Carnoy&#8217;s solution<\/b> <\/span><span class=\"s3\"><sup>(4,5)<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">involvement of adjacent roots:<br \/>\n<b>surgical microscope and microsurgery instruments<\/b><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">thin periodontium:<br \/>\n<b>marginal incision without vertical releasing incisions<\/b><\/span><\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10167\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0074_8816-small-min-1024x680.jpg\" alt=\"DSC_0074_8816-small-min\" width=\"940\" height=\"624\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0074_8816-small-min-1024x680.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0074_8816-small-min-300x199.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0074_8816-small-min-768x510.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0074_8816-small-min-602x400.jpg 602w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\"><i>4. Sharif et al. Interventions for the treatment of keratocystic odontogenic tumours (KCOT). Cochrane Data Base Syst Rev, 2010.<\/i><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><i>5. Stoelinga PJ. The Management of Aggressive Cysts of the Jaws. JOMS, 2012.<\/i><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Technical steps in the video clip<\/b> <\/span><\/p>\n<ul>\n<li class=\"li1\"><span class=\"s1\">Excision of the lesion with preservation of the bone walls<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Treatment of residual cavity with Carnoy&#8217;s fluid<\/span><\/li>\n<\/ul>\n<p><iframe loading=\"lazy\" width=\"1170\" height=\"658\" src=\"https:\/\/www.youtube.com\/embed\/LmlHG6Cwp80?feature=oembed\" frameborder=\"0\" allow=\"autoplay; encrypted-media\" allowfullscreen><\/iframe><\/p>\n<p class=\"p1\"><span class=\"s1\">The protocol involves a follow-up with clinical and radiographic controls every year up to 10 years. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Clinical follow-up 3 years later. <\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10169\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0296_18596-min-1024x845.jpg\" alt=\"DSC_0296_18596-min\" width=\"940\" height=\"776\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0296_18596-min-1024x845.jpg 1024w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0296_18596-min-300x248.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0296_18596-min-768x634.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/DSC_0296_18596-min-485x400.jpg 485w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\">Radiographic follow-up 3 years after surgery. <\/span><\/p>\n<p class=\"p1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-10178\" src=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.14.03-min-660x1024.jpg\" alt=\"Schermata 2016-04-07 alle 12.14.03-min\" width=\"660\" height=\"1024\" srcset=\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.14.03-min-660x1024.jpg 660w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.14.03-min-193x300.jpg 193w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.14.03-min-768x1192.jpg 768w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.14.03-min-258x400.jpg 258w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.14.03-min-300x466.jpg 300w, https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2016\/04\/Schermata-2016-04-07-alle-12.14.03-min.jpg 782w\" sizes=\"auto, (max-width: 660px) 100vw, 660px\" \/><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>RECOMMENDED REFERENCES<\/b><\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><i>Arcuri C, Bartuli FN, Germano F, Docimo R, Cecchetti F. Bilateral anesthesia into Spix&#8217;s spine. Ten years&#8217; experience. Minerva Stomatol. 2004 Mar;53(3):93-9.<\/i><\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><i>Brown R, Rhodus NL. Epinephrine and local anesthesia revisited. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005.<\/i><\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><i>Haug R H, Perrott D H, Gonzalez M L, Talwar R M. The American Association of Oral and Maxillofacial Surgeons Age-Related Third Molar Study. J Oral Maxillofac Surgery 2005.<\/i><\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><i>Rood &amp; Shehab. The radiological prediction of inferior alveolar nerve injury during third molar surgery. Br J Oral Maxillofac Surg. 1990.<\/i><\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><i>SEDENTEXCT Project 2016.<br \/>\n<\/i><a href=\"http:\/\/www.sedentexct.eu\/content\/guidelines-cbct-dental-and-maxillofacial-radiology\"><span class=\"s2\"><i>http:\/\/www.sedentexct.eu\/content\/guidelines-cbct-dental-and-maxillofacial-radiology<\/i><\/span><\/a><\/span><\/p>\n<p class=\"p3\"><span class=\"s1\"><i>Weltman N, Al-Attar Y, Cheung J, Duncan D, Katchky A, Azarpazhooh A, Abrahamyan L. Management of Dental Extractions in Patients taking Warfarin as Anticoagulant Treatment: A Systematic Review. J Can Dent Assoc 2015.<\/i><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Root canal therapy of a molar tooth was a sophisticated treatment 50 years ago: the extraction was the rule. Endodontics of a molar tooth is still a sophisticated treatment today, but it has become a normal dental procedure in any dental office. What has changed? Tools, techniques, mentality of the dentist and patient needs. Dentists today are used to working in very narrow spaces. Progress in some surgical disciplines, such as periodontology and implantology, has been extraordinary. Oral surgery, however, was excluded: the tools and techniques for the extraction of wisdom teeth are the same as 50 years ago, even in the video clips we see today on the Internet. The contrast is even more striking when we consider that dentists safely perform sinus lift procedures in their offices, while referring cases of cysts to hospitals. Yet, the elevation of the sinus membrane requires greater skill than the detachment of a cyst wall.<\/p>\n","protected":false},"author":22,"featured_media":10179,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[41],"tags":[],"coauthors":[25,36,35],"class_list":["post-10163","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-oral-surgery"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Complex Oral Surgery in the Office: Dr. R. Barone, C. Clauser, A. Baleani<\/title>\n<meta name=\"description\" content=\"How to align oral surgery to today&#039;s high dentistry standards to carry out even complex oral surgery in the office safely and without stress? 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