Oral Surgery in General Practice. Part II.

Oral Surgery in General Practice. Part II.

 

                Residual cysts are general capable of demonstration in the radiogram. A rounded radioparent area is seen, surrounded by a dense radiopaque line. Fig. 8. Such areas are approached in the manner just described for residual infections, but it is necessary to remove enough of the overlying buccal alveolar plate to give free exit to the cyst. With the back of a blunt curet, the cyst wall should  be enuclated from its bony socket. It is probable that the cyst wall will be punctured during this procedure, in which event the cyst fluid should be withdrawn from the field by the aspirator. The cyst wall should be grasped with the thumb forceps and the careful dissection continued until it can be gently withdrawn in one piece. It is of the utmost importance that no part of the cyst wall be left, for when this is done, a new cyst formation, which may take on the form of a multilocular cyst, may be the result.

After the cyst wall has been entirely removed, the tissue flap may be closely adapted and sutured without provision for drainage. In favorable cases the cyst cavity will be filled with a blood cot which will organize and eventually result in a new bone formation. If the clot breaks down, and this is usually due to failure to remove all loose particles from the operated field it will become necessary to remove enough sutures to permit the cyst cavity to be packed with iodoform gauze, carbolized or vaseline gauze. This packing must be fairly tight and requires changing almost daily. The period of healing will be prolonged more or less depending upon the size of the cyst cavity.

It is not uncommon to find root remnants or foreign bodies such as filling material or particles of the tooth crown, or calculi immediately under the gum surface but not within the bone. These may be removed through a simple incision which should be left open for drainage.

Judgment Must be Tempered by Experience

There are a number of operations in oral surgery which even the qualified specialist cannot approach without the feeling that complications are apt to ensue. Among these may be cited: the extraction of impacted teeth, the exposure of unerupted cupids, the excision of flabby fibromatous gum tissue in edentulous moths, the removal of the torus paratinus, the treatment of extensive osteomyelitis or acute cellulitis and plastic operations to cover defects. In addition to this there are certain operations which can be performed efficiently on after judgment has been tempered by experience; such as complete alveolectomy and complete surgical pyorrhea elimination. It would seem sensible therefore for the man whose surgical background is limited, to immediately refer such case to the qualified oral surgeon. There are other operations in the mouth, in addition to those for which the technic has already been given, which may be successfully performed by the general practitioner, such as root resection, the removal of various types of small epuli, the resection of the labial frenum and the relief of high alveolar attachments in the buccal region of edentulous cases. Pyorrhea pockets about a few teeth may be eliminated by surgical procedure, and edentulous areas which are being compressed and irritated by fixed bridge pontics may be reduced to obviate the necessity for rebuilding the bridge.

Root resection is an operation which belongs more definitely in the field of general practice than any other, for the reason that this operation should never be undertaken until the root canal has been opened and enlarged, sterilized, and properly filled. The percentage of successful results will be increased if the apical third of the canal is filled with copper amalgam. This material acts as a long continued mild antiseptic by the diffusion of copper salts into the dentine and perhaps into the periapical region, thus maintain sterility until such time as the natural repair shall have taken place.

The technic of inserting copper amalgam is as follows: the amalgam is mixed in the ordinary manner. The hands of the operator having been thoroughly scrubbed and washed in alcohol, the material is removed from the mortar and kneaded in the palm of the hand, until absolutely smooth. Most of the excess mercury is expelled by squeezing the mix through sterile gauze. It is then returned to the palm of the left hand and rolled into points with the middle finger of the right hand. As these points are made they are picked up with cotton pliers, gently washed in alcohol, and placed on a sterile gauze pad until used. A Condit’s celluloid conductor, designed originally for the application of silver nitrate solution, is cut off at the apical end, so that it reaches only about to the upper third of the canal. It is washed in alcohol, dried out with the warm air blast and inserted in the canal. The amalgam point may now be taken in the cotton pliers and be placed in the conductor. A root canal plugger small enough to reach the end of the root is then used to pack the amalgam to place. Additional amalgam points are inserted until the apical third of the root is filled and thoroughly condensed with copper amalgam. The conductor is then withdrawn and the lower part of the canal is filled with a large gutta percha point, cut back so as to approximately fill the lower two-thirds of the canal. The gutta percha should be warmed until it is slightly soft before insertion, then packed to place with cement. When the filling is inserted in this manner there is little danger of tooth discoloration from the amalgam.

 

Root Canal Should be Filled Before Root Resection is Done

The root resection proper should be postponed for at least twenty four hours in order to permit the amalgam to thoroughly set. The operation is best performed under infiltration anaesthesia. A V- shaped incision, which starts at the labio-gingival fold above the interproximal space, distal to the next tooth, is carried downward and forward to a point about two millimeters above the middle of the gingival margin of the tooth to be operated, where it is turned sharply upward and backward to the labio-gingival fold, above the interproximal space distal to the next tooth. The V-shaped flap is lifted away from the bone by blunt dissection and forced upward until the bone overlying the apical region is freely exposed. The tissues at the lower part of the incision are also slightly freed from the bone at this time in order to facilitate subsequent suturing. The flap may be held back by passing a suture through its point and making a loop for the insertion of the finger or it may be held back with a tissue retractor. The bone of the apical region should now be carefully examined with a spot light and if there is no disintegrated area to indicate the point of approach, and pressure with a stiff pointed probe will usually indicate the area of periapical disease. Sufficient of

                The cortical bone must be removed with chisels to thoroughly disclose the pathological area and some of the root coronal to it. Fig. 9. The apex is now resected through this latter region with a cross cut fissure bur, care being taken to avoid puncturing the palatal plate or injuring the roots of the adjacent teeth. After the bur has completely severed the apex, it may be lifted out with a small curet and in some instances the granuloma or cyst will adhere to it. In other cases it will be necessary to curet the area to remove all traces of soft tissue and disintegrated bone. If the periapical disease is a true radicular cyst, the cyst cavity will be lined with a dense layer of white bone and this does not need to be interfered with. The root stump must now be examined very carefully with the spot light, keeping the field clear with the aspirator. Any sharp spicules of angles discernible should be smoothed down either with a bur or a prophylactic file. The operative field should be absolutely clean before the flap is sutured. One suture at the point of the flap should be inserted first and this should be fortified by one in each side incision.

Ordinarily these cases heal by first intention, unless the root has not been properly field. In the latter case, the bloodclot will not organize and there will be pain and swelling. The suture at the point of the incision must then be removed and the wound must be cleaned out and packed with gauze from day to day until it heals by granulation. A radiogram should be made before the case is dismissed, for comparison with those which must be taken at intervals of six months until a complete reformation of the lamina dura is demonstrable.

Arthur B. Crane,

Harry Kaplan,

1726 Eye St. N.W., Washington, D.C.