Common Syndromes and developmental anomalies found in Head and Neck region implication on dental treatments

Important definitions

Malformation definition

A morphologic defect of an organ, part of an organ or large area of the body resulting from a developmental abnormality (intrinsic).

Eg: Cleft lip

Deformation definition

Abnormal form of the body part due to mechanical forces.

Disruption definition

Defect of an organ, part of an organ or large area of the body due to interference with a normal developmental process.

Eg: Amneotic bands leads to amputation

Sequence

Multiple defects occur as a result of single presumed structural abnormality.

Eg: Pierre Robin’s Sequence

Syndrome

Combination of signs and/or symptoms that forms as a distinct clinical picture indicative of a particular disorder.

Eg: Down’s syndrome

Common Syndromes and developmental anomalies found in Head and Neck region

• Cleft lip and palate
• Valocardiofacial syndrome
• Pierre Robin’s syndrome
• Treacher Collins syndrome
• Golden har syndrome
• Apert and Crouzen syndrome

Approch to diagnosis

There are over 3000 known syndromes. But only very few are found in common during dental practice. idea of this post is to explain important clinical features of commonly found syndromes and their implication on dental practice.

History plays a major role in diagnosis of a developmental anomaly. Under history these factors are of uttermost important in diagnosis.

• Medical pedigree
• Maternal and paternal age
• Consanguinity
• Previous abortions
• Teratogens (Fetal alcohol syndrome)

These factors should be thoroughly examined during physical examination

• Compare siblings and other family member’s photographs
• Major and minor abnormalities
• Isolated minor anomalies (15%)
• More than 3 minor anomalies with major anomalies (90%)
• Mental retardation associated

Down’s syndrome

Etiology: nondisjunction mutation resulting in trisomy of 21 chromosome.

Prevalence 1:700

Down’s syndrome is the most common chromosomal abnormality.

It is associated with maternal age more than 37 years.

Facial characteristics

• Macroglossia
• Micrognathia
• Midface hypoplasia (Class III)
• Flat occiput
• Flat nasal bridge
• Epicanthal fold
• Up slanting palpebral fissures
• Progressive enlargement of lips

Airway concerns

Due to midface hypoplasia

Obstructive sleep apnoea

Prevalence: 54-100% down’s patients.

 As a combination of anatomic and functional mechanisms.(midface hypoplasia,macroglossia, etc. and hypotonia of pharyngeal muscles)

Cardiovascular abnormalities found in 40% down’s patints.

ASD,VSD, Tetralogy of fallot’s, PDA

Gastrointestinal abnormalities found in 10-18% of down’s patients.

Malignancies are associated with some down’s cases

Valocardiofacial Syndrome (VCFS)

Autosomal dominant condition. Velocardiofacial syndrome (VCFS) is a genetic condition characterized by abnormal pharyngeal arch development that results in defective development of the parathyroid glands, thymus, and conotruncal region of the heart.

Etiology:  by deletion of chromosome 22

Clinical Features: congenital heart diseases, hyper nasal speech, and cleft palate

Basicranial angle flexion- Therefore longer face

Puffy eyelids

Vascular anomalies are very common

Anomalies of the head and neck region are common.

Treacher collin’s syndrome

Autosomal dominant condition

60% are from new mutation

Characteristics: likely due to abnormal migration of neural crest cells into first and second branchial arch structures.

Usually bilateral and symmetrical

Down slanting eyebrows and palpebral fissures

Retruded mandible

Apert and Crowzen’s syndromes

Belong to family of craniosynostosis

Apert’s syndrome is also called as Acrocephalosyndactyly

Facial Characteristics:

• Craniosynostosis (coronal sutures fused at birth and head circumference is larger than the average head circumference.
• Hypertelorism
• Shallow orbits with Exopthalmus
• Maxillary hypoplasia causing retruded midface with relative prognathism.
• Beaked nose
• Downward slanting palpebral fissures
• Syndactyly

Airway concerns

Treatment

Fronto orbital advancement surgery can be done and get good protection to eyes. Syndactyly can be corrected with surgical reconstruction.

Pierre Robin’s syndrome

Characterize by triad of micrognathia, Glossoptosis, Cleft palate.

80% syndromic

Mechanism of cleft palate formation

Mandibular deficiency causes hypoplastic and retruded mandible (Micrognathia). Therefore Tongue remains retruded and high in oropharynx causing failure of fusing lateral palatal shelves. This results in cleft palate.

Airway obstruction is a marked feature.

Pierre Robin’s syndrome can be associated with other anatomic and neuromuscular components.

Airway management

Temporizing modalties

Prove positioning

Nasopharyngeal airway

Mandibular traction devices

Tongue lip adhesion.

Tracheostomy done if above not worked

Distraction osteogenisis can be done in infants

Goldenhar syndrome

Features

Facial asymmetry and ear deformity.

Vertebral malformations

Uppereyelid coloborma

Auricular malformations

EAC stenosis

Vascular anomalies during fetal life

Unilateral craniofacial malformations

1^st and 2^nd arch defects

Other concerns

Hearing concerns in greater than 50% patients

Sensoneural occationally.

Osteodystrophies of Oro-maxillo facial Region Clinical Features, Radiological Features, Histological Features and Management

Osteodystrophies definition

Osteodystrophies are disorders of bone other than neoplastic and inflammatory conditions.

Classification of osteodystrophies in OMF region

1.       Fibro cement osseous lesions

2.       Giant cell lesions

3.      Inherited and developmental disorders of bone

4.       Metabolic disorders of bone

5.       Miscellaneous

Fibro cement osseous lesions-Classification

A.Developmental

·         Mono ostotic fibrous dysplasia

·         Polyostatic Fibrous dysplasia

·         Polyostatic fibrous dysplasia with endocrinopathy (Macune Albright’s syndrome)

·         Polyostatic fibrous dysplasia with pigmentation (Jaffe-Lichtenstein syndrome)

·         Polyostatic fibrous dysplasia with myxomas

·         Craniofacial fibrous dysplasia

B.Reactive lesions

·         Hereditary

o   Familaial gigantiform cementoma

·         Non Hereditary

o   Periapical cemento osseous dysplasia

o   Florid cement osseous dysplasia

o   Focal cemento osseous dysplasia

C.Neoplastic

·         Conventional cemento ossifying fibroma

·         Juvenile aggressive cement ossifying fibroma

Fibro osseous lesions

One in which bone is replaced by cellular fibrous tissue which gradually matures with the formation of woven bone, lamellar bone ,or very dense amorphous mineralization.

Diagnosis of fibrocemento osseous lesions

The diagnoses of fibrocemento osseous lesions are done using clinical, radiological and histopathological correlation, not by features in isolation.

Fibrous Dysplasia

A benign self limiting but unencapsulated lesion, normally occurring in young subjects. Fibrous dysplasia clinically presents as a painless swelling of the bone involved. Usually, fibrous dysplasia is a self-limiting disease. Therefore, treatment is only required if there are problems due to local increase in size of the affected bone. Sometimes, an osteosarcoma may arise in fibrous dysplasia.

• Caused by mutation in the GNAS-1 gene
• Mutation is not inherited but somatic
• Mutation of gene in causing different types of fibrous dysplasia depending on the time of mutation.
• If gene is mutated very early embryonic life (undifferentiated stem cells) it affects osteoblasts, melanocytes and endocrine cells),many affected daughter cells are present in different organs and Albright’s syndrome results.
• If gene is mutated in later stages (after migration and differentiation of skeletal progenitor cells), it affects multiple bones causing polyostatic fibrous dysplasia.
• Onset 1^st and 2^nd decades of life
• Commonly occurring in maxilla and adjacent bones

Albright’s syndrome

Is a combination of

1.       Polyostotic fibrous dysplasia

2.       Cutaneous pigmentation

3.       Endocrine abnormalities (diabetes mellitus ,precocious puberty)

4.       Premature skeletal maturation

Radiology

The classical appearance is described as orange-skin or groundglass radiopacity without defined borders.

Initially appear as well defined radiolucency, later with indistinct margins. Fine trabeculation forming “Ground Glass” appearance as lesion develops. Jaw swelling with thinning of original cortex.

Monostotic fibrous dysplasia

• Commener than polyostotic form
• Give rise to a bony swelling caused by a poorly circumscribed area of fibro osseous proliferation
• Starts in childhood-undergoes arrest in early childhood
• Jaws are common sites-when the jaws are involved,a painless,smoothy rounded swelling usually of the maxilla is typical
• When the mass become large malocclusion occur
• Lesions affecting the maxilla may spread to involve contiguous skull bones causing deformity of the orbit ,base of  the skull and cranial nerve lesions
• Radiologically-normal bone trabecullation replaced by ground glass or orange peel pattern.
• Lesions merge imperceptibly with normal bone at margins

Histopathology

In the jaws, fibrous dysplasia may consist of both woven and lamellar bone, as shown in this photomicrograph taken with the use of partly polarised light to enhance the collagenous scaffold of the bone.

• Vary with age of the lesion
• Loose fibrous tissue(Whorled, fascicular,random)
• The normal bone replaced by fibrous connective tissue containing slender trabecullae of bone
• Early lesions bony trabeculae do not join each other
• Trabeculae of bone in the cellular areas show a “Chinese letter appearance”
• Osteoblasts are scattered throughout the substance of the trabecullar rather than surrounding them
• Older lesions lamellar maturation reversal lines and parallel arrangement of bony trabeculae(onion skin appearance)
• Usually becomes inactive with skeletal  maturation

Polypstotic fibrous dysplasia

·         Females>males

·         Histologically and radiologically indistinguishable from monostotic form

Management

Disease is self limiting. Grossly disfiguring lesions need to be excised(Contouring,resectiona dn reconstruction) . This should be delayed if possible until the process become inactive. Small risk of sarcomatous changes in poly ostotic type.

Osseous Dysplasia

Osseous dysplasia is a pathologic process of unknown aetiology located in the tooth-bearing jaw areas in the vicinity of the tooth apices and is thought to arise from the proliferation of periodontal ligament fibroblasts that may deposit bone as well as cementum. The condition occurs in various clinical forms that bear different names. However, all have the same histomorphology: cellular fibrous tissue, trabeculae of woven as well as lamellar bone and spherules of cementum-like material. The ratio of fibrous tissue to mineralized material may vary and it has been shown that these lesions are initially fibroblastic, but over the course of several years may show increasing degrees of calcification. This variation in ratio of soft tissue to hard tissue is reflected in the radiographic appearance; lesions are predominantly radiolucent, predominantly radiodense or mixed.

Osseous dysplasia lacks encapsulation or demarcation,but tends to merge with the adjacent cortical or medullary bone. The several subtypes of osseous dysplasia are distinguished by clinical and radiological features.

Periapical osseous dysplasia occurs in the anterior mandible and involves only a few adjacent teeth.

A similar limited lesion occurring in a posterior jaw quadrant is known as Focal osseous dysplasia.

Florid osseous dysplasia is non-expansile, involves two or more jaw quadrants and occurs in middle-aged black females.

Familial gigantiform cementoma is expansile, involves multiple quadrants and occurs at a young age. This type of osseous dysplasia shows an autosomal dominant inheritance with variable expression, but sporadic cases without a history of familial involvement have also been reported. Simple bone cysts may be seen with florid and focal osseous dysplasia. Osseous dysplasia has to be distinguished from ossifying

fibroma. Osseous dysplasia is a mixed radiolucent- radiodense lesion with ill-defined borders in the tooth-bearing part of the jaws, either localised or occupying large jaw areas depending on the type. In contrast, ossifying fibroma is usually a localised lesion that expands the jaw, and is predominantly radiolucent with radiodense areas. Osseous dysplasia also has to be differentiated from sclerosing osteomyelitis. Sclerotic lamellar bone trabeculae and well-vascularised fibrous tissue with lymphocytes and plasma cells define sclerosing osteomyelitis,

Whereas cementum-like areas and fibrocellular soft tissue are lacking. The various forms of osseous dysplasia do not require treatment unless necessitated by complications such as

Infection of sclerotic bone masses, as may occur in florid osseous dysplasia, or facial deformity, as may be seen in familial gigantiform cementoma.

Management

Management of focal cemental dysplasia is usually difficult because surgical removal resulting in small hemorrhagic gritty fragments.

Cemento ossifying fibroma

Ossifying fibroma , formerly also called cemento-ossifying fibroma is a well-demarcated lesion composed of fibrocellular tissue and mineralised material of varying appearance. It occurs most often in the 2nd through the 4th decades. The lesion shows a predilection for females, is mostly seen in the posterior mandible and may occur multifocally. Chromosomal abnormalities have been observed in ossifying fibromas. Data are still too scarce to determine their pathogenetic significance.

Ossifying fibroma contains both cell-rich and cell-poor areas as well as well-structured bone and amorphous calcifi ed material

Ossifying fibroma may also contain more smoothly contoured bony elements, formerly thought to represent cementum

 Juvenile trabecular ossifying fi broma shows slender bony trabeculae rimmed with osteoblasts that merge with an extremely cellular stroma

At higher magnification, the plump osteoblasts that line the bony trabeculae in juvenile trabecular ossifying fi broma are shown to be a prominent feature

Ossifying fibroma is composed of fibrous tissue that may vary in cellularity from areas with closely packed cells displaying mitotic figures to almost acellular sclerosing parts within one and the same lesion. The mineralized component may consist of plexiform bone, lamellar bone and acellular mineralised material, sometimes all occurring together in one single lesion. Juvenile psammomatoid and juvenile trabecular ossifying fibroma are subtypes. Juvenile trabecular ossifying fibroma consists of cell-rich fibrous tissue with bands of cellular osteoid together with slender trabeculae of plexiform bone lined by a dense rim of enlarged osteoblasts. Sometimes these trabeculae may anastomose to form a lattice. Mitoses are present, especially in the cell-rich areas. Also, multinucleated giant cells, pseudocystic stromal degeneration and haemorrhages may be present. Due to its cellularity and mitotic activity, the lesion may be confused with osteosarcoma. However, atypical cellular features or abnormal mitotic figures are not seen.

Moreover, the lesion is demarcated from its surroundings. Juvenile psammomatoid ossifying fibroma is characterized by a fibroblastic stroma containing small ossicles resembling psammoma bodies, hence its name. The stroma varies from loose and fibroblastic to intensely cellular. The spherical or curved ossicles are acellular or include sparsely distributed cells. They should not be confused with the cementum-like deposits that are present in conventional ossifying fibroma. These particles have a smooth contour whereas the ossicles in juvenile psammomatoid ossifying fibroma has a peripheral radiating fringe of collagen fibres. Ossicles may coalesce to form trabeculae. Sometimes, juvenile psammomatoid ossifying fibroma contains basophilic, concentrically lamellated particles, as well as irregular thread-like or thorn-like calcified strands in a hyalinised background. Other features such as trabeculae of woven bone as well as lamellar bone, pseudocystic stromal degeneration and haemorrhages resulting

• Benign neoplasms of the bone
• Arising exclusively in the jaws,facial bones and skull
• Typically causes a painless swlling in the mandibular premolar and molar region
• Females>males
• Fibro osseoue lesion
• Has similarities to fibro osseous dysplasia
• Radiographycally-starts as small radiolucency and expands slowly
• Calcification develops centrally as the lesion enlarges
• Most become densely calcified
• The lesion has a sharply defined margin often within radiolucent rim surrounded by a narrow zone of cortication

Microscopy

• Well demarcated from surrounding bone
• Appearances are widely variable degrees of cellularity and scanty calcifications to densely calcified nodules with little stroma
• The types of calcification

1. trabecullae of woven bone with osteoblastic rimming
2. dystrophic calcifications
3. rounded calcificatons resembling cemmentricles
4. calcifications grow gradually,fuse and ultimately from a dense mass

histologically indistinguishable from fibrous dysplasia

Juvenile aggressive cemento ossifying fibroma

• Commener in children
• The loose fibroblastic stroma contains very fine,lace like trabeculae of immature osteoid entrapping plum osteoblasts
• Focal collection of  giant cells are common
• Histological appearance similar to osteoblastoma  or osteosarcoma
• Radiological features can avoid this misdiagnosis

Benign cementoblastoma

Benign neoplasm of cementum forming cells. The spherical masses of cemntum usually attach to tooth apex.

·         Patients mostly under 25 years

·         Lesion usually attached to apex of mandibular molar or premolar.

Histopathology

·         Dense bulbosity around tooth apex and is encapsulated

·         Mass of mineralized cementum like tissue with numerous resting and reversal lines.

·         Numerous small vascular spaces throughout the mass

·         Partial resorption of the root apex

·         Peripheral cellular zone unmineralized “Cementoid”.

Giant cell lesions

True giant cell lesions

·         Central giant cell granuloma

·         Peripheral giant cell granuloma

·         Broen tumor of hyperparathyroidism

·         Giant cell tumour

·         Cherubism

Lesions that may contain giant cells

·         Paget’s disease

·         Fibrous dysplasia

·         Aneurismal bone cyst

Central giant cell granuloma

• Benign hyperplastic lesion of unknown aetiology
• More common in young females over a wide age range
• Very expensile and may be destructive may penetrate cortical bone and periosteum
• Solid but appear as unilocular or multilocular cyst like radiolucency
• Forms in alvelor ridge,anterior to 6s more fequently in the mandible but often in the maxilla
• No changes in the blood chemistry
• Treated by curettage
• Lobulated mass of proliferating vascular connective tissue packed with giant cells

Cherubism

• Inherited as autosomal dominant triat
• Jaw swellings appear in infancy
• Angle regions of mandible affected symmetrically giving typical chubby face
• Symmetrical involvelment of maxillae also in ore severe cases
• Radiolographycally lesions appear as multilocular cyst like areas
• Histologically lesions consist of giant cells in vascular connective tissue
• Lesions regress with skeletal maturation and normal facial contour restored

Paget’s Disease

Paget’s disease (osteitis deformans) is a common condition affecting particularly the skull, pelvis, vertebral column and femur in people over 40 years of age. The cause is not yet certain, but the presence in many cases of paramyxovirus-like structures seen within osteoclasts has prompted the suggestion that Paget’s disease may be of viral aetiology and the measles virus and canine distemper viruses have been under scrutiny as candidates. The pathological change is one of active bone formation proceeding alongside active bone destruction.

The affected bones are enlarged, porous and deformed. Microscopically, bone formation is seen in

trabeculae of bone with a lining of numerous osteoblasts. A mosaic appearance is formed by the frequent successive deposition of bone, cessation of deposition resulting in thin, blue “cement lines”, followed again by resumption of deposition and its cessation, and so production of further cement lines. Bone destruction is shown by the presence of numerous, large osteoclastic giant cells with Howship’s lacunae. Areas of chronic inflammatory exudate intermixed with the bone are common.

In the temporal bone the petrous apex, the mastoid and the bony part of the Eustachian tube are most frequently affected. The periosteal part of the bony labyrinth is the first to undergo pagetoid changes and the pagetoid changes spread through the bone towards the membranous labyrinth, usually with a sharp line of demarcation between the pagetoid area and the normal bony labyrinth.

 Osteogenisis imperfecta

Osteogenesis imperfecta is a general bone disease with a triad of clinical features: multiple fractures, blue sclera and conductive hearing loss. There is a congenital recessive form in newborns that is often rapidly fatal and a tardive one in adults that is inherited as a mendelian dominant and is more benign. Mutations of type I collagen genes have been established as the underlying cause leading to a general disturbance in the development of collagen, hence the thin sclerae appearing blue as well as poorly formed bone tissue. In the long bones the resorption of cartilage in the development of bone is normal, but the bony trabeculae themselves are poorly formed and the same may be seen in the temporal bone. The ossicles in the tardive form are very thin and subject to fractures. The stapes footplate is also frequently fixed. The disturbance in lamellar bone formation can lead to extreme thinness, dehiscence, and non-union of the stapedial superstructure with the footplate, or thickening with fixation of the footplate. The nature of the bony tissue causing this fixation is problematical. It has been suggested that osteogenesis imperfecta can be associated with otosclerosis so that the fixation is indeed otosclerotic. Otosclerosis, like osteogenesis imperfecta, may indeed be part of a general connective tissue disturbance. Indeed, some cases of clinical otosclerosis may be related to mutations within the COL1A1 gene that are similar to those found in mild forms of osteogenesis imperfecta.

Osteopetrosis

Osteopetrosis (often known as marble bone disease) is a rare disease of bone, in which there is a failure to absorb calcified cartilage and primitive bone due to deficient activity of osteoclasts. A relatively benign form, inherited as a dominant, presents in adults, and a malignant one, inherited as a recessive, in infants and young children. The patients with the benign form often survive to old age and present prominent ontological symptoms. The intermediate, endochondral portion of the otic capsule is swollen and appears as an exaggeratedly thickened form of the normal state. Globuli ossei composed of groups of calcified cartilage cells are normally present in this region, and in osteopetrosis they are greatly increased in number and are arranged into a markedly thickened zone. The periosteal bone is normal. The ossicles are of foetal shape and filled with unabsorbed, calcified cartilage. The canals for the seventh seventh and eighth cranial nerves are greatly narrowed by the expanded cartilaginous and bony tissue and these changes are probably responsible for the characteristic symptoms of facial palsy and hearing loss respectively.

Cleidocranial Dysplasia

Transmitted by autosomal dominant triat. Defect in CBFA-1 (Nuclear protein). Defective formation of clavicles, delayed closure of frontanells,sometimes retrusive mandible. Partial or complete loss of clavicles allow patient to bring shoulder’s together in front of the chest.not only membranous bones but all part of the skeleton is affected.

Radiological features

·         Aplasia or hypoplasia of claicles

·         Skull shows

o   Delayed closure of frontanells

o   Open skull sutures

o   Sunken sagittal suture-sagittal suture

o   Frontal and occipital bossing

o   Widened cranium-

·         Jaws shows

o   Underdeveloped maxilla-maxillary micrognathia

o   Multiple supernumerary teeth-anterior to permanent molars

o   Unerupted or delayed eruption of permanent teeth

o   Prolonged retention of primary teeth

o   Mandibular prognathism-normal in size

o   Sometimes multiple dentigerous cysts.

Achondroplasia

·         Most common type of genetic skeletal disorders

·         Manifest as short limb dawfism

·         Failure of normal cartilage proliferation in the epiphysis and base of the skull

·         Normal intelligence.CNS not affected.

Hyperparathyroidism

·         Two types

·         Primary and secondary hyperparathyroidism

·         Predominantly in middle aged females

·         Excessive parathomone secreting adenomas

·         Present with generalized osteoclastic activity with fibrosis of marrow

·         In addition, focal areas of bone resorption result in brown tumour formation.

·         Usually present with giant cell epulis and cystic lesions.

Management

Surgical removal of adenoma and subtototal excision of hyperplasia

Rickets and osteomalacia

·         Due to deficiency or resistance to Vitamin D

·         Present with reduced bone density and failure of bone mineralaization.

Equipments, Instruments and Materials used in Oral Surgery (Armamentarium)

This Post describes the necessary armamentarium,that is equipment and instruments, as well as the rest of the materials the dentist may use in oral surgery.

Surgical Unit and Handpiece

The surgical unit includes the following:

Surgical micromotor. This is a simple machine with quite satisfactory cutting ability. Technologically advanced machines, which function with nitrous dioxide or electricity and have a much greater cutting ability than the afore mentioned micromotor.

The surgical hand piece is attached to the above unit, includes many types, and is manufactured to suit the needs of oral surgery. Its advantages are as

follows:

·         It functions at high speeds and has great cutting ability.

·         It does not emit air into the surgical field.

·         Itmay be sterilized in the autoclave.

·         The handpiece may receive various cutting instruments.

Electric surgical micromotor with adjustable speed

High-speed surgical handpiece

Bone Burs

The burs used for the removal of bone are the round bur and fissure bur. A large bone bur similar to an acrylic burmay be usedwhen the surgical procedure involves greater bone surface area (torus) or smoothing of bone edges of the wound.

Scalpel (Handle and Blade)

Handle. Themost commonly used handle in oral surgery is the Bard–Parker no. 3. Its tip may receive different types of blades.

Blade. Blades are disposable and are of three different types (nos. 11, 12, and 15). The most common type of blade is no. 15, which is used for flaps and incisions on edentulous alveolar ridges. Blade no. 12 is indicated for incisions in the gingival sulcus and incisions posterior to the teeth, especially in the maxillary tuberosity area. Blade no. 11 is used for small incisions, such as those used for incising abscesses. The scalpel

Various types of surgical burs

Scalpel and various types of scalpel blades (nos. 11, 12, 15) commonly used in oral surgery

Correct way to load the scalpel blade on the handle of the scalpel

Sliding of scalpel blade, with the male portion of the fitting facing upward, with the aid of a hemostat

blade is placed on the handle with the help of a needle holder, or hemostat, with which it slides into the slotted receiver with the beveled end parallel to that of the handle. The scalpel is held in a pen grasp and its cutting edge faces the surface of the skin or mucosa that is to be incised.

Scalpel is held in a pen grasp

Periosteal Elevator

This instrument has many different types of end. The most commonly used periosteal elevator in intraoral surgery is the no.9 Molt, which has two different ends: a pointed end, used for elevating the interdental papillae of the gingiva, and a broad end, which facilitates elevating the muco periosteum from the bone. The Freer elevator is used for reflecting the gingiva surrounding the tooth before extraction. This instrument is considered suitable, compared to standard elevators, because it is easy to use and has thin anatomic ends. The elevator may also be used for holding the flap after reflecting, facilitating manipulations during the surgical procedure. The Seldin elevator is considered most suitable for this purpose.

Hemostats

The hemostats used in oral surgery are either straight or curved. The most commonly used hemostat is the curved mosquito type or micro-Halsted hemostat, which has relatively small and narrow beaks so that they may grasp the vessel and stop bleeding. Hemostats may also be used for firmly holding soft tissue, facilitating manipulations for its removal.

Various types of periosteal elevators. a Seldin. b Freer. cNo. 9 Molt

Micro-Halsted hemostats. a Straight. b Curved

Surgical forceps. a Standard. b Adson tissue forceps

Anatomic dissecting forceps. a Standard. b Adson dissecting forceps

Surgical – Anatomic Forceps

Surgical forceps are used for suturing the wound, firmly grasping the tissues while the needle is passed. There are two types of forceps: the long standard surgical forceps, used in posterior areas, and the small, narrow Adson forceps,used in anterior areas.

The beak of the forceps has a wedge-shaped projection or tooth onone side, and a receptor on the other,which fit into each other when the handles are locked. This mechanism allows the forceps to grasp the soft tissues found between the beaks very tightly. Anatomic forceps do not have a wedge-shaped projection, but parallel grooves. This type of forceps is used to aid in the suturing of thewound, as well as grasping small instruments, etc., during the surgical procedure.

Rongeur Forceps

This instrument is used during intraoral surgery as well as afterwards, to remove bone and sharp bone spicules. The ends and sides of the sharp blades become narrow, so that when the handles are pressed, they cut the bone found in between without exerting particular pressure.There is a spring between the handles, which restores the handles to their original position every time pressure is applied for cutting bone. Themost practical rongeur in oral surgery is the Luer– Friedmann, because its blades are both end-cutting and side-cutting.

Bone File

This instrument has two ends: one small end and another with a large surface. The cutting surface is made up of many small parallel blades, which are set in such a way that only pulling is effective. The bone file is used in oral surgery to smooth bone and not to remove large pieces of bone.

Luer–Friedmann rongeur forceps with side-cutting/end-cutting edge

Double-ended bone file with small and large ends

Surgical mallet and chisels. a Partsch monobevel chisel. b Lucas chisel with concave end. c Lambotte bibevel chisel

Chisel and Mallet

Mallets are instruments with heavy-weighted ends. The surfaces of the ends are made of lead or of plastic so that some of the shock is absorbed when the mallet strikes the chisel. The chisels used in oral surgery have different shapes and sizes. Their cutting edges are concave, monobeveled or bibeveled. The bibevel chisel is used for sectioning multi-rooted teeth.

Needle Holders

Needle holders are used for suturing the wound. The Mayo–Hegar and Mathieu needle holders are considered suitable for this purpose. The first type looks similar to a hemostat and is preferred mainly for intraoral placement of sutures. The hemostat and needle holder have the following differences:

·         The short beaks of the hemostat are thinner and longer compared to those of the needle holder.

·         On the needle holder, the internal surface of the short beaks is grooved and crosshatched, permitting a firmand stable grasp of the needle, while the short beaks of the hemostat have parallel grooves which are perpendicular to the long axis ofthe instrument.

·         The needle holder can release the needle with simple pressure, because of the gap in the last step of the locking handle, whereas the hemostat requires a special maneuver, because it does not have that gap in the last step of the locking handle.

Needle holders. a Mayo–Hegar needle holder. b Mathieu needle holder

Beak of the needle holder grasps a suture needle. The needle holder’s beak face is crosshatched, ensuring stability of the needle during tissue penetration

Correct position of the fingers for holding the needle holder

Standard suture scissors. bGoldman–Fox soft tissue scissors

a Blunt-nosed Metzenbaum soft tissue scissors. b Lagrange soft tissue scissors

The correct way to hold the needle holder is to place the thumb in one ring of the handle and the ring finger in the other. The rest of the fingers are curved around the outside of the rings, while the fingertip of the index finger is placed on the hinge or a little further up, for better control of the instrument.

Scissors

Various types of scissors are used in oral surgery, depending on the surgical procedure. They belong to the following categories: suture scissors and soft tissue scissors. The most commonly used scissors for cutting sutures have sharp cutting edges, while Goldman–Fox, Lagrange (which have slightly upward curved blades), and Metzenbaum are used for soft tissue. Lagrange scissors are narrow scissors with sharp blades and are mainly used for removing excess gingival tissue, while theMetzenbaumare blunt-nosed scissors and are suitable for dissecting and undermining the mucosa from the underlying soft tissues. Scissors are held the same way as needle holders.

 Correct way to hold scissors

Towel clamps

Towel Clamps

Towel clamps are mainly used for fastening sterile towels and drapes placed on the patient’s head and chest, as well as for securing the surgical suction tube and the tube connected to the handpiece with the sterile drape covering the patient’s chest.

 Farabeuf retractors for retraction of the cheek and mucoperiosteal flap

 Kocher–Langenbeck retractors, used in the sameway as Farabeuf retractors

Minnesota retractors for retraction of the cheek and tongue

Retractors

Retractors are used to retract the cheeks and mucoperiosteal flap during the surgical procedure. The most commonly used retractors are Farabeuf, Kocher–Langenbeck, and Minnesota retractors. Tongue retractors may be used to retract the tongue medially away from the surgical field, facilitating manipulations

 Weider retractor for retraction of tongue to the side during surgical procedure

Rubber bite blocks for adults (a) and for children (b)

 Side action adjustable mouth props

Bite Blocks and Mouth Props

These instruments facilitate opening and keeping the mouth openwhen the surgical procedure requires this for prolonged periods and when patients cannot fully cooperate with the dentist. The types usually used are rubber bite block, and the side action adjustable mouth prop.

a Fergusson suction tip with wire stylet used as a cleaning instrument. b Disposable suction tip

a Special irrigation system for irrigating the surgical field with a steady stream of saline solution. b Regular plastic syringe used for the same purpose

Surgical Suction

There are a variety of designs and sizes of surgical suctions that are used for removing blood, saliva, and saline solution from the surgical field. Certain types of surgical suctions are designed so that they have several orifices, preventing injury to soft tissues (greatest danger for sublingual mucosa) during the surgical procedure. The standard surgical suction has a main orifice for suctioning and only one smaller orifice on the handle, for the reasons mentioned above. This orifice is usually covered when rapid suctioning of blood and saline solution from the surgical field is required.

Irrigation Instruments

Irrigating the surgical field with saline solution during bone removal is necessary and a plastic syringe or a special irrigation system with a steady stream of saline solution may be used for this purpose. In the first case, the syringe used is large, with a blunt needle that is angled (facilitating irrigation especially in posterior areas) with its end cut off so that it does not damage soft tissues. In the second case, the special irrigation system is directly connected to the bottle of saline solution, with a small tube. A knob stops the flow of solution.

Electrosurgical Unit

This is an electrical device, providing high-frequency radio waves for cauterization (hemostasis) of the vessels and incision of tissues. Incising tissues with the help of electricity is called electrosurgery. The main parts of the electrosurgical unit are:

The active electrode, to which the handpiece is usually connected. The end of the handpiece receives a metallic electrosurgical tip for incision or an electrosurgical ball for hemostasis. There are other designs of electrodes as well, such as loops and needles, which may be used according to the needs of the surgical procedure.

The passive electrode, or ground plate, which is a separate electrode connected to the metallic plate, sized 30 - 20 cm. The metallic plate is placed in direct contact with the naked skin of the patient and is necessary for his or her safety.

Foot pedal. This usually includes a separate switch for incising tissue and another one for electrocoagulation (hemostasis). On certain units, the handle of the positive cable controls this function.

Switches. The main switches are: cauterization switch, voltage switch, switch for incising tissue, and a mixed switch for cauterization and incision. The last switch is found only on more modern units and is very useful, because the surgeon may alternately incise and cauterize, so that turning the switch back and forth from one function to the other is avoided. There are also small portable electrosurgical units that are battery-operated and simple to use. They may be disposable or used more than once, depending on the model.

Electrosurgical unit with various handpieces

Portable electrosurgical units. a Disposable. b Unit that may be used many times

Binocular Loupes with Light Source

This system is comprised of binocular loupes, which may be adapted to eyeglass frames or a headband, en- suring good vision of the surgical field. This system also has a light source that projects intense light into difficult areas of the surgical field (e.g., posterior teeth), where vision by means of standard lighting is not satisfactory.

Binocular loupes with light source, adapted to a headband

Binocular loupes with light source, adapted to eyeglass frames

Maxillary extraction forceps used for the six anterior teeth of the maxilla (superior and side view)

Extraction Forceps

The simple intra-alveolar extraction is accomplished with the help of extraction forceps and elevators. Each extraction forceps is composed of two parts, which are crossed in such a way that they make up one instrument when used to extract a tooth. The basic components of the extraction forceps are the handle, which is above the hinge, and the beaks, which are below the hinge. The instrument is held in the hand by the handle, upon which pressure is exerted during the extraction. The beaks are the functional component of the forceps and grasp the tooth at the cervical region and remove it fromthe alveolar socket. Because tooth anatomy varies, extraction forceps with specially designed beaks have been manufactured, so that they may be used for specific teeth. So, according to the size and shape of the handles and beaks, the following types exist.

Maxillary Extraction Forceps for the Six Anterior Teeth of the Maxilla.

Beaks that are found on the same level as the handles characterize these forceps, and the beaks are concave and not pointed.

 Maxillary universal forceps or no. 150 forceps (mainly used for upper premolars)

Maxillary right molar forceps, for the first and second upper molars of the right side

Maxillary left molar forceps, for the first and second upper molars of the left side

Maxillary Universal Forceps or No. 150 Forceps.

The forceps used for premolars have a slightly curved shape and look like an“S.” Holding the forceps in the hand, the concave part of the curved part of the handle faces the palm,while the concave part of the beaks is turned upwards. The ends of the beaks of the forceps are concave and are not pointed. These forceps may also be used for extraction of the six anterior teeth of the upper jaw.

Maxillary Molar Forceps, for the First and Second Molar.

There are two of these forceps: one for the left and one for the right side. Just like the previouslymentioned forceps, they have a slightly curved shape that looks like an “S” . The buccal beak of each forceps has a pointed design, which fits into the buccal bifurcation of the two buccal roots, while the palatal beak is concave and fits into the convex surface of the palatal root.

Maxillary third molar forceps

Maxillary root tip forceps

Maxillary Third Molar Forceps.

These forceps have a slightly curved shape, just like the aforementioned forceps, and are the longest forceps, due to the posterior position of the third molar. Because this tooth varies in shape and size, the beaks of the forceps are concave and smooth (without pointed ends), so that these forceps may be used for extraction of both the left and right thirdmolar of the upper jaw.

Maxillary Cowhorn Molar Forceps.

The upper cowhorn forceps are a variation of the maxillary molar forceps. The beaks of this type of forceps have sharply pointed ends, which fit into the trifurcation of the roots of the molars. They are primarily used for extraction of teeth with severely decayed crowns, because when they are used to extract intact teeth, they may fracture the buccal alveolar bone due to the large amount of force they generate.

Maxillary Root Tip Forceps.

The handles of the root tip forceps are straight, while the beaks are narrow and angle-shaped. The ends of the beaks are concave and without a pointed design.

Mandibular Forceps for Anterior Teeth and Premolars or Mandibular Universal Forceps or No. 151 Forceps.

 Unlike the maxillary forceps, the beaks and handles of these forceps face the same direction, creating an arch.When the forceps are held in the hand, the concave part of the arch of the handles faces the palm, while the beaks obviously face downward. The ends of the beaks are concave,withoutpointedends. The no. 151 forceps are used for extraction of the six anterior teeth and the four premolars of the lower jaw.

Mandibular Molar Forceps.

These forceps are used for both sides of the jaw and have straight handles while the beaks are curved at approximately a right angle compared to the handles. Both beaks of the forceps have pointed ends, which fit into the bifurcation of the roots buccally and lingually. These forceps are used for the removal of both the first and second molar of the right and left side of the lower jaw.

Mandibular forceps for anterior teeth and premolars of the mandible or mandibular universal forceps or no. 151 forceps

Mandibular molar forceps

Mandibular third molar forceps

Mandibular Third Molar Forceps.

These forceps also have straight handles, while the beaks, just like those of the first and second molar forceps, are curved at a right angle compared to the handles. The beaks are a little longer compared to the previous forceps, due to the posterior position of the third molar in the dental arch. Because this tooth varies in size and shape and because there is usually no root bifurcation, the ends of the beaks of the forceps are concave without a pointed design.

Mandibular Cowhorn Molar Forceps.

The lower cow horn forceps or no. 23 forceps are a variation of the mandibular molar forceps. In comparison to the standard forceps, the beaks have a semicircular shape with sharply pointed ends so that they can fit into the bifurcation of the roots and firmly grasp the tooth. Owing to the function of these forceps, tooth extraction may be achieved quite easily as long as the roots are not curved. With the beaks of the forceps grasping the crown of the molar and the

Mandibular cowhorn molar forceps for sectioning roots. They are used for extracting molars with intact crowns, and also when only sectioning of roots is necessary

Mandibular cowhorn forceps adapted to molars

English-style forceps with the hinge in the vertical direction

sharp ends fitting into the root bifurcation, the surgeon squeezes the handles and, using small buccolingual movements, slides the tooth out of the socket. Also, the cowhorn forceps are very useful for sectioning roots of posterior teeth in the lower jaw, when their crowns are severely decayed. After grasping the roots, the teeth are easily sectioned after applying pressure at the bifurcation point.

Vertical Hinge Forceps.

These English-style forceps differ from the aforementioned forceps in that their hinges have a vertical direction. Their use is limited, because large amounts of force can be generated during extraction with this type of forceps, so that if the bone is not elastic, there is increased risk of fracture of the alveolar bone.

Mandibular root tip forceps

Mandibular Root Tip Forceps.

The handles of the root tip forceps are straight,while the beaks are curved at a right angle. Their ends are very narrow and meet at the tip when the forceps are closed.

Elevators

The elevator is the second most important instrument (after the extraction forceps) with which tooth extraction is achieved or aided. It is composed of three parts: the handle, the shank, and the blade. The shape of blade differs for each elevator type, and each is used as the need dictates. There are three main types of elevators used today in oral surgery: the straight elevator, the pair of elevators with T-shaped or crossbar handles, and the pair of double-angled elevators.

Straight Elevator.

This is the most commonly used type of elevator for the removal of teeth and roots, in both the upper and lower jaws. As already mentioned, the elevator’s components are the handle, shank, and blade. The handle is pear-shaped, and big enough to be held comfortably in the hand for the surgeon to apply pressure to the tooth to be luxated. The shank is narrow and long and connects the handle to the blade. The blade has two surfaces: a convex and a concave one. The concave surface is placed buccally, either perpendicular to the tooth or at an angle, and always in contact with the tooth to be luxated. The elevator is held in the dominant hand, and the index finger is placed along the blade almost reaching its end. The end of the blade is left exposed and is seated between the socket and the tooth to be luxated.

Pair of Elevators with T-shaped or Crossbar Handles.

This type of elevator  is used only in the lower jaw for removal of a root of a molar, after the other root has already been removed with the straight elevator. Each of these elevators is composed of the handle, shank, and blade. The shank is connected to themiddle of the handle, giving the elevator a T-shaped appearance, while the connection of the shank to the blade is angled, and the blade end is sharp-tipped. The blades on this pair of elevators face in opposite directions, and the appropriate one is used according to the root that has to be removed. One elevator is used to remove the mesial root, and the other for the distal root, for each side of the lower jaw. Angled Seldin elevators are a variation of the elevators with T-shaped handles.

In certain cases, the T-shaped elevator may be used to remove a whole thirdmolar of the lower jaw. The tip of the elevator is placed into the root bifurcation buccal to the tooth, using the external oblique ridge as a fulcrum.

Pair of Double-Angled Elevators.

Double-angled elevators are mainly used to remove root tips in both jaws. They are also very useful instruments for the extraction of impacted third molars of the upper jaw. Their handle is similar to that of the straight elevator. The shank has a double angle, so that the instrument may enter the socket, and the two elevators face in opposite directions. The blade has a convex and concave surface, ending in a sharp point. There are also double-angled elevators with narrow blades and very sharp ends, which may easily remove small broken root tips.

Straight Bein elevator

StraightWhite elevator with slightly curved blade, suitable for extracting posterior maxillary teeth

 Pair of elevators with crossbar or T-shaped handles

Pair of angled Seldin elevators suitable for extracting roots in the mandible

Pair of double-angled elevators

Chompret elevators; a straight, and b curved

Sharp-tipped angled elevators suitable for removal of root tips

Other Types of Elevators

Straight Chompret Elevator.

The narrow blade of this instrument means that this type of elevator may also be used as a straight elevator. The straight Chompret elevator may only be used this way when the width of the straight elevator blade prevents its correct placement for the luxation of the tooth or root.

Curved Chompret Elevator and Doubleangled Elevators with Narrow Blades and Sharp Tipped Ends.

These instruments are used by the dentist as the need dictates.

a Special instrument for removing roots belowthe margin of alveolar bone. b Bur for widening the root canal

Periapical curettes with ends of different sizes

Desmotomes. a Straight. b Curved

Special Instrument for Removal of Roots

The instrument in is used to remove broken roots found below the alveolar crest. The spiral end of the instrument is placed inside the extraction socket, and, after screwing the instrument into the root canal of the broken root, traction is used to remove the root from the socket.

Periapical Curettes

These are angled double-ended, spoon-shaped instruments. The most commonly such used instrument is the periapical curette, whose shape facilitates its entry into bone defects and extraction sockets. The main use of this instrument is the removal of granulation tissue, small cysts, bone chips, foreign bodies, etc.

Desmotomes

These instruments are used to sever the soft tissue attachment, and are either straight or curved. The straight desmotome is used for the anterior teeth of the upper jawand the curved desmotome for the rest of the teeth of the upper jaw as well as all of the teeth of the lower jaw.

Set of instruments necessary for simple tooth extraction

Set of instruments necessary for surgical tooth extraction

Sets of Necessary Instruments

For practical reasons, sterilized and packaged full sets of instruments for the most common surgical procedures must always be available. These sets include:

a. Set for simple tooth extraction:

1. Local anesthesia syringe, needle, and ampule.

2. Desmotome or Freer elevator.

3. Retractor or mouth mirror.

4. Extraction forceps

(depending on the tooth to be removed).

5. Surgical or anatomic forceps.

6. Elevators.

7. Sterile gauze.

8. Periapical curette.

9. Suction tip.

10. Towel clamp.

11. Needle holder.

b. Set for surgical tooth extraction:

1. Local anesthesia syringe, needle, and ampule.

2. Scalpel and blade.

3. Periosteal elevators.

4. Elevators.

5. Bone chisel.

6. Mallet.

7. Rongeur forceps.

8. Bone file.

9. Periapical curette.

10. Bone burs.

11. Hemostat

Set of instruments necessary for soft tissue specimen sampling by biopsy

Set of instruments necessary for incision and drainage of abscesses

12. Retractors.

13. Needle holder.

14. Surgical forceps and anatomic forceps.

15. Scissors.

16. Towel clamps.

17. Disposable plastic syringe.

18. Suction tip.

19. Straight handpiece.

20. Bowl for saline solution.

21. Sutures.

22. Sterile gauze.

c. Set of instruments for surgical biopsy (bone and soft tissue) :

1. Local anesthesia syringe, needle, and ampule.

2. Scalpel and blade.

3. Periosteal elevator.

4. Scissors.

5. Surgical forceps and anatomic forceps.

6. Periapical curette.

7. Needle holder.

8. Hemostats.

9. Rongeur forceps.

10. Towel clamps.

11. Suction tip.

12. Sutures.

13. Sterile gauze.

14. Retractors.

d. Set of instruments for incision and drainage of abscess :

1. Local anesthesia syringe, needle, and ampule.

2. Scalpel and blade.

3. Hemostats.

4. Surgical and anatomic forceps.

5. Scissors.

6. Needle holder.

7. Suction tip.

8. Towel clamps.

9. Sutures.

10. Sterilized Penrose rubber drain 1/4 in.

11. Sterile gauze.

Different types of resorbable sutures made fromgut tissue and synthetic material

Sutures

Great progress in sutures has been made since 1865, when disinfection and sterilization first started being used in surgery. There is a big variety in the size of  surgical sutures available today, and two basic categories: (1) resorbable, and (2) nonresorbable sutures.

Resorbable Sutures.

These sutures are resorbed after a certain time, which usually coincideswith healing of the wound. These sutures are made of gut or vital tissue (catgut, collagen, fascia, etc.) and are plain or chromic, or of synthetic material, e.g., polyglycolic acid (Dexon) . Plain catgut sutures are resorbed postsurgically over 8 days, chromic sutures in 12– 15 days,and synthetic (Dexon) sutures in approximately 30days. These types of sutures are used for flaps with little tension, children, mentally handicapped patients, and generally for patients who cannot return to the clinic to have the sutures removed.

Nonresorbable Sutures.

These sutures remain in the tissues and are not resorbed, but have to be cut and removed about 7 days after their placement. They are fabricated of various natural materials, mainly surgical silk (monofilamentous or multifilamentous, in many diameters and lengths) and surgical cotton suture. Silk sutures are the easiest to use and the most economical, and have a satisfactory ability to hold a knot. The most commonly used suture sizes are 4–0 and 3–0 for resorbable sutures, and 3–0 and 2–0 for nonresorbable sutures. These kinds of sutures are sold in sterilized packages with pre-attached atraumatic needles or in bundles without needles.

Nonresorbable surgical sutures made of silk

Cross-sectional view of needles. a Round tapered (1), oval tapered (2), cutting (3, triangular with one of the three cutting edges on the inside of the semicircle), reverse-cutting (4, triangular with two cutting edges on the inside of the semi-circle). b Size of needle compared to regular circle: one-quarter of a circle (1), three-eighths of a circle (2), half a circle (3), three-quarters of a circle (4)

Needles

A variety of needles are available in oral surgery, and they may differ in shape, diameter, cross-sectional view, and size. They are usually made of stainless steel, which is a strong and flexible material. The needles preferred by surgeons today are atraumatic disposable needles with pre-attached sutures on their posterior ends. Needles that may be used and sterilized many times are also available, with an eye or groove in the needle, through which the suture is passed.

Needles with Round or Oval Cross-Sectional View.

These are considered atraumatic and are mainly used for suturing thin mucosa. Their disadvantage is that great pressure is required when passing through the tissues, which may make suturing the wound harder.

Triangular Needles.

These needles have sharp cutting edges and are preferred for suturing thicker tissues. When they are used for thin mucosa, care is required because they may tear the tissues. The most suitable needles are semicircular or three-eighths of a circle and 19–20mmlong, in both cases.

Local Hemostatic Drugs

These drugs are suitable only for local use and can stop heavy bleeding, which is due to injury of capillaries or arterioles. The main hemostatic drugs are listed below.

Alginic Acid. This is sold in powder form in special 5-mg packages. It is placed on the bleeding surface, creating a protective membrane that applies pressure to the capillaries and helps hold the blood clot in place.

Natural Collagen Sponge. This is a white sponge material, non antigenic and fully absorbable. Its hemostatic ability is due to promotion of platelet aggregation. Also, it activates coagulation factors XI and XIII. It is used for patients who are prone to hemorrhage after dental surgical procedures.

Hemostatic powder suitable for stopping capillary bleeding

Absorbable hemostatic natural collagen sponges. These are indicated in cases of postextraction bleeding

Fibrin Sponge. The fibrin sponge is nonantigenic, and is prepared from bovine material that has been processed in order to avoid allergic reactions. It is used locally in the bleeding area and especially in the postextraction socket. It promotes coagulation, creating a normal hemostatic blood clot, but it also functions as a plug over the edges of the bleeding area. The fibrin sponge is fully absorbed by the tissues within 4–6 weeks.

Gelatin Sponge. This is a relatively spongy material, nonantigenic and fully absorbable. Its hemostatic action and application are the same as that of the fibrin sponge.

Oxidized Cellulose. This is an absorbable hemostatic material, which is manufactured by controlled oxidation of cellulose by nitrous dioxide. It is available in gauze form or pellet form (Fig. 4.67). It is used topically as a hemostatic material, because it releases cytotoxic acid, which has significant affinity for hemoglobin. Its attachment to the walls of the postextraction socket for the treatment of bleeding is quite satisfactory and therefore it is considered superior to various other hemostatic sponges, which have a tendency to expel thematerial from the socket.

Bone Wax. Bone wax is a sterilized, nonabsorbable mix of waxes, and is composed of white beeswax, paraffin wax, and an isopropyl ester of palmitic acid It is white and available as a solid rectangular plate weighing 2.5 g. It is used to control bleeding that originates in bone or chipped edges of bone. Before its application, bone wax is first warmed with the fingers, so that the desirable consistency is reached. Its hemostatic action is brought about through mechanical obstruction of the osseous cavity, which contains the bleeding vessels.

Gelatin sponges. These are used to treat postextraction bleeding

Oxidized cellulose in pellet form

Surgical bone wax for treatment of bone hemorrhage

Petrolatum (VaselineR) gauze in a sterile container

Materials for Covering or Filling a Surgical Wound

Petrolatum Gauze.

Petrolatum (VaselineR) gauze is available in sterilized packages and is used mainly for covering exposed wounds, for tamponade of bone cavities after marsupialization of cysts, for surgical procedures in themaxillary sinus, etc. Before its application, the excess petrolatummust be removed and the gauze saturated with antibiotic ointment (oxytetracycline), if deemed necessary.

Iodoform Gauze.

This gauze has antiseptic, analgesic and hemostatic properties. Its indications for use are the same as for petrolatum gauze, although it may remain in place for longer. The iodoform gauze is also available in small-sized packages, for the treatment of dry socket.

Surgical Dressing.

This is an autopolymerized puttylike paste, available in sterilized packaging. It is used in periodontology and oral surgery as a temporary protective covering of intraoral wounds after surgical procedures.

Clinical photograph showing closure of the operative field with surgical dressing

Materials for Tissue Regeneration

Sometimes during surgical procedures (removal of cysts, extraction of impacted teeth, etc.) large bony defects are created, which cause problems associated with esthetics, function, and the healing process, or They may even affect the stability of the jaw bone. Recently, application of a variety of materials in oral surgery to the area around these bony defects aids bone regeneration and eliminates the defect or limits its size. These materials may also prove useful in the regeneration of periodontal tissues, for the filling of bone defects around an implant, or for augmentation of a deficient alveolar ridge, etc. The most commonly used such materials are membranes and bone grafts.

Membranes. These may be absorbable or non absorbable. Synthetic polymer and collagen membranes are absorbable. Non absorbable membranes include those reinforced with titanium, aswell asmetallic titanium network membranes. The main disadvantage of non absorbable membranes is the need to perform a second surgical procedure for their removal.

Bone Grafts. These belong to four categories:

1. Autografts, which are composed of tissues from the actual patient.

2. Allografts, which are composed of tissues from another individual.

3. Heterografts, which are composed of tissues from various animals.

4. Alloplastic grafts, which are composed of synthetic bone substitutes, e.g., hydroxylapatite, phosphoric calcium ceramics, and oily calcium

a Absorbable collagen membrane used for guided bone regeneration. b Clinical photograph showing stabilization of the membrane in an area of bone deficit after surgical extraction

Heterografts of bovine bone (Bio-Oss) for the regeneration of large osseous defects; a in compact form, and b in granules

a Synthetic bone substitute (hydroxylapatite) in granules. b Clinical photograph of transplantation of lateral incisor of the maxilla. The area of osseous defect is filled with hydroxylapatite

Amelogenin (base and catalyst) used for tissue regeneration

a Oily calciumhydroxide in creamformused for bone regeneration. b Postextraction socket with buccal loss of bone. The area is filled with synthetic material

Other materials that contain amelogenin as the active ingredient, amelogenin being one of the proteins associated with tooth enamel, may also promote tissue regeneration. Of all the grafts, bone autografts give the best results. In spite of that, their use of limited, because a second concurrent surgical procedure is required. For this reason, the aforementioned synthetic substitute materials are used today instead, and bone regeneration in areas with large bone defects is accomplished satisfactorily.