BAB 2 Exam, Vestiplast, Window, Indi Contindi

7/30/2019 BAB 2 Exam, Vestiplast, Window, Indi Contindi

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FOREWORD

Praise to God for His blessings so that this group report could be finished well. This

report is the result of Group 10 discussion for the seventh scenario in this Block 10. Authorshave tried to do our best through this report. However, as a mere human being, this report that

we create may have some mistakes. Therefore, authors will be glad to receive critics and

suggestions from information providers, all lecturers, friends and all readers.

Authors would also like to thank Group 10 facilitator for this scenario, drg. Bramma

Kiswanjaya, Ph.D and all who have contributed in the making of this group report.

Lastly, we hope this report would be beneficial for the education in Indonesia, especially

in the Faculty of Dentistry University of Indonesia. We sincerely apologize if there are mistakes

in this paper or mistakes during the writing process.

Jakarta, March 31

th

2013Authors

Group 10


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BAB I

Description

Mr Laode 35 years old, comes to RSGMP FKGUI with complain of eating trouble since she has

a sharp tooth that thrust into the tongue. From anamnesis, Mrs Laode explain that she is on her

3rd

month of pregnancy. Her sister sisi, 17 years old, who also comes, wants to make her tooth

alignment. Clinical examination shows that 13 is unerupted but planted on the jawbone in

vertical position. On anemsis, the patients says that for the previous month she was easily

getting tired, often felt thirsty and hungry eventhough she has already taken her meals, and also

loose her height.

Key words:

Female 35 years old :

Eating rouble due to sharp tooth that thrust into the tongue 3rd month of pregnancy

Female 17 years ols

Wants her tooth aligned 13 is unerupted Lump on the gum 13 is planted in the jawbone in the vertical position 2 month of easily getting tired, often feel thisty and hungry and also loose weight

Problems

1. Why does mrs laode has sharp teeth ?2. What is the treatment for mrs laode condition, considering her first trimester of

pregnancy ?

3. What do the symptoms sisis indicate ?4. What is the treatment for sisi problem ? considering her systemic conditions ?5. What is the diagnosis for sisis problem ?


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Hypothesis

1. The cause for mrs laode sharp tooth is unknown because there is not enough information.The treatment plan for mrs laode is preprosthetic surgery followed by prosthetic

treatment that has to be done after her labour.

2. Sisis is suffering from insulin dependent diabetes mellitus3. Sisis suffering from canine impaction4. Tretment plan for sisi is to undergo preorthodontic surgery then followed by orthodontic

treatment that has to be done when her DM is controlled.

Mind map

Pretreatment

surgery

Examination:

Radiology

Clinical examination

Indication and

contraindication

Diagnosis (e,g

abnormalities)

Consideration

Pregnancy

DMtypes

Pre-orthodontic Pre-prosthetic

Procedure and

technique for:Frenectomy

Alveolectomy

Vestibuloplasty

Sulces deepening

windowing


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Learning objective

1. Examination for pre-prosthetic and pre-othrodontic surgery2. Diagnosis for pre-othrodontic and prosthetic surgery3. Consideration for pre-prosthetic and pre-othrodontic surgery4. Indication and contraindication for pre-prosthetic and pre-othrodontic surgery5. Procedure and technique for the following surgery:

A. Frenectomy C. Vestibuloplasty E. Windowing

B. Alveolectomy D. Sulcus deepening


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BAB 2

CONTENT

Preprosthetic surgery

Preprosthetic surgery involves operations aiming to eliminate certain lesions or abnormalities ofthe hard and soft tissues of the jaws, so that the subsequent placement of prosthetic appliances is

successful.

Examination

A. Examination for pre-prosthetic treatment1. Anamnesis

Chief complaint and goal of treatment (aesthetic and function) Physiologic adaptation and denture wearing experience General medical conditions and medications taken

2. Intra oral examination Vestibulum: check for presence of inflammation Attachment of muscle and frenum on alveolar crest Pathologic condition of soft tissue and bone Gag reflex on palate

3. Radiographic examination Orthopantomograph (OPG): digital panoramic Lateral cephalogram 3D CT Scan Important anatomic structure that should be examined:

o Tooth radiceso Impacted tootho Cyst and tumoro Position of mental forameno Bone density in maxilla and mandibula


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B. Examination for pre-orthodontic treatment

(Exposure of impacted canine)

Radiographic examination:

Combination of periapical, occlusal, panoramic radiograph with tube shift method Buccal object rule: SLOB (same sidelingual, opposite sidebuccal) Periapical occlusal technique

Diagnosis for Pre-Treatment Surgery

A. Pre-prosthetic SurgeryDefinition: procedures designed to optimize the stability, retention, support, and comfort

of removable dentures through the selective modification of soft and hard tissues.

Conditions and Diagnosis for Pre-prosthetic Surgery:

a. Dental caries and periodontal diseaseExtraction is not always thought of as a pre-prosthetic procedure nor is it usually

thought of as a preventative procedure. The removal of teeth is the definitive pre-

prosthetic surgical procedure particularly if the patient is being edentulated. Care is

needed to minimize bone loss and create an optimal ridge form. The timely extraction

of non-restorable or periodontally doomed teeth prevents the ongoing bone loss that

would be associated with the infection or surgical extraction of decayed teeth oruncontrolled periodontal disease.

b. Ridge irregularitiesThe elimination of protruding spicules or points of bone allows for more uniform

loading of the ridge. While somewhat more technically demanding, the removal of

tori eliminates point loading in the area of the torus. In the case of lingual tori,

removal often allows for extension of the lingual flange with increased retention and

resistance.

c. UndercutsElimination of bony undercuts allows for more intimate contact of denture base to

bone and therefore more uniform loading of the ridge.

d. Flabby ridge tissue


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The trimming of flabby ridges allows for more intimate adaptation of denture to

mucosa and more uniform loading of ridges. This reduces denture movement and

reduces resultant "rubbing" of the mucosa.

e. Hyperplastic tuberositiesf. Occasionally, posterior interarch space may be reduced by hyperplasia (usually soft

tissue but occasionally osseous) of the tuberosity. This reduces the space available for

the placement of a denture base over the tuberosity or the retro-molar pad. This

results in denture heel interference. Soft tissue hyperplasia can be reduced by wedge

excision of the tissue followed by undermining of the wound edges and primary

closure. Hard tissue reduction is carried out essentially the same way, with osseous

reduction done prior to closure. The amount of bone reduction allowed is a function

of the level of the floor of the sinus.

g. Decreased retention: Loss of retention as a function of ongoing atrophy is difficult toregain.

Vestibuloplasty: With time and bone atrophy, there is a relative loss ofvestibular depth. This is a function of resorption of the ridge crest in a sulcular

direction, toward the attachment of the sulcular muscles (mentalis, buccinator,

etc.). In a fashion similar to the excision of epulis fissuratum, the sulcus depth

can be regained and maintained by the creation of a partial thickness wound(leaving periosteum intact and on the bone) and then relining the defect with

palatal mucosa or a partial thickness skin graft. This procedure is technically

demanding and carries with it increased morbidity (pain, swelling and

potential complications. This requires wiring of the denture in place for

approximately two weeks. This is usually done with fixation screws or

circummandibular / circumzygomatic wires.

Bone grafting to the ridge from hip (iliac crest) or rib is technically verydemanding, and carries with it a high level of morbidity (pain, swelling, risk

of complications). Furthermore, it also has a relatively poor prognosis, with a

return to pre-op bone levels within five years.


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B. Pre-orthodontic Surgery (Orthognatic)Most permanent teeth erupt into occlusion. In some individuals, however, the permanent

teeth may fail to erupt and become impacted within the alveolus.

The timing of orthodontic treatment, type of surgical procedure to uncover the impacted

tooth, orthodontic mechanics necessary, and potential problems with treatment vary,

depending on which tooth has become impacted.

The most commonly impacted tooth is the maxillary canine, followed by the maxillary

central incisor. The usual cause of impaction of the maxillary central incisor is the

presence of a supernumerary tooth or mesiodens. If the supernumerary tooth is

discovered early and extracted, the central incisor may erupt spontaneously. If the root of

the impacted incisor forms completely and the mesiodens has not been removed,

however, then the central incisor may not erupt spontaneously. Labial impaction of the

maxillary canine over the maxillary lateral incisor occurs occasionally. This type of

impaction is due to one of two causes. Either the canine moves ectopically over the labial

surface of the maxillary lateral incisor root and fails to erupt, or the maxillary dental

midline may shift toward the canine, causing it to be impacted labially.

Indication and Contraindication of pre-treatment surgery

Hard Tissue Lesions or Abnormalities

The abnormalities associated with hard tissues are classified into two categories:

a. Those that may be smoothed with alveoloplasty immediately after extraction of the teeth

(sharp spicules, bone edges),or those detected an drecontoured in an edentulous alveolar ridge.

b. Congenital abnormalities, such as torus palatinus, torus mandibularis, multiple exostoses.

After the natural dentition is lost, the patient can have an alveolar ridge with irregularities,

undercuts, scarring, and insertion of perioral muscles that interfere with the stability of the

prosthesis. Changes in the soft tissues are related to the degree of underlying jaw atrophy.

Subsequent to extractions, nature steps in to begin the process of alveolar ridge resorption. This


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process is rapid following extractions and then slows down to achieve a balance between

osteoblastic and osteoclastic activity. Over a period of years, patients often end up with an

edentulous bony ridge that lacks adequate prosthetic support. Immediate and late consequences

of edentulism require a careful evaluation of the intraoral supporting structures in order to

provide proper rehabilitation and to minimize the ongoing process of bone loss. Irregular

alveolar ridges, undercuts, tori, large maxillary tuberosities, and shallow vestibules are some of

the problems that can interfere with dental prosthetic rehabilitation.

1. Indicationa. Complete or partial edentulism secondary to early tooth lossb. Naturally occurring reduction of the residual bony ridge

- Jaw atrophy (Class II - VI)- Mucosal atrophy- Interarch changes (vertical, anterior/posterior, transverse)- Reduction of denture bearing are- Muscle hypotonia- Facial changes

c. Pain (not remedial by conventional prosthetic measures) due to :- Mucositis (a burning discomfort of the mucosa membrane)- Neuropathy (alteration of sensation of the lips varying from objective/subjective

paraesthesia to anaesthesia or pain arising from traumatized nerve trunks)

- Local recurrent ulceration of unsupported crestal soft tissues and thin atrophicmucosa

- Temporomandibular join pain- Dental roots or unerupted teeth

d. Dysfunction (not remediable by conventional prosthetic means) of- Mastication- Speech- Deglutition


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e. Disproportionate growth of the jaws of facial skeleton producing mechanicallyimpossible conditions for mastication and denture retention. This skeletal deformity

may be :

- Class II or relative mandibular retrusion or maxillary protrusion- Class III or relative mandibular protrusion or maxillary retrusion

f. Craniofacial deformity which results from abnormal growth patterns of the skull baseand facial skeleton

g. Oligodontia, anodontiaa naturally occurring failure of tooth developmenth. Enhanced gag reflexpatient have an excessive sensitivity of the soft palate which if

contacted produces retching.

2. Contraindicationa. Uncontrolled diabetesb. Leukemiac. Heart failured. Renal Failuree. Liver diseasef. Pregnancy

COMPROMISED CONDITION

Diabetes Mellitus

Diabetes mellitus is caused by and underproduction of insulin, a resistance of insulin receptors in

end-organs to the effect of insulin, or both. Diabetes is divided into insulin-dependent and non-

insulin-dependent.

1. Insulin dependent usually begins in children or teenagers.Effect: The major problem of insulin dependent DM is the inability of the patient to use

glucose. The serum glucose rises above the level that the renal can reabsorb normally and

causing glucosuria. The osmotic effect of the glucouse solute results in polyuria,

stimulating the patient thirst and causing polydypsia. The carbohydrate metabolism is


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altered, leading to fat breakdown and production of ketone bodies. This can produce

ketoacidosis and tachypnea with somnolence (sleepy) and eventually coma.

People with insulin-dependent DM must strike a balance among caloric intake, exercise,

and insulin administration. Any decrease in regular caloric intake or increase in activity,

metabolic rare, or insulin dose can lead to hypoglycemia and vice versa.

2. Non-insulin-dependent produce insulin but in insufficient amounts because ofdecreased insulin activity, insulin receptor resistance, or both. This form of diabetes

begins in adulthood, is exacerbated by obesity, and usually does not require insulin

therapy. It is treated by weight control, dietary restriction, and the use of oral

hypoglycemics. Insulin is required only if the patient is unable to maintain acceptable

serum glucose label s using the usual therapeutic measures. Severe hypoglycemia in non-

insulin-dependent diabetic patients rarely produces ketoacidosis but leads to a

hyperosmolar state with altered levels of consciousness.

Consideration to diabetes mellitus

Hypoglycemic patient

Untreated insulin-dependent diabetes patient has a risk of ketoacidosis and its attendant alteration

of consciousness require the emergency treatment. Short-term mild-to-moderate hyperglycemia

usually is not a significant problem for people with diabetes. Therefore when an oral surgical

procedure is planned it is best to err on the side of hyperglycemia rather than hypoglycemia. It is

good to avoid an excessive insulin dose and to give a glucose source. Ambulatory oral surgery

procedures should be performed early in the day, using an anxiety-reduction program. If

intravenous sedation is not being used, the patient should be asked to eat a normal meal and take

the usual morning amount of regular insulin and a half dose of NPH ( neutral protamine

Hagedorn)insulin. The patients vital signs should be monitored, and, if signs of hypoglycemia,

such as hypotension, hunger, drowsiness, nausea, diaphoresis, tachycardia, or a moodchange occur, an oral or intravenous supply of glucose should be administered. If the patient

temporarily will be unable to eat after surgery, any delayed-action (most commonly NPH)

insulin normally taken in the morning should be eliminated and restarted only after normal

caloric intake resumes. The patient should be advised to monitored urine of serum glucose

closely for the first 24 hours postoperatively. Some dental offices have their own serum glucose-


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monitoring equipment to use to quickly test diabetic patients while in the office. If a patient must

miss a meal before an oral surgical procedure, the patient should be told not to take any morning

insulin until intravenous glucose in water is started in the office. One half of the usual dose of

regular insulin and no NPH insulin should be used in this situation. Regular insulin should then

be used, with the dose based on serum or urinary glucose monitoring and as directed by the

patients physician.

Emergency Procedure also can be stopped if the patient has the symptom of hypoglycemia

and allow the patient to consume a high-caloric carbohydrate (e.g: packets of sugar, a glass of

fruit juice, or sugar containing carbonated soda). If the patient falls rapidly into unconsciousness

or unable to take the sugar from the mouth access, intra venous access can be applied with an

ampule (50 ml) of 50% glucose (dextrose) in water administered 2 to 3 minutes. If intravenous

cannot be accessed, the intramuscularly access can be applied with 50% of glucose and glucagon,

or subcutaneously with 0.5 ml dose of 1:1000 epinephrine that repeated every 15 minutes.

Body defense

People with well-controlled diabetes are no more susceptible to infections than people without

diabetes, but they have more difficulty containing infections. This is caused by altered leukocyte

function, as well as by other factors that affect the bodys ability to control an infection.

Difficulty in containing infections is more significant in people with poorly controlled diabetes.

Therefore elective oral surgery should be deferred in patients with poorly controlled diabetes

until control is accomplished. However, if an emergency situation or a serious oral infection

exists in any person with diabetes, consideration should be given to hospital admission to allow

for acute control of the hyperglycemia and aggressive management of the infection. Many

clinicians also believe that prophylactic antibiotics should be given routinely to patients with

diabetes undergoing any surgical procedure. However, this position is controversial.

Management

Insulin-dependent

1. Defer surgery until diabetes is well controlled, consult to the physician2. Schedule an early morning appointment, avoid lengthy appointments


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3. Use anxiety reduction protocol, but avoid deep sedation techniques in outpatients4. Monitor pulse, respiration, and blood pressure before, during, and after surgery5. Maintain verbal contact with patient during surgery6. If patient must not eat or drink before treatment, instruct the patient not to take the usual

dose of regular or NPH insulin

7. If allowed, have the patient eat normal breakfast before surgery and take usual dose ofregular insulin but only half dose of NPH insulin

8. Advise the patient not to resume normal insulin dosage until they are able to return tousual level caloric intake and activity level

9. Consult to the physician if any question concerning modification of the insulin regimenarise

10.Watch the sign of hypoglycemia11.Treat infections aggressively

Non-insulin-dependent

1. Defer surgery until the diabetes is well controlled2. Schedule an early morning appointment, avoid lengthy appointment3. Use an anxiety-reduction protocol4. Monitor pulse, respiration, and blood pressure before, during, and after the treatment5. Maintain verbal contact with patient during surgery6. If patient must not eat or drink before treatment and will have difficulty eating after

surgery, instruct the patient to skip any oral hypoglycemic that day

7. If the patient can eat normal breakfast before surgery, instruct the patient to eat normalbreakfast and to take the usual dose of hypoglycemic agent.

8. Watch for sign of ypoglycemia9. Treat infections aggressively

Dental treatment for diabetes based on fingerstick blood glucose testing

Finger stick blood glucose (mg/dL %) Dental treatment


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Less than 85 Administer glucose; postpone elective

treatment

85-200 Stress reduction; consider antibiotic

prophylaxis for extraction

200-300 Stress reduction; antibiotic prophylaxis;

referral to primary care physician

300-400 Avoid elective treatment; referral to primary

care physician or emergency room at nearby

hospital

Greater than 400 Avoid elective treatment; send to emergency

room at nearby hospital

PREGNANT

A pregnant patient, although not considered medically compromised, poses a unique set

of management considerations for the dentist. Dental care must be rendered to the mother

without adversely affecting the developing fetus, and although routine dental care generally is

safe for the pregnant patient, the delivery of such care involves some potentially harmful

elements, including the use of ionizing radiation and certain drugs. Thus, the prudent practitioner

must balance the beneficial aspects of dentistry with potentially harmful procedures byminimizing or avoiding exposure of the patient (and the developing fetus).

DENTAL MANAGEMENT

Medical Considerations

Management recommendations during pregnancy should be viewed as general

guidelinesnot as definitive rules. The dentist should assess the general health of the patient

through a thorough medical history. Information to ascertain includes current physician,

medications taken, use of tobacco, alcohol, or illicit drugs, history of gestational diabetes,

miscarriage, hypertension, and morning sickness. If the need arises, the patients obstetrician

should be consulted.

Pregnancy is a special event in a womans life; hence, it is an emotionally charged

experience. Establishing a good patient-dentist relationship that encourages openness, honesty,


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and trust is an integral part of successful management. This kind of relationship greatly reduces

stress and anxiety for both patient and dentist.

As with all patients, measuring vital signs is important for identifying undiagnosed

abnormalities and the need for corrective action. At a minimum, blood pressure and pulse should

be measured. Systolic pressure at or above 140 mm Hg and diastolic pressure at or above 90 mm

Hg are signs of hypertension. Also, clinical concern is appropriate if the patients blood pressure

increases 30 mm Hg or more in systolic or increases 15 mm Hg in diastolic blood pressure over

pre-pregnancy values, because these changes can be a sign of preeclampsia. 16 Confirmed

hypertensive values dictate that the patient be referred to a physician to ensure that preeclampsia

and other cardiovascular disorders are properly diagnosed and managed.

Preventive Program.

An important objective in planning dental treatment for a pregnant patient is to establish a

healthy oral environment and an optimum level of oral hygiene. This essentially consists of a

plaque control program that minimizes the exaggerated inflammatory response of gingival

tissues to local irritants that commonly accompany the hormonal changes of pregnancy.

Acceptable oral hygiene techniques should be taught, reinforced, and monitored. Diet

counseling, with emphasis on limiting the intake of refined carbohydrates and carbonated soft

drinks, should be provided. Coronal scaling and polishing or root curettage may be performed

whenever necessary. Preventive plaque control measures should be provided and emphasized

throughout pregnancy, including the first trimester, for benefit to the pregnant mother and the

developing baby.

Treatment Timing

Other than as part of a good plaque control program, elective dental care is best avoided

during the first trimester because of the potential vulnerability of the fetus. The second trimester

is the safest period during which to provide routine dental care. Emphasis should be placed on

controlling active disease and eliminating potential problems that could occur later in pregnancy

or during the immediate postpartum period, because providing dental care during these periods

often is difficult. Extensive reconstruction or significant surgical procedures are best postponed

until after delivery.


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The early part of the third trimester is still a good time to provide routine dental care.

After the middle of the third trimester, however, elective dental care is best postponed. This is

because of the increasing feeling of discomfort that many expectant mothers may experience.

Prolonged time in the dental chair should be avoided, to prevent the complication of supine

hypotension. If supine hypotension develops, rolling the patient onto her left side affords return

of circulation to the heart. Scheduling short appointments, allowing the patient to assume a

semireclining position, and encouraging frequent changes of position can help to minimize

problems.

Dental Radiographs

Dental radiography is one of the more controversial areas in the management of a

pregnant patient. Pregnant patients who require radiographs often have anxiety about the adverse

effects of x-rays on their baby. In some instances, their obstetrician or primary care physician

may reinforce these fears. In almost all cases involving dental radiography, these fears are

unfounded. The safety of dental radiography has been well established, provided that features

such as fast exposure techniques (e.g., high-speed film or digital imaging), filtration, collimation,

lead aprons, and thyroid collars are used. Of all aids, the most important for the pregnant patient

are the protective lead apron and the thyroid collar. In addition, the use of digital radiography

markedly reduces radiation exposure to no more than that with the use of F-speed film.

In spite of the safety of dental radiography, ionizing radiation should be avoided, if

possible, during pregnancy, especially during the first trimester, because the developing fetus is

particularly susceptible to radiation damage. However, should dental treatment become

necessary, radiographs may be required for accurate diagnosis and treatment. The American

Academy of Pediatrics and the American College of Obstetricians and Gynecologists have

published guidelines stating: Diagnostic radiologic procedures should not be performed during

pregnancy unless the information to be obtained from them is necessary for the care of the


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patient andcannot be obtained by other means. Therefore, the dentist should understand the

risks of ionizing radiation and know how to proceed as safely as possible in the event that

radiographs are needed.Bitewing, panoramic, or selected periapical films are recommended for

minimizing patient dose.

Drug Administration

Another controversial area in the treatment of the pregnant dental patient is drug

administration. The principal concern is that a drug may cross the placenta, with the potential for

toxic or teratogenic effects on the fetus. Additionally, any drug that is a respiratory depressant

may cause maternal hypoxia, resulting in fetal hypoxia, injury, or death.

Ideally, no drug should be administered during pregnancy, especially during the first

trimester. Strict adherence to this rule, however, is sometimes impossible. Fortunately, most of

the commonly used drugs in dental practice can be given during pregnancy with relative

safety, although a few exceptions are notable. Table available below presents a suggested

approach to drug usage for pregnant patients.


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Local Anesthetics. Local anesthetics administered with epinephrine generally are considered

safe for use during pregnancy. Although both the local anesthetic and the vasoconstrictor cross


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the placenta, subtoxic threshold doses have not been shown to cause fetal abnormalities. Because

of adverse effects associated with high levels of local anesthetics, it is important not to exceed

the manufacturers recommended maximum dose.

Analgesics. The analgesic of choice during pregnancy is acetaminophen. Aspirin and

nonsteroidal antiinflammatory drugs convey risks for constriction of the ductus arteriosus, as

well as for postpartum hemorrhage and delayed labor. The risk of these adverse events increases

when agents are administered during the third trimester. Risk also is more closely associated

with prolonged administration, high dosage, and selectively potent anti-inflammatory drugs, such

as indomethacin. Codeine and propoxyphene are associated with multiple congenital defects and

should be used cautiously and only if needed. The safety of hydrocodone and oxycodone is

unclear.

Antibiotics. Penicillins (including amoxicillin), erythromycin (except in estolate form),

cephalosporins, metronidazole, and clindamycin are generally considered to be safe for the

expectant mother and the developing child. The use of tetracycline, including doxycycline is

contraindicated during pregnancy. Tetracyclines bind to hydroxyapatite, causing brown

discoloration of teeth, hypoplastic enamel, inhibition of bone growth, and other skeletal

abnormalities.

Anxiolytics. Few anxiolytics are considered safe to use during pregnancy. if N2O-O2 is used

during pregnancy:

Use of N2O-O2 inhalation should be minimized to 30 minutes.

At least 50% oxygen should be delivered to ensure adequate oxygenation at all times.

Appropriate oxygenation should be provided to avoid diffusion hypoxia at the termination of

administration.

Repeated and prolonged exposures to nitrous oxide are to be avoided.

The second and third trimesters are safer periods for treatment because organogenesis occurs

during the first trimester.


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PRE-PROSTHETIC SURGERY

ALVEOPLASTY

Alveoplasty is contouring of the alveolar ridge to remove any irregularities and undercuts. Most

alveoplasties are performed on the maxilla and anterior mandible. The goals are to provide a

stable base for the prosthesis and preserve as much alveolar bone as possible. Always be

conservative when removing bone.

Surgical Technique for an Al veoplasty in an Edentu lous Patient

1. After adequate local anesthesia is obtained, a crestal incision is made over the area. Avertical release incision should be made when there is a risk of tearing the soft tissue flap.

An ellips incision also can be made for single alveoplasty. Be careful with anatomical

structures such as the mental nerve and always maintain a wide-base flap. A thin ridge in

the anterior mandible presents a challenge because it is possible to end up in the floor of

the mouth.

2. Use a periosteal elevator to raise a fullthickness flap. Keep the pointed edge of theelevator against bone at all times to minimize tissue perforation. If a vertical release

incision was made, start the reflection where it joins the crestal incision.

3. Reflect the flap enough to identify the areas needing to be smoothed. When the full-thickness flap is reflected, use a Seldin or Minnesota retractor to retract and protect the

flap.

4. Contour the bone with a bone file, rongeurs, and/or round bur mounted on a slow-speedhandpiece. Undercuts and sharp edges are eliminated, but the contouring does not have to

be perfectly smooth. Frequently reposition the flap and try to feel the bone (with a gloved

finger through soft tissue) for irregularities. Never perform digital palpation of the bone

directly because some irregularities are minimal and will not be noticeable or significant

enough to remove with the flap in position.

5. Use the bone file for final contouring and smoothing of the bone.6. Irrigate the areaespecially at the bottom of the flap, where bone debris frequently

accumulates. Normal saline irrigation is used to keep bony temperatures < 47C to

maintain bone viability.

7. Reposition the flap to its original position


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8. Suture with interrupted or continuous sutures.9. Analgesics should be prescribed, but antibiotics are usually not necessary

Figure. The arrow in the picture shows a severe loss of inter-ridge distance. There is no space to

restore the edentulous span.

Figure. Increased inter-ridge distance after alveoloplasty.

ALVEOLECTOMY AND ALVEOLOTOMY

According to Pedersen, Alveolectomy is a radical surgery to reduce or take alveolar processus ,

so mucosa apposition can be done, which is a procedure that is done to prepare the ridge before

radiation therapy. Alveolotomy is partial taking of alveolar processus or the bone between roots

in order to get molding and contouring.


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The indications for these procedures are rare but may be of value where excessive anterior

projection of the ridge in the upper premaxillary area might pose problems for future denture

aesthetics or stability.

Management

Alveolectomy involves reduction in both the height and width of the ridge and is mainly

accomplished by reduction of the labial plate. The mucoperiosteum is best raised with a 'U'-

shaped incision to allow access. Bone rongeurs or larger 'acrylic' burs can be used to reduce the

labial plate prominence and, on occasion, also the interdental septae. The bony margin is then

smoothed with a file and the wound closed with sutures.

Transeptal or interseptal alveolotomy reduces the labial prominence but maintains the height of

the ridge. Following extraction of the incisors and canines, the interdental septum is removed

between each socket and the labial plate is then fractured inwards with firm digital pressure. A

vertical cut may be needed over the canine prominence labially to facilitate this fracture. The

labial plate will still be attached to its overlying periosteum and should therefore remain viable.

These operations may be facilitated by cooperation with the prosthodontist, who can provide the

surgeon with a template of acrylic that is made on the cast trimmed to the desired contour.

Unless the patient desires an aesthetic change, these procedures are becoming less frequent.

Treatment of the Labial and Lingual Frenum

Labial Frenectomy

Labial frenum attachments consist of thin bands of fibrous tissue covered with mucosa extending from the

lip and cheek to the alveolar periosteum. The height of this attachment varies from individual to

individual; however, in dentate individuals frenum attachments rarely cause a problem. In edentulous

individuals frenum attachments may interfere with fit and stability, produce discomfort, and dislodge the

overlying prostheses.

Several surgical methods are effective in excising these attachments. Simple excision and Z-plasty are

effective for narrow frenum attachments. Vestibuloplasty is often indicated for frenum attachments with a

wide base.

Local anesthetic infiltration is performed in a regional fashion that avoids direct infiltration into the

frenum itself; such an infiltration distorts the anatomy and leads to misidentification of the frenum.

Eversion of the lip also helps one identify the anatomic frenum and assists with the excision. An elliptic


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incision around the proposed frenum is completed in a supraperiosteal fashion. Sharp dissection of the

frenum using curved scissors removes mucosa and underlying connective tissue leading to a broad base

of periosteum attached to the underlying bone. Once tissue margins are undermined and wound edges

are approximated, closure can proceed with resorbable sutures in an interrupted fashion. Sutures should

encounter the periosteum, especially at the depth of the vestibule to maintain alveolar ridge height.

This also reduces hematoma formation and allows for the preservation of alveolar anatomy.

In the Z-plasty technique, excision of the connective tissue is done similar to that described previously.

Two releasing incisions creating a Z shape precede undermining of the flaps. The two flaps are eventually

undermined and rotated to close the initial vertical incision horizon- tally. By using the transposition flaps,

this technique virtually increases vestibular depth and should be used when alveolar height is in question.

Wide-based frenum attachments may best be treated with a localized vestibuloplasty technique. A

supraperiosteal dissection is used to expose the underlying periosteum. Superior repositioning of the

mucosa is completed, and the wound margin is sutured to the underlying periosteum at the depth of the

vestibule. Healing proceeds by secondary intention. A preexisting denture or stent may be used for patient

comfort in the initial postoperative period.

Lingual Frenectomy

High lingual frenum attachments may consist of different tissue types including mucosa, connective tissue,

and superficial genioglossus muscle fibers. This attachment can interfere with denture stability, speech,

and the tongues range of motion. Bilateral lingual blocks and local infiltration in the anterior mandible

provide adequate anesthesia for the lingual frenum excision. To provide adequate traction, a suture is

placed through the tip of the tongue. Surgical release of the lingual frenum requires dividing the

attachment of the fibrous connective tissue at the base of the tongue in a transverse fashion, followed by

closure in a linear direction, which completely releases the ventral aspect of the tongue from the alveolar

ridge Electrocautery or a hemostat can be used to minimize blood loss and improve visibility. After

removal of the hemostat, an incision is created through the area previously closed within the hemostat.

Careful attention must be given to Whartons ducts and superficial blood vessels in the floor of the mouth

and ventral tongue. The edges of the incision are undermined, and the wound edges are approximated and

closed with a running resorbable suture, burying the knots to minimize patient discomfort.


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RIDGE EXTENSION

VESTIBULOPLASTY

Vestibuloplasty A surgical procedure to restore alveolar ridge height by lowering muscles

attaching to the buccal, labial, and lingual aspects of the jaws

Maxillary alveolar bone resorption frequently results in mucosal and muscle attachments that

interfere with denture construction, stability, and retention. Excess soft tissue may accompany

bony resorption, or soft tissue may require modification. Several techniques provide additional

fixed mucosa and vestibular depth in the maxillary denture-bearing area

Traditional Flap Vestibuloplasty (Lip Switch)

In this procedure a mucosal flap pedicled from the alveolar ridge is elevated from the underlying

tissue and sutured to the depth of the vestibule. The inner portion of the lip is allowed to heal by

secondary epithelialization.

When adequate mandibular height exists, this procedure increases the anterior vestibular area,

which improves denture retention and stability. The primary indications for the procedure

include adequate anterior mandibular height (at least 15 mm), inadequate facial vestibular depth

from mucosal and muscular attachments in the anterior mandible, and the presence of an

adequate vestibular depth on the lingual aspect of the mandible.

These techniques provide adequate results in many cases and generally do not require

hospitalization, donor-site surgery, or prolonged periods without a denture.

Disadvantages include unpredictability of the amount of relapse of the vestibular depth, scarring

in the depth of the vestibule, and problems with adaptation of the peripheral flange area of the

denture to the depth of the vestibule.


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Vestibule and Floor of Mouth Extension Procedures

In addition to the attachment of labial muscles and soft tissues to the denture-bearing area, the

mylohyoid and genioglossus muscles in the floor of the mouth present similar problems on the

lingual aspect of the mandible. Trauner described detaching the mylohyoid muscles from the

mylohyoid ridge area and repositioning them interiorly, effectively deepening the floor of the

mouth area and relieving the influence of the mylohyoid mus-

cle on the denture. After the two vestibular extension techniques, a skin graft can be used to

cover the area of denuded periosteum. The combination procedure effectively eliminates thedislodging forces of the mucosa and muscle attachments and provides a broad base of fixed kera-

tinized tissue on the primary denture-bearing area.

Split-thickness skin grafting with the buccal vestibuloplasty and floor-of-mouth procedure is

indicated when adequate alveolar ridge for a denture-bearing area is lost but at least 15 mm of


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mandibular bone height remains. The remaining bone must have adequate contour so that the

form of the alveolar ridge exposed after the procedure is adequate for denture construction.

Endosteal implants are generally a much more suitable treatment and therefore vestibuloplasty

with skin grafting is not commonly performed. If gross bony irregularities exist, such as large

concavities in the superior aspect of the posterior mandible, they should be corrected through

grafting or minor alveoloplasty procedures before the soft tissue procedure.


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The advantage of early covering of the exposed periosteal bed improves patient comfort and

allows earlier denture construction, the long-term results of vestibular extension are predictable.

Disadvantage need for hospitalization and donorsite surgery combined with the moderate

swelling and discomfort experienced by the patient. Patients rarely complain about the

appearance or function of skin in the oral cavity. If the skin graft is too thick at the time of


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harvesting, hair follicles may not totally degenerate, and hair growth may occasionally be seen in

isolated areas of the graft.

Tissue other than skin has been used effectively for grafting over the alveolar ridge. Palatal tissue

offers the potential advantages of providing a firm, resilient tissue, with minimal contraction of

the grafted area. Although palatal tissue is relatively easy to obtain at the time of surgery, the

limited amount of tissue and the discomfort associated with donor-site harvest-ing are the

primary drawbacks. In areas where only a small localized graft is required, palatal tissue is

usually adequate.

Full-thickness buccal mucosa harvested from the inner aspect of the cheek provides advantages

similar to those of palatal tissue. However, the need for specialized mucotomes to harvest buccal

mucosa and extensive buccal mucosa scarring after harvesting of a full-thickness graft are

disadvantages. This mucosa does not become kera-tinized, is generally mobile, and often results

in an inade-quate denture-bearing surface.

Maxillary Submucosal Vestibuloplasty

The submucosal vestibuloplasty may be the procedure of choice for correction of soft tissue

attachment on or near the crest of the alveolar ridge of the maxilla. This technique is particularly

useful when maxillary alveolar ridge resorption has occurred but the residual bony maxilla is

adequate for proper denture support. Underlying submucosal tissue is either excised or

repositioned to allow direct apposition of the labiovestibular mucosa to the periosteum of the

remaining maxilla.

To provide adequate vestibular depth without producing an abnormal appearance of the upper lip,

adequate mucosal length must be available in this area. A simple test to determine whether

adequate labiovestibular mucosa is present is performed by placing a dental mouth mirror under

the upper lip and elevating the superior aspect of the vestibule to the desired postoperative depth.

If no inversion or shortening of the lip occurs, then adequate mucosa is present to perform a

proper submucosal vestibuloplasty.


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The submucosal vestibuloplasty can generally be performed with local anesthetic and

intravenous (IV) sedation in an outpatient setting. A midline incision is made in the anterior


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maxilla, and the mucosa is undermined and separated from the underlying submucosal tissue. A

supraperiosteal tunnel is then developed by dissecting the muscular and submucosal attachments

from the periosteum. The intermediate layer of tissue created by the two tunneling dissections is

incised at its attachment area near the crest of the alveolar ridge. This submucosal and muscular

tissue can be repositioned superiorly or excised. After closure of the midline incision, a

preexisting denture or prefabricated splint is modified to extend into the vestibular areas and is

secured with palatal screws for 7 to 10 days to hold the mucosa over the ridge in close apposition

to the periosteum. When healing takes place, usually within 3 weeks, the mucosa is closely

adapted to the anterior and lateral walls of the maxilla at the required depth of the vestibule.

The maxillary submucosal vestibuloplasty can also be combined with HA augmentation of the

alveolar ridge area. A subperiosteal tunnel can be created using a tech-nique similar to standard

maxillary HA augmentation procedures.33

By incising the periosteum high on the lat-eral aspect

of the mandible, the periosteal envelope can be enlarged to allow greater HA augmentation in

this area.


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Increasing the size of the alveolar ridge

There are two aspects to surgically increasing the denture bearing area:

Sulcus deepening Ridge augmentation

Sulcus deepening

The size of the denture-bearing area can be increased by deepening the sulci providing there is

adequate underlying bone. That this is difflcult to do satisfactorily is proved by the number of

operations designed to this end, of which only a few are described here.

Deepening of the buccal sulcus in the maxilla is seldom necessary as the palate provides a large

denture-bearing area.

Retention and support for the lower denture would often benefit from deepening of the sulci

particularly where muscle attachments have come to lie near the crest of the ridge:

Anteriorly the mentalis muscle laterally the buccinators muscle and lingually the mylohyoid muscle are involved.

To deepen the sulci effectively, these muscles must be detached from the mandible and the

mucosa made to heal with a new reflection at a lower level. This last is the most difficult part of

the operation. It is complicated by the presence of the mental nerve which must be located and

preserved from accidental damage.

The procedures available can be considered in four groups.

1. Mucosa is advanced to line both sides of an extended sulcus (submucosal vestibuloplasty)An example of this group is obwegeser's operation. This attempts to divide the muscle

attachments and deepen the buccal sulcus without making a flap or leaving raw areas. The

procedure is usually performed in the maxilla.

Two vertical incisions 1cm long are made in the buccals sulcus of the canine regions or asingle incision in the mid-line. Scissors or a scalpel are then passed between mucosa and

periosteum. The muscle attachments on the buccal aspect are cut, as far back and upwards as

possible to free the mucosa. This is drawn up and the sulcus maintained by using a denture lined

with gutta percha.one or two bones crewsin the palate retain the denture for 2 weeks.


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Obwegeser's operation has the disadvantage that it is performed blind and if bleeding occurs the

new sulcus may be obliterated.

2. skin is transplanted to line both sides of an extended sulcus (buccal inlay)In this operation a pouch is made in the mandibular buccal sulcus which is lined with a split-

thickness skin graft from the patient's arm or thigh.

An incision is made in the mandibular labial sulcus and a pouch dissected to the required size.

This must leave the periosteum intact and attached to bone. An acrylic splint with a gutta percha

mould, larger than will eventually be required, is made. where the skin graft and mucous

membrane meet, the mould is grooved so that on healing the ring scar contracts into the groove.

The mould is chilled and the skin graft attached to it with the raw surface outwards. This is then

placed in the pouch and the splint secured to the mandible with circumferential wires for two

weeks.

3. skin is transplanted to line one side of an extended sulcus (lower labial vestibuloplasty)An incision is made along the mandibular alveolar crest from canine to canine. The incision

goes through the mucosa bur not through the mentalis muscle or the periosteum. The mucosal

flap is dissected off periosteum and muscles. care must be taken not to tear the mucosa.

Dissection is continued past the reflection just short of the inner margin of the lip. The mentalis

muscle is then divided with a scapel close to the periosteum which is left undisturbed. The

muscle will retract into the deepert issues. The mucosal flap is repositioned to cover the labial

side of the new sulcus and held in position by sutures through the periosteum. A split thickness

skin graft is placed against the raw area of the periosteum with a gutta percha mould on an

acrylic splint. In this way,the labial aspect of the new sulcus is lined with mucosa, and the

periosteum with the skin graft.

4. Lowering of floor of mouth and vestibuloplasty.This operation, described by Obwegeser, combines a buccal vestibuloplasty skin graft with a

vestibuloplasty on the lingual aspect of the ridge which heals by secondary epithelialisation. The

mucosal flaps on the buccal and lingual sides are held down in the depths of the new sulci by

sutures passing under the mandible.


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In the vestibuloplasty procedures, the splint or modifled denture must maintained in place for 2-3

weeks to allow initial healing. During this period, a high standard of oral hygiene is vital.

Following removal of the splint, there is a marked tendency for the sulcus to contract. To reduce

this, the denture must be modifled to extend into the full depth of the sulcus and be worn

contiously for several weeks.

PRE-ORTHODONTHY SURGERY

Surgical exposure of impacted teeth

In general, there are 2 basic approaches to surgically exposing impacted teeth:

1. The open eruption techniqueIn this method, the teeth is exposed to the oral environment, while surrounded by freshly

trimmed soft tissue of the palate or labial oral mucosa, following the removal of the

mucosa and bone which is actually covering the tooth.

Divided into 2 method:

a. The window techniqueWindow technique involves the surgical removal of a circular section of the

overlying mucosa and the thin bony recovering. For most labially displaced teeth,

due to their height, this entire surgical procedure would most likely only bepossible above the level of attached gingival, in the mobile area of the mucosa.

This is the simplest, most conservative and most direct manner to expose a tooth

which is palpable immediately under the oral mucosa and it may often be

accomplished with surface anaesthetic spray only.

An attachment may then be bonded to the tooth and orthodontically encouraged

eruption may proceed without delay, to complete its alignment within a very short

time.


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The only situation in which this exposure procedure is clinically advantageous is

when there is a very wide band of attached gingival and where a labially impacted

tooth is situated well down in this band, such that a simple removal of the tissue

overlying the crown will still leave 1-2 mm of bound epithelial attachment

inferior to the free, movable, oral mucosal lining of the sulcus.

The palatal mucosa is very thick and thighly bound down to the underlying bone.

Thus, no parallel precausions need to be made to ensure a good attachment for the

final periodontal status of a palatally impacted tooth, following its eruption into

the palate. When the window technique is used on the palatal side, the cut edges

of the wound need to be substantially trimmed back and the dental follicle

removed to prevent re-closure of the very considerable width of palatal soft tissue

over the exposed tooth. For a deeply buried palatal canine, the exposure will

additionally need to be maintained using a surgical pack.

b. The apically repositioned flapThe apically repositioned flap is an alternative way of performing an open

exposure technique on the buccal side. It is aimed at improving the periodontal

outcome by ensuring that attached gingival covers the labial aspect of the erupted

tooth in the final instance. This is done by raising a labial flap, taken from the

crest of the ridge, and relocating it higher up on the crown of the newly exposed

tooth. This particular method of exposure is best situated above the band of


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attached gingival, but which are not displaced mesially or distally from their place

in the dental arch.

2.

The closed eruption technique

The closed eruption technique has an attachment placed at the time of the exposure and

the tissues fully replaced and sutured to their former place, to re-cover the impacted tooth.

For a buccally impacted tooth, a surgical flap is raised from the attached gingival at the

crest of the ridge, with suitable vertical releasing cuts, and elevated as high as is

necessary to expose the unerupted tooth. An attachment is then bonded and the flap fully

sutured back to its former place. The twisted stainless steel ligature wire or gold chain,

which is preferred by some clinicians, which has been tied or linked to the attachment, is

then drawn inferiorly and through the sutured edges of the fully replaced flap. The

surgical wound is, therefore, completely closed and the exposed tooth and its newattachment are sealed off from the oral environment. Traction is then applied to the

twisted stainless steel ligature or gold chain to bring about the full eruption of the tooth.

In this method, the tooth progresses towards and through the area of the attached gingiva

several weeks or months after complete healing of the repositioned surgical flap has

occurred and it creates its own portal through which it exits the tissues and erupts into the

mouth. As such, it very closely simulates normal eruption and the clinical outcome will

usually be difficult to distinguish from any normally and spontaneously erupting tooth, in

terms of its clinical appearance and objective periodontal parameters.


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BAB III

CLOSING

Hypothesis

The cause for mrs laode sharp tooth is unknown because there is not enough information. The

treatment plan for mrs laode is preprosthetic surgery followed by prosthetic treatment that has to

be done after her labour.

Accepted, mrs Laode will undergo selective tooth grinding. Tooth extraction is not indicate to

prevent changes on her arch

Sisis is suffering from insulin dependent diabetes mellitus

Accepted, obvious systemic condition can be observed with her being hungry despite shes

already taken meal just before. Ketoacidosis examination can be done to determine her DM type

by smelling her breath.

Sisis suffering from canine impaction

Accepted

Tretment plan for sisi is to undergo preorthodontic surgery then followed by orthodontic

treatment that has to be done when her DM is controlled.

Accepted, the pre-orthodontic surgery is done with windowing technique to expose the impacted

technique, when the canine is exposed, surgeon will put bracket at the buccal site of the canine

crowns then refer it to the orthodontist for activations. The proper time for her surgery is when

her blood glucoe is on the range of 85


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treatment, patient glucose blood level should be measured, for patient with blood glucose level

around 85-300 mg/dl treatment can be done but always monitor for his/her blood glucose level

during and after surgery. If hypoglycemia occurred during treatment, stop the treatment and have

the patient ingest glucose containing food/drink immidietly. If hyperglycemia occurred, IV

injection of insulin should be administered, treatment can be continued when the glucose blood

level is lowering.

Documents

BAB 2 Exam, Vestiplast, Window, Indi Contindi