Oral surgery in general practice. Part III

Many Soft Tissue Growths Should be Removed

The Technique of Removal and Treatment is Discussed by

Arthur B. Crane, D.D.S., and Harry Kaplan, D.D.S., in

“ORAL SURGERY IN GENERAL PRACTICE” PART III

 

                Various types of benign new growths spring from the periosteum or epithelium along the gingival borders. They are commonly loosely classified as epuli. Those springing from the epithelium are mostly papiliomata, and those from the periosteum are fibromata or giant cell tumors.

Those growths may be sessile (flat) or they may be pedunculated (attached by a pedicle). The operation in either type is practically the same. It consists in making a circumscribed incision will back in the healthy tissue so that the knife does not pass through any part of the growth. The tumor is then removed by blunt dissection including the underlying periosteum. The wound is allowed to heal by granulation.

Where the radiogram shows destruction of interproximal bone, especially in the pedunculated types, it is better to remove the tooth or teeth thus affected and to chisel out all of the affected bone. In the sessile type of tumor, the margins of the wound should be cauterized with the actual cautery. The block of tissue removed should be dropped in a bottle of 10 percent formaldehyde solution and be sent to the pathological laboratory for confirmation of the diagnosis.

The labial frenum is often attached through the interproximal space of the upper central incisors. In young subjects this should be resected before the lateral incisors erupts if possible. In adults, this operation is rarely necessary except in edentulous cases, where the frenum would interfere with proper denture service.

The operation is best done with the actual cautery, under infiltration anaesthesia. The extreme lower tip of the frenumshould be dissected free with the point of the cautery knife, and tip should then be grasped with the thumb forceps and the lip pulled back so as to put tension on the tissues. The lateral margins of the frenum attachment will now be clearly defined and may be incised with the cautery, back to the point where permanent attachment is desired. With gentle traction on the tip, the whole frenum is now dissected back to that point and as much of it as has been freed is cauterized off by a cross incision.

It is seldom necessary to use sutures, but occasionally a transverse suture drawn through the extremities of the cross incision, and tightly tied, will insure retraction.

An operation similar to that just described is sometimes necessary before denture service, to relieve high attachments of the buccal or labial mucosa. These operations, if they involve a considerable area of the ridge, are better performed with the cold knife. By using extreme care it is possible to make an incision along the ridge at the point of attachment, which will not involve the underlying perosteum.

At each extremity of this incision, perpendicular incisions should be made outlining the area of tension. The tissue flap is grasped in the thumb forceps and carefully dissected away from the periosteum by use of a sharp knife. A part of this flap should be trimmed off with the scissors and the remaining portion should be sutured in such a manner as to turn the edge under. It is very helpful in these cases if the patient is wearing a denture, to add sufficient modeling compound to the periphery of the plate to hold the soft tissues back in the desired position. The wound should be dressed each day until it has a new epithelial covering.

When the pontics of a fixed bridge are so tightly pressed into the tissues that hypertrophy results, and the bridge is otherwise satisfactory, the hypertrophy may be relieved by a simple surgical operation. An incision is made along the lingual surface of the pontics to the middle of each abutment tooth. The tissue flap is then dissected back with blunt instruments toward the buccal surface and retracted until the alveolar ridge under the pontics is freely exposed.

With suitable chisels or bone burs, the contour of the ridge may be reduced sufficiently to allow for the excess length of the pontics. The field is then thoroughly cleaned, the flap slipped back under the pontics, and sutured from the lingual side.

The surgical elimination of pyorrhea which involves a large number of teeth is an operation which requires considerable surgical ability, but when there is a deep pocket which is confined to the facial or lingual surface of one or two teeth, or where there is evidence of deep interproximal pyorrhea of a limited area, the operation is less difficult. Usually when the pocket is confined to the labial or lingual, it is only necessary to excise the gum tissue which forms it and to pack the case.

Treatment of the Interproximal Area

Where the interproximal area is involved, it is necessary in addition to removing the overlying gum, to saw away the disintegrated bone and to level the interproximal margins before packing. The packing must be treated daily until the causative factors have been eliminated as thoroughly as possible.

This may involve the relief of occlusal traumatisms, the reduction of new proximal contacts. The packing which is used is composed of equal parts of oxide of zinc and finely pulverized resin for the powder and equal parts of fresh eugenol and heavy mineral oil for the liquid. The mix should be made as stiff and dry as possible.

No operator should accept any case unless he feels confident of his ability to take care of all possible post-operative complications. In oral surgery, healing is ordinarily expected to be uneventful because of the abundant blood supply of the tissues.

Most post-operative complications will be avoided, if it is a routine procedure to leave the operative field absolutely clean, with no sharp or uncovered bone margins and no jagged edges of soft tissue. The patient should be kept under observation in the office until a hard blood clot has formed, completely filling all depressions. The use of caustics, antiseptics, or gauze packings at the time of operations is contra-indicated in practically all types of operations.

The patient should be instructed to avoid the use of mouth washes for a period of at least three hours following the operation and then to use them, if at all, in a gentle manner, so as to avoid washing the blood clot out of the wound. There will be but little post-operative pain subsequent to simple operations, provided these precautions are observed.

When tissue flaps are tightly sutured it may happen that some blood will drain into the deeper tissues and result in swelling and eventually in a bruised appearance of the overlying skin. There is little that can be done about this, other than to ease the patient’s mind by the assurance that it does not indicate anything serious, and will be taken care of by natural tissue reactions.

More extensive or complicated operations should be followed by the application of the ice-bag for a period of three hours or longer. Acetylsalicylic acid, acetanilid or barbituric acid preparations should be administered at frequent enough intervals to insure comfort. When the patient is extremely nervous and especially where there has been insomnia preceding the operation, it is a good plan to administered a hypnotic at bed time, the night following the operation.

A post-operative rise in temperature, if accompanied by swelling, usually indicates the presence of pyogenic infection. In such cases the wound should be immediately opened to its extreme depth in order to insure adequate drainage and continuous fomentations. Saturated solution of magnesium sulphate should be applied. When complications arise, laxative treatment should be advised and the patient should be kept as quiet as possible.

Following extraction there should be little pain after the first few hours. If for any reason however, the blood clot is washed out of the wound exposing the bone, a dry socket is apt to supervene. This condition is extremely painful and should be promptly controlled. The method of doing this, is to gently remove with the curet and atomizer spray the remainder of the blood clot and other debris from the socket.

Packing Socket Protects Tissues

The undercut parts of the socket are then lightly filled with idoform gauze saturated with eugenol and the remainder of the socket is filled with the packing just referred to under the treatment of pyorrhea. The packing should be wedged against the adjacent teeth in such a manner as to prevent the plug from coming out of the socket. Generally this treatment has the effect of quickly relieving the pain. The packing should be left in place for three or four days and then should be renewed and this routine continued. Examine the wound carefully at each visit until the shell of bone, which constitutes the sequestrum, is loose enough to pick out with the cotton pliers, after which the wound will need but little treatment. It should be remembered that a dry socket is in reality an acute localized osteomyelitis and because of this, curettage of the bone or the use of caustics in the socket is absolutely contra-indicated.

When a tooth socket appears to be healing satisfactorily for several days and then presents with granulation tissue protruding through the orifice, it indicates that there is either a residue of the pathological periapical tissue, one or more loose fragments of bone, or some foreign substance in the tooth socket.