Augmentation of the Inferior Border of the Mandible

Mandibular augmentation refers to surgical procedures aimed at increasing the height or contour of the mandible, particularly the inferior border. This type of augmentation is often performed to improve the support for dentures, enhance facial aesthetics, or correct deformities. Below is an overview of the advantages and disadvantages of augmenting the inferior border of the mandible.

Advantages of Inferior Border Augmentation

1. Preservation of the Vestibule:

   • The procedure does not obliterate the vestibule, allowing for the immediate placement of an interim denture. This is particularly beneficial for patients who require prosthetic support soon after surgery.

2. No Change in Vertical Dimension:

   • Augmentation of the inferior border does not alter the vertical dimension of the occlusion, which is crucial for maintaining proper bite relationships and avoiding complications associated with changes in jaw alignment.

3. Facilitation of Secondary Vestibuloplasty:

   • The procedure makes subsequent vestibuloplasty easier. By maintaining the vestibular space, it allows for better access and manipulation during any future surgical interventions aimed at deepening the vestibule.

4. Protection of the Graft:

   • The graft used for augmentation is not subjected to direct masticatory forces, reducing the risk of graft failure and promoting better healing. This is particularly important in ensuring the longevity and stability of the augmentation.

Disadvantages of Inferior Border Augmentation

1. Extraoral Scar:

   • The procedure typically involves an incision that can result in an extraoral scar. This may be a cosmetic concern for some patients, especially if the scar is prominent or does not heal well.

2. Potential Alteration of Facial Appearance:

   • If the submental and submandibular tissues are not initially loose, there is a risk of altering the facial appearance. Tight or inelastic tissues may lead to distortion or asymmetry postoperatively.

3. Limited Change in Superior Surface Shape:

   • The augmentation primarily affects the inferior border of the mandible and may not significantly change the shape of the superior surface of the mandible. This limitation can affect the overall contour and aesthetics of the jawline.

4. Surgical Risks:

   • As with any surgical procedure, there are inherent risks, including infection, bleeding, and complications related to anesthesia. Additionally, there may be risks associated with the grafting material used.

Classification and Management of Impacted Third Molars

Impacted third molars, commonly known as wisdom teeth, can present in various orientations and depths, influencing the difficulty of their extraction. Understanding the types of impactions and their classifications is crucial for planning surgical intervention.

Types of Impaction

1. Mesioangular Impaction:

   • Description: The tooth is tilted toward the second molar in a mesial direction.
   • Prevalence: Comprises approximately 43% of all impacted teeth.
   • Difficulty: Generally acknowledged as the least difficult type of impaction to remove.

2. Vertical Impaction:

   • Description: The tooth is positioned vertically, with the crown facing upward.
   • Prevalence: Accounts for about 38% of impacted teeth.
   • Difficulty: Moderate difficulty in removal.

3. Distoangular Impaction:

   • Description: The tooth is tilted away from the second molar in a distal direction.
   • Prevalence: Comprises approximately 6% of impacted teeth.
   • Difficulty: Considered the most difficult type of impaction to remove due to the withdrawal pathway running into the mandibular ramus.

4. Horizontal Impaction:

   • Description: The tooth is positioned horizontally, with the crown facing the buccal or lingual side.
   • Prevalence: Accounts for about 3% of impacted teeth.
   • Difficulty: More difficult than mesioangular but less difficult than distoangular.

Decreasing Level of Difficulty for Types of Impaction

• Order of Difficulty:
  • Distoangular > Horizontal > Vertical > Mesioangular

Pell and Gregory Classification

The Pell and Gregory classification system categorizes impacted teeth based on their relationship to the mandibular ramus and the occlusal plane. This classification helps assess the difficulty of extraction.

Classification Based on Coverage by the Mandibular Ramus

1. Class 1:

   • Description: Mesiodistal diameter of the crown is completely anterior to the anterior border of the mandibular ramus.
   • Difficulty: Easiest to remove.

2. Class 2:

   • Description: Approximately one-half of the tooth is covered by the ramus.
   • Difficulty: Moderate difficulty.

3. Class 3:

   • Description: The tooth is completely within the mandibular ramus.
   • Difficulty: Most difficult to remove.

Decreasing Level of Difficulty for Ramus Coverage

• Order of Difficulty:
  • Class 3 > Class 2 > Class 1

Pell and Gregory Classification Based on Relationship to Occlusal Plane

This classification assesses the depth of the impacted tooth relative to the occlusal plane of the second molar.

1. Class A:

   • Description: The occlusal surface of the impacted tooth is level or nearly level with the occlusal plane of the second molar.
   • Difficulty: Easiest to remove.

2. Class B:

   • Description: The occlusal surface lies between the occlusal plane and the cervical line of the second molar.
   • Difficulty: Moderate difficulty.

3. Class C:

   • Description: The occlusal surface is below the cervical line of the second molars.
   • Difficulty: Most difficult to remove.

Decreasing Level of Difficulty for Occlusal Plane Relationship

• Order of Difficulty:
  • Class C > Class B > Class A

Summary of Extraction Difficulty

• Most Difficult Impaction:
  • Distoangular impaction with Class 3 ramus coverage and Class C depth.
• Easiest Impaction:
  • Mesioangular impaction with Class 1 ramus coverage and Class A dep

Hockey Stick or London Hospital Elevator

The Hockey Stick Elevator, also known as the London Hospital Elevator, is a dental instrument used primarily in oral surgery and tooth extraction procedures. It is designed to facilitate the removal of tooth roots and other dental structures.

Design and Features

• Blade Shape: The Hockey Stick Elevator features a straight blade that is angled relative to the shank, similar to the Cryer’s elevator. However, unlike the Cryer’s elevator, which has a triangular blade, the Hockey Stick Elevator has a straight blade with a convex surface on one side and a flat surface on the other.

• Working Surface:

  • The flat surface of the blade is the working surface and is equipped with transverse serrations. These serrations enhance the instrument's grip and contact with the root stump, allowing for more effective leverage during extraction.

• Appearance: The instrument resembles a hockey stick, which is how it derives its name. The distinctive shape aids in its identification and use in clinical settings.

Principles of Operation

• Lever and Wedge Principle:
  • The Hockey Stick Elevator operates on the same principles as the Cryer’s elevator, utilizing the lever and wedge principle. This means that the instrument can be used to apply force to the tooth or root, effectively loosening it from the surrounding bone and periodontal ligament.
• Functionality:
  • The primary function of the Hockey Stick Elevator is to elevate and luxate teeth or root fragments during extraction procedures. It can be particularly useful in cases where the tooth is impacted or has a curved root.

Mandibular Tori

Mandibular tori are bony growths that occur on the mandible, typically on the lingual aspect of the alveolar ridge. While they are often asymptomatic, there are specific indications for their removal, particularly when they interfere with oral function or prosthetic rehabilitation.

Indications for Removal

1. Interference with Denture Construction:

   • Mandibular tori may obstruct the proper fitting of full or partial dentures, necessitating their removal to ensure adequate retention and comfort.

2. Ulceration and Slow Healing:

   • If the mucosal covering over the torus ulcerates and the wound exhibits extremely slow healing, surgical intervention may be required to promote healing and prevent further complications.

3. Interference with Speech and Deglutition:

   • Large tori that impede normal speech or swallowing may warrant removal to improve the patient's quality of life and functional abilities.

Surgical Technique

1. Incision Placement:

   • The incision should be made on the crest of the ridge if the patient is edentulous (without teeth). This approach allows for better access to the torus while minimizing trauma to surrounding tissues.
   • If there are teeth present in the area, the incision should be made along the gingival margin. This helps to preserve the integrity of the gingival tissue and maintain aesthetics.

2. Avoiding Direct Incision Over the Torus:

   • It is crucial not to make the incision directly over the torus. Incising over the torus can lead to:
     • Status Line: Leaving a visible line on the traumatized bone, which can affect aesthetics and function.
     • Thin Mucosa: The mucosa over the torus is generally very thin, and an incision through it can result in dehiscence (wound separation) and exposure of the underlying bone, complicating healing.

3. Surgical Procedure:

   • After making the appropriate incision, the mucosal flap is elevated to expose the underlying bone.
   • The torus is then carefully removed using appropriate surgical instruments, ensuring minimal trauma to surrounding tissues.
   • Hemostasis is achieved, and the mucosal flap is repositioned and sutured back into place.

4. Postoperative Care:

   • Patients may experience discomfort and swelling following the procedure, which can be managed with analgesics.
   • Instructions for oral hygiene and dietary modifications may be provided to promote healing and prevent complications.

5. Follow-Up:

   • Regular follow-up appointments are necessary to monitor healing and assess for any potential complications, such as infection or delayed healing.

Osteoradionecrosis

Osteoradionecrosis (ORN) is a condition that can occur following radiation therapy, particularly in the head and neck region, leading to the death of bone tissue due to compromised blood supply. The management of ORN is complex and requires a multidisciplinary approach. Below is a comprehensive overview of the treatment strategies for osteoradionecrosis.

1. Debridement

• Purpose: Surgical debridement involves the removal of necrotic and infected tissue to promote healing and prevent the spread of infection.
• Procedure: This may include the excision of necrotic bone and soft tissue, allowing for better access to healthy tissue.

2. Control of Infection

• Antibiotic Therapy: Broad-spectrum antibiotics are administered to control any acute infections present. However, it is important to note that antibiotics may not penetrate necrotic bone effectively due to poor circulation.
• Monitoring: Regular assessment of infection status is crucial to adjust antibiotic therapy as needed.

3. Hospitalization

• Indication: Patients with severe ORN or those requiring surgical intervention may need hospitalization for close monitoring and management.

4. Supportive Treatment

• Hydration: Fluid therapy is essential to maintain hydration and support overall health.
• Nutritional Support: A high-protein and vitamin-rich diet is recommended to promote healing and recovery.

5. Pain Management

• Analgesics: Both narcotic and non-narcotic analgesics are used to manage pain effectively.
• Regional Anesthesia: Techniques such as bupivacaine (Marcaine) injections, alcohol nerve blocks, nerve avulsion, and rhizotomy may be employed for more effective pain control.

6. Good Oral Hygiene

• Oral Rinses: Regular use of oral rinses, such as 1% sodium fluoride gel, 1% chlorhexidine gluconate, and plain water, helps prevent radiation-induced caries and manage xerostomia and mucositis. These rinses can enhance local immune responses and antimicrobial activity.

7. Frequent Irrigations of Wounds

• Purpose: Regular irrigation of the affected areas helps to keep the wound clean and free from debris, promoting healing.

8. Management of Exposed Dead Bone

• Removal of Loose Bone: Small pieces of necrotic bone that become loose can be removed easily to reduce the risk of infection and promote healing.

9. Sequestration Techniques

• Drilling: As recommended by Hahn and Corgill (1967), drilling multiple holes into vital bone can encourage the sequestration of necrotic bone, facilitating its removal.

10. Sequestrectomy

• Indication: Sequestrectomy involves the surgical removal of necrotic bone (sequestrum) and is preferably performed intraorally to minimize complications associated with skin and vascular damage from radiation.

11. Management of Pathological Fractures

• Fracture Treatment: Although pathological fractures are not common, they may occur from minor injuries and do not heal readily. The best treatment involves:
  • Excision of necrotic ends of both bone fragments.
  • Replacement with a large graft.
  • Major soft tissue flap revascularization may be necessary to support reconstruction.

12. Bone Resection

• Indication: Bone resection is performed if there is persistent pain, infection, or pathological fracture. It is preferably done intraorally to avoid the risk of orocutaneous fistula in radiation-compromised skin.

13. Hyperbaric Oxygen (HBO) Therapy

• Adjunctive Treatment: HBO therapy can be a useful adjunct in the management of ORN. While it may not be sufficient alone to support bone graft healing, it can aid in soft tissue graft healing and minimize compartmentalization.

Glasgow Coma Scale (GCS): Best Verbal Response

The Glasgow Coma Scale (GCS) is a clinical scale used to assess a patient's level of consciousness and neurological function, particularly after a head injury. It evaluates three aspects: eye opening, verbal response, and motor response. The best verbal response (V) is one of the components of the GCS and is scored as follows:

Best Verbal Response (V)

• 5 - Appropriate and Oriented:

  • The patient is fully awake and can respond appropriately to questions, demonstrating awareness of their surroundings, time, and identity.

• 4 - Confused Conversation:

  • The patient is able to speak but is confused and disoriented. They may answer questions but with some level of confusion or incorrect information.

• 3 - Inappropriate Words:

  • The patient uses words but they are inappropriate or irrelevant to the context. The responses do not make sense in relation to the questions asked.

• 2 - Incomprehensible Sounds:

  • The patient makes sounds that are not recognizable as words. This may include moaning or groaning but does not involve coherent speech.

• 1 - No Sounds:

  • The patient does not make any verbal sounds or responses.