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Simple Surgery - Courtesy ROOTS
The opinions within this web page are not ours. Authors have been credited for the individual posts and images where they are.

From: Randy Hedrick
Sent: Thursday, 8 June 2006 2:06 AM
To: ROOTS
Subject: [roots] Simple surgery

Here is a simple surgery I did recently on #6.  The endo was done by someone else 11 months prior and the
patient found a tender nodule at the apex of #6.  She had only minor bite and percussion symptoms but she
can feel the nodule, she won't leave it alone and is in fear of developing an infection.  I have included
a few clinical frames from my 1 chip video camera.  The detail is not great but you can see what is going
on.  You can see the GP through the mucosa. The dentist who did the endo needed to trust his apex locator.
If he used one this patient may have been able to avoid a surgery.  - Randy Hedrick

simple surgery

simple surgery

simple surgery

simple surgery

simple surgery

simple surgery

simple surgery

simple surgery

simple surgery

Hi Randy, Interesting case!! Question---your horizontal incision seems to be in alveolar mucosa as opposed to the keratinzed tissue. What was the reason if I may ask? - Fred Fred, Good question. I wanted to keep the scar above the smile line. I do a semi-lunar incision for apical surgery about once every 3-5years. The etiology was so obvious that I didn't have any expectation of finding any other sites that would need to be repaired on the root like a lateral canal at midroot. That would be a big problem with a semi-lunar incison. I normally do an intrasulcular incision with full thickness flap. - Randy Yeah, but still - why the semilunar in mucosa? That's BOUND to scar up. Intrasulcular also isn't necessary. I agree with Fred. Keep it keratinized. Here's an OLD surgery I had lying around in my laptop. ( It must have been around 8 years ago - IO camera pics, monster silk sutures etc. Stuff I never use now. That was one BIG lesion.) Its a typical "BU" flap - which is essentially a Luebke-Oschenbein flap - stretched out to minimum 1.5 teeth on either side of the tooth to be surgerized. I also have NO problem with vertical releasing incisions as necessary. Yeah, I know that is big... but the whole idea is to mimimize trauma from flap retraction - so WIDEN the flap ( when reasonable) and you get less PO swelling, trauma and possibel bruising/soreness. Mucosa (like in a semilunar) is also sometimes tough to retract without turning the edges into hamburger. That means more ragged incison line and lousy cosmetics. Drop incision into the attached gingiva, just a few mm above the M-G junction and the horizontal incision basically heals with ideal primary intention. I rarely use intrasulcular incisions anymore- except when I suspect VRF. Why risk the recession when you don't have to? Yeah, it takes a LOT longer to suture, but if you take the time to use individual sutures along the suture line, spaced at regular intervals and scallop the incision to give you position guides) you can get some pretty impressive results without risking scarring or recession. I'll see if I can post a few examples tommorrow when I get to work. - Rob Kaufmann simple surgery

Rob, Thanks for the input and providing another way to get success. Once again, the formation if a scar is irrelevant if it is above the smile line. Significant swelling also did not occur in this case and there was no bruising. I look forward to your posts of your previous cases. - Randy Hedrick Randy: Doesn't the usual intrasulcular incision with full thickness elevation potentially cause some cosmetic/recessional issues? Certainly it gives the best view of the surgical site, but I'm curious if you have any concerns about recession, especially in thin tissue morphs. - Gary Gary, I have not experienced that problem except in my first year on an attorney who didn't want to pay the bill. I even had a photo from before the surgery showing exposed crown margins but she was going to create problems so it was easier to let it go. It is a concern but we explain it to the patient and I haven't had any complaints from patients or dentists. What is most important, in my opinion, is firm finger pressure on the flap with the flap in it's proper position after suturing. Firm pressure allows a fibrin reattachment of the flap to the bone which stops bleeding and maintains the position of the flap. I think that pressure on the flap is almost more important than sutures. If there is bleeding between the flap and the bone, a thick blood clot forms causing 3 significant problems. 1. The flap loosens from the bone, floats on the clot and is held in place only by the sutures. We all know how much an intrasulcular incision full thickness flap can move around when only held in place with sutures. 2. The clot will cause substantial swelling, pain, and inflammation as macrophages and other immune system/inflammatory components are attracted to the clot to resorb the clot and repair the injury. 3. Bruising will be increased There is some wound shrinkage that can expose crown margins but I have found that the marginal gingiva returns to it's normal position in a month or two. If you eliminate excessive clot formation pain is so minimal that I rarely prescribe narcotics after a surgery. In fact there is less post op pain after a surgery than most non-surgical endo. In the case I think an intrasulcular incision would have excessive since the etiology was apparent and I knew I only would need access to the tip of the apex. I didn't even have to create a bony crypt to get the job done. - Randy I agree with all of your comments. Sometimes in thin tissue types or perio cases, I will make my incision at the m-g junction and stay away from from free edge, but the full elevation is the way I was actually taught to do the procedure a long time ago. - Gary Very neat - been there myself in the days before RootZX - Simon

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