Oral Surgery Post Surgical Considerations Dr. Michael J. Strohecker DMD
Postoperative Bleeding Gauze Pack Direct Pressure Often overlooked, but very effective Unravel 2X2 gauze, stuff into exo site using Dubakie Forceps or cotton pliers, keep direct pressure on gauze for 5 minutes. Repeat if needed Clotting Agent Surgicel Gel-Foam
Ecchymosis and Edema Who s at Risk? Ecchymosis Bruise in the oral tissue of the face Caused by blood in subcutaneous tissue Often seen in older patients due to decreased tissue tone and weaker intercellular attachment. Often appears the next day Looks scary but isn t Self limiting / Self resolving Inform patient in advance
Edema Who s at Risk? Occurs with most surgical extractions when a mucoperiosteal flap is used. Reaches maximum in 48 72 hrs If swelling continues to increase may be due to infection Ice Pack first 24 hours Warm moist compresses second 24 hours Inform patient in advance that swelling will occur
Trismus Now what do I do? Limited post-surgical occlusal opening due to inflammation of muscles of mastication Self Limiting Inform patient in advance Possible Causes Injection of anesthetic most often into medial pterygoid Complicated surgical procedure requiring full thickness mucoperiosteal flaps and osteotomy such as third molar exodontia
Lock Jaw Now what do I do? First yell Dag Gum It! Condyle slips past Articular Eminence /disc May occur if patients over articulate Patients usually know, so ask in advance Patients are often able to reposition TMJ themselves If help is needed Multiple tongue blade s over posterior occlusal surfaces of mandible Downward pressure, ease mandible inferiorly and posteriorly May snap back into place keep thumbs clear
Post-Op Pain #1 Alveolar Osteitis / Dry Socket Describes appearance of socket Not associated with infection (?) Usually appears 3 4 days post-op Best way to avoid: Good Surgical Technique / minimally invasive Debride all granulation tissue after extraction if possible Irrigate w/ distilled / sterile water Most commonly associated with tobacco smokers (90%)
Alveolar Osteitis Treatment Systemic Analgesics Topical Analgesics Debride area of poor clot via Chlorohexadine Place Dry Socket Dressing Sultan Paste on Gel-Foam Sultan Paste on Iodoform Gauze Canfield Dressing Do not keep in place for longer than 72 hours Repeat if needed Combination of Both
Post-Op Pain Subperiostial Space Infection Antibiotics usually ineffective Mandibular Swelling where mucoperiostial flap surgery was performed Initial healing appears to be WNL Usually appears two weeks post surgery Often caused by foreign body or invasion of infectious organism between bone and periostium Requires exploratory surgery Access, curettage / debride, irrigate, reapproximate
Soft Tissue Injury During Oral Surgery Mucoperiosteal Flap tears or is perforated in an undesired area Causes Thin / friable tissue Poor surgical technique Patient moves Treatment - Inform Patient - Reapproximate and suture - Time Heals all Wounds
Injury to Osseous Structures Fractured or removed Tuberosity If you haven t fractured a tuberosity then you haven t taken out enough teeth! CAPT H. J. Willoughby OMFS
Injury to Osseous Structures Fractured or removed Tuberosity Can splint tooth and retry in 6-8 weeks using surgical technique Can remove crown w/ handpiece, (may need pulpectomy) allow to heal 6-8 weeks then remove retained roots using surgical technique Proper Pre-surgical planning When in doubt, send it out! Good surgical technique Section tooth Distal osteotomy
Oroantral Communication AKA: Sinus Exposure Often Associated with extraction of Maxillary third Molars BEWARE OF THE LONE MOLAR!!! Careful Case Selection Does the patient have a thin Antrum? Usually assoc w/ older patients Divergent roots? Deep Radicular Sinus Penetration? If you decided to extract Avoid closed forcep extraction Section tooth Laterally engage root segments avoiding superior force that would displace these segments into sinus. When in doubt..send it out!
Oroantral Communication AKA: Sinus Exposure If an Oroantral Communication is suspected Test w/ Valsalva Technique If >2mm no surgical tx is needed / avoid sinus pressure (No nose blowing, sneeze w/ open mouth, do not smoke / suck through straw) If <2mm then primary closure is required May be achieved using clotting agent such as Gel- Foam sutured into place w/ figure eight stitch Sliding Flap techniques / Gortex or foil membrane (>7mm) Systemic coverage: Antibiotics such as Augmentin, Penicillin, Erythromycin OTC decongestants Afrin nose spray may be considered When in doubt send it out!
Fracture of Mandible Know your limits! Careful case selection Careful Surgical Technique Avoid considerable lateral forces if using forceps Consider surgical extraction Considerations: Inferior Border of Mandible is thin Tooth takes up large volume of mandibular structure as in impacted third molar's
Questions?
Thanks!