Дентал центр "Ліпінський"
SURGERY

Dental surgery. Teeth extraction, sinus lift
Dental surgery is a treatment methodology of advanced diseases of the oral cavity, which includes surgery of teeth extraction, bone grafting, preparation for dental implantation and various esthetic manipulations. As a rule, doctors turn to dental surgery in those instances where therapeutic intervention is ineffective.
1. TOOTH EXTRACTION
Modern dentistry uses delicate solutions for painless tooth extraction. Any extraction is surgery under anesthesia, which is carried out only as a last resort when the tooth can't be saved and it can only be extracted from the alveolar socket. Depending on the reasons, which caused the extraction, there are elective and urgent surgeries.
The necessity of urgent extraction appears in the case of severe toothache when acute suppurating inflammation is spreading to the bone. And the elective surgery is a necessary treatment method of an underlying disease.
INDICATIONS:
✓ diagnosing of acute tooth disease, which is dangerous to the whole organism;
✓ impossibility of the use of non-surgical treatment methods;
✓ destruction of the crown or root as a result of advanced caries and its complications or trauma;
✓ tooth malalignment, which prevents dental prosthetics or bite correction.
Depending on the complexity of each particular case, there are two types of tooth extraction in dentistry – simple and surgical.

SIMPLE EXTRACTION takes several minutes and is used when the doctor must extract the tooth with one root. This procedure doesn't require complex tools, forceps and elevators will do – the tooth is intensively loosened and removed from the alveolar bone of the jaw.

SURGICAL EXTRACTION can take a long time if the root is complex and has several branches. In this case, the tooth is split up with a drill and taken out of the gum in pieces. This wound is stitched up after the extraction.
REVIEWS OF OUR PATIENTS:
2. ATYPICAL EXTRACTION: WISDOM TEETH
Wisdom teeth (third molars) – eighth in succession teeth starting with the arch center. They usually emerge at the age of 18-27 years, sometimes later, sometimes they don't emerge at all.

Distinctive features:
- they emerge in the formed bone tissue;
- they don't have the adjacent tooth on one side;
- absent baby tooth, which prepares the permanent one.
The main reason for the necessity of surgery of wisdom tooth extraction is malalignment. It can grow towards the adjacent tooth or jaw, traumatizing the surrounding tissue and roots of the adjacent teeth, causing the sense of discomfort, which evolves into the pain and inflammatory process.

It's not only bones, which can hinder the wisdom tooth but also the gum, which is why the growth causes a range of inconveniences: pain when chewing, risk of displacement of adjacent teeth that will change the bite etc.
There are 4 types of wisdom tooth impactions:
  1. distal – grows towards the other teeth;
  2. mesial – overlaps the existing teeth;
  3. horizontal – is placed perpendicularly to the others;
  4. vertical – unable to emerge.
Symptomatology:
- Acute, aching or colicky pain.
- Redness and swelling of the gum in the area of the tooth.
- Inflammatory fluid buildup admixed with leucocytes and other cells under the gum.
- General disorder of a body state: heat, fatigue, loss of appetite, headache.
Wisdom teeth aren't useful, they can be a support for the prosthesis and they can facilitate the preservation of the bone tissue if there are no other molars. However, if the wisdom tooth is aching, you should visit a dentist, who will make the right decision after the examination and diagnosing. Most times the therapeutic impact on the wisdom teeth is ineffective, so the extraction is the preferred treatment method.

Wisdom tooth extraction is a quite difficult procedure, which is carried out on an outpatient basis under the local anesthesia and antibacterial therapy.
Extraction stages:
  1. Gum incision and separation from the tooth neck.
  2. Removal of the bone under the tooth with the dental drill or ultrasound.
  3. Extraction.
  4. Alveolar socket treatment with a sanitizer.
  5. Suturing the gum.
* Postoperative period lasts a few days or a week; in some instances, the doctor assigns a special diet and systemic therapy.
3. DENTAL SURGERY
Dental surgery combines the numerous treatment methods of inflammatory diseases of teeth, bone tissue, gum, mucous membranes, and palate. It's characterized by abscess opening and sanitation of affected surface combined with antibacterial and pain-killer therapy.
TOOTH RESECTION is a type of root surgery, which makes it possible to remove the affected tip of a tooth root and to leave the materials of cysts, root tip and other ones to save the tooth. The root most often becomes a center of an inflammatory process, so the resection helps to get rid of pain, sense of discomfort and prevents the deterioration. Resection includes the removal of inflamed cells and partial removal of the affected area of the root.
Indications for tooth root resection:
✓ inflammatory disease in the root tip;
✓ other methods of nerve canal treatment are ineffective.
Surgery is carried out under local anesthesia and in several stages:
  1. Pulp removal
  2. Obturation of canals of the aching tooth.
  3. The gum is cut and peeled, then the incision in bone tissue is made to get access to the bone.
  4. The inflamed tissue is removed from the formed cavities.
  5. The fragment of the root is cut off with the drill (the cavity is scraped off if needed).
  6. Treatment with a sanitizer is provided, bone tissue is restored and the formed empty space is filled with a synthetic material.
  7. The doctor sutures the area of surgical intervention and places the special protective membrane, which is absorbed after a while.
Traumatized tissue is restored rather quickly after the surgery, however, bone tissue regenerates at least in a month.
TOOTH ROOT EXTRACTION is a surgery of extraction of all tooth roots, which are affected by the inflammatory process. A doctor makes a decision about this surgery only after a thorough examination and X-ray study.

Relative contraindications of the extraction of the roots:
  1. Blood disease.
  2. Diabetes.
  3. Pregnancy.
  4. Mental disorders.
  5. Cardiovascular diseases.

Extraction is carried out the same way and in the same stages as the resection.
PERIODONTAL SURGERY – operative (surgical) intervention in case of a significant inflammatory process in soft tissue, which caused periodontitis or periodontal disease.

The following treatment methods are used when there are signs of these diseases:
  1. Gum pockets resection.
  2. Soft tissue transplantation (preventing the fusion of gum pockets).
  3. Bone tissue restoration with the use of synthetic materials.
  4. Pocket purification in case of destruction of periodontal ligaments and soft tissue.
  5. Flap surgery is the cleaning of deep sub-gingival deposit in bone pockets.
GUM POCKET RESECTION is a surgery of removal of gum fragment, which detached from the tooth with the removal of gumline to a depth of up to 3 mm. The remaining part of gum pockets is treated with curettage or ultrasound and is covered with a bandage. The tampons, soaked in 2% hydrogen peroxide are placed if needed.

Gum pocket resection helps to clean the deep cavities, where the supportive environment for bacterial growth develops as a result of food getting inside.
FLAP SURGERY is needed for one tooth in severe cases if there are multiple deep periodontal pockets and significant involvement of bone tissue in the inflammatory process. After numbing the area with a local anesthetic, the mucoperiosteal flap is formed with the incisions, partial gingivectomy is carried out, sub-gingival deposit and granulation are removed, and the tooth root is planed. To make up for the loss of bone tissue, the bone-forming materials are used. The flap then is anchored in place using stitches and your periodontist may cover the surgical site with an intraoral bandage.
Types of flap surgery:
  1. bone pockets surgery.
  2. gum shape correction.
  3. guided periodontal tissue regeneration.
  4. secondary engraftment surgery.
  5. mucoperiosteal surgery.
  6. combined one.
Indication for the flap surgery:
  • Bleeding and gum inflammation, which make it difficult to eat and maintain hygiene.
  • Significant displacement / loosening of one or several teeth.
  • Gum contour defect.
  • Second-degree teeth loosening.
  • The depth of periodontal pockets is more than 5 mm.
  • The necessity of gumline correction.
Your doctor will first remove plaque and tartar (calculus) from around your teeth and conduct anti-inflammatory therapy. The main point of the surgery is to get open access to the site of inflammation with the purpose of removal.

The doctor makes several gum incisions to form the flap and to get access to the roots. This enables him to purify the root of sub-gingival deposit: pus, granulation, inflamed tissue. After the necessary manipulations, the flap is sewed back and covered with a special bandage.
Possible complications after the flap surgery:
- Soft tissue swelling, which goes away in a few days.
- Increased sensitivity of tooth neck, which becomes normal if using special toothpaste.
- Preservation of tooth loosening within a certain period of time (2-3 days).
FRENULOPLASTY is a surgery, which corrects the mucous membranes of the oral cavity that are responsible for proper bite, clear speech, and smile esthetics. Depending on medical indications, the doctor can carry out the surgery of upper lip frenulum, lower lip frenulum, and tongue frenulum.

It's used to get rid of speech problems, trouble breathing, swallowing problems, the inadequate blood supply of tissues that surround the lips, malocclusion.
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SINUS LIFT is a surgery, which is aimed at the bone augmentation in the area of premolar or molar teeth of the upper jaw, in case of a loss in bone height. It's done by lifting the sinus floor by a detachment of the sinus membrane, which the bone graft is placed under. This bone graft later becomes the patient's own bone tissue.
Types of sinus lift:
  • Direct – a window is made on the lateral wall of the maxillary sinus, which enables the doctor to exfoliate the sinus membrane with special tools and to place the bone graft.
  • Indirect – an implant site is prepared in the bone ridge, 1 mm above the sinus floor. Then the remaining bone is broken inside lifting the sinus floor.

Before the bone tissue insertion, the Schneider membrane is protected with collagen or fibrin membrane.
BONE GRAFTING OF THE LOWER JAW is an increase in the amount of bone tissue, which is often necessary during the implant placement. Bone grafting of the posterior mandible is needed in case of a reduction of height and width of the alveolar process and reduction of distance to the mandibular canal. Significant loss of bone amount in the lower jaw can lead to the proper bite turning into the mesial one (when the lower jaw moves forward).
4. MATERIALS USED IN SURGERIES
DENTAL MEMBRANE is a thin elastic material, which resembles a sponge cloth, it's placed on jawbones under the gum to hold the osteoplastic material or implants. Almost every bone augmentation surgery requires membranes – they're widely used not only during flap surgeries but also during the reconstruction of big amounts of bone.
The use of membranes helps to prevent the bone resorption and prepare the tissue for the implant placement surgeries. In modern dentistry membranes are used during the implant placement, to restore the amount of the jawbone, to fix loosened teeth in periodontics, and to prevent the bone resorption.
Depending on the material, there are 2 types of membranes:
Non-resorbable – made of dense hypoallergenic and biocompatible titanium, which doesn't resorb in time and they're removed surgically.
Resorbable – made of biodegradable materials, resorb after a while without additional manipulations and reoperations.

The most widespread ones are natural resorbable membranes made of collagen, which resorb under the influence of natural ferments without inflaming the surrounding tissue. Separation of soft tissue occurs far less often than if using non-resorbable membrane: no inflammatory processes, no rejection by the organism, no allergic reaction.
Membranes are placed:
✓ to prevent the bone resorption after the tooth extraction;
✓ to fix the minerals of bone material during its insertion for the bone augmentation;
✓ during the bone augmentation in blocks;
✓ as a reinforcing means during the implant placement;
✓ during the periodontal flap surgery to fix the loosened teeth, which is caused by periodontitis.
DENTAL PINS are the elements for stable and durable fixation of membranes in the case of guided bone regeneration.

They are contraindicative at hypersensitivity and they might cause side effects: allergic reaction and minor burns of the oral cavity due to the use of the concentrated solution.
BONE GRAFT is a material to restore the bone tissue during the surgery. It's needed as a rule in those cases where there isn't enough amount of bone tissue in the place of implant fixation. Organic or synthetic special material, which has one or two properties: osteoconductive (to form the bone) і osteoinductive (to accelerate the bone tissue restoration).
A bone graft can be natural or synthetic.
Natural:
  • Autograft is a patient's bone, which was taken from another body zone (hip or chin). It's the best option because it has both properties and doesn't cause rejection. The only disadvantage is that the additional surgical manipulation is needed to take it.
  • An allograft is also a part of human bone, however, it's of another person. The advantage is that additional surgical intervention isn't needed. There's one disadvantage – the risk of rejection.
  • A xenograft is a material of animal origin, most times it's taken from cattle. It has only an osteoinductive property. It's not suitable for all types of surgeries, it's as a rule used in surgery of sinus lift.
Synthetic bone graft material – human-made material based on calcium phosphates (or orthophosphates), bioactive glass and calcium sulfate. To make it, advanced technologies are being used, and the researches in the field of biochemistry and molecular biology are being done.
Advantages of synthetic bone grafts in dental surgery are the following:
✓ Excellent survival.
✓ Sterility and absence of postoperative complications.
✓ Ability to biodegrade.
✓ Acceleration of regeneration of the patient's own bone tissue.
✓ No allergic reactions.
✓ Elimination of risk of getting an injury.
Disadvantage:
- no osteoinductive property.
The bone graft can have the following properties:
  • Osteoconductive — to form the bone;
  • Oseteoinductive — to accelerate the regeneration of bone tissue.
SUTURAL MATERIAL is a medical means to tighten the tissues during surgery.

Distinguished by structure and biodegradation speed, materials can be:
  • monofilament (filaments of a single strand, with a smooth structure);
  • multifilament (multiple filaments braided together) and combined ones.

By biodegradation speed:
  • absorbable;
  • non-absorbable.

The choice of suture material depends on its physical and biological properties, which influence on the healing process of a postoperative wound, and on the possible reaction of the organism. They can be absorbable and non-absorbable. Absorbable strands can have various resorption period (from one week to two months).
5. CENTRIFUGE AND ITS USE IN DENTISTRY
A dental centrifuge is a device, meant for separating granular materials and liquids of different specific gravities. It's done with the use of centrifugal force. The centrifuge is the necessary device to conduct a plasma therapy, for example, PRP treatment, as a result of which the postoperative period proceeds painlessly.

Plasma is used during implant placement, teeth extraction, and bone surgery.

Plasma contains growth factors, which facilitate the bone augmentation, wound healing, bone epithelialization. Biocompatibility and use of plasma have no contraindications.
ADVANTAGES:
✓ Acceleration of growth of bone tissue cells.
✓ Fast tissue regeneration.
✓ Postoperative swelling reduction.
✓ No allergic reactions.
✓ Peri-implantitis prevention.
✓ Fast healing of mucous membranes.
✓ Gum inflammation reduction.
6. PRP TREATMENT IN DENTISTRY
PRP treatment in dentistry is an injection of platelet-rich plasma in the gum tissue. Plasma is isolated from the patient's blood, which was centrifuged. Plasma contains a lot of proteins, ferments, and hormones, which facilitates regeneration not only of soft tissue but also of bone tissue.

PRP treatment is successfully used in dentistry to solve periodontal problems and to reduce the rehabilitation time after the surgical intervention.

Plasma derives from the centrifugation, and it's supplemented with additional platelet, which facilitates the growth and expansion of cells that are responsible for the restoration and healing of damaged tissue.
Plasma injections provide the following effects:
- reduction of the sense of discomfort in the gum;
- enhancing the process of tissue regeneration;
- reduction of gum bleeding, vessel strengthening;
- immunity improvement;
- fast implant healing;
- reduction of risk of implant failure;
- restoration of gum anatomy;
- acceleration of alveolar socket healing after surgical or atypical tooth extraction;
- gum tissue nutrition, stimulation of blood circulation and bone tissue restoration;
- reduction of teeth loosening.
ADVANTAGES:
✓ no allergic reactions, because only the patient's own tissue is used;
✓ no possibility to transmit the infection by blood;
✓ no side effects and influence on the internal organs;
✓ covers a wide range of indications;
✓ is used in combined therapy;
✓ non-addictive.
DISADVANTAGES:
- PRP treatment is a new procedure and it isn't widespread yet;
- requires expensive equipment, certain doctor's skills, and additional staff.
- the procedure might cause redness, swelling, hematomas, but these symptoms go away in a few days.
Cellulitis is a diffuse purulent-necrotic process in subcutaneous fat. It's accompanied by heat, change (worsening) of overall condition, significant local edema of soft tissue, painful infiltration, function abnormality (eating, swallowing, breathing and speech), hyperemia of skin cover, and possible signs of lymphadenitis. It's identified by severe pain in the area of face and neck and in hyperemic lymph nodes. Exacerbation of this disease is accompanied by trouble breathing, eating, swallowing and the emergence of speech problems. Treatment is provided in the special hospital – maxillofacial unit.
A subperiosteal abscess is a local pus process, caused by an accumulation of pus on the internal or external surface of the alveolar process of the jaw.
The treatment provides the abscess opening and drainage with medication therapy.