5. Surgery overview

Surgery

Luc Vrielinck Afdeling Mond-,Kaak- en Aangezichtsheelkunde Ziekenhuis Oost-Limburg, Genk

Overview   

Anesthesy techniques Surgery Postoperative care

Anesthesy techniques    

Local anesthesy Loco-regional Loco-regional + sedation General anesthesy

NB 30 min before surgery glucocorticoid IM or IV

Anesthesy techniques    

Local anesthesy Loco-regional Loco-regional + sedation General anesthesy

Local anesthesy 

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Buccally up to infraorbital nerve Palatal infiltration 

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incl. palatine nerve and incisal canal

Externally: zygomatic region

Anesthesy techniques    

Local anesthesy Loco-regional Loco-regional + sedation General anesthesy

Regional anesthesy 

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Maxillary nerve block = Pterygopalatine block Necessary for pterygoid implants Techniques: Intraorally  Externally 

Pterygoid block intraorally Needle 8-10 cm  Needle in line with the pupil  In lateral view midpoint of the zygomatic arch  Insert until contact with roof of infratemporal fossa  Tilt the point upwards for 30° and inject 5 ml 

Pterygoid block intraorally

Pterygoid block extraorally   

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Coronoid notch Mouth half-opened Perpendicular insertion At 5 cm depth contact with lateral pterygoid plate Tilt 30° anterior and insert 1 cm deeper before injecting 5 ml

Neural blockade in clinical anesthesia and management of pain by Michael J. Cousins, Phillip O. Bridenbaugh Edition: 3, published by Lippincott Williams & Wilkins, 1998 ISBN 0397511590, 9780397511594

Pterygoid block 

Possible complications: 

Hematoma 

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Temporal hematoma: Branches of facial artery Through inferior orbital fissure: black eye

Trismus by hematoma in pterygoid muscles Temporary blindness by spread to optical nerve

Treatment: conservative: resolves in a few days

Anesthesy techniques    

Local anesthesy Loco-regional Loco-regional + sedation General anesthesy

Loco-regional anesthesy + sedation  

IV access Monitoring Pulse-oximeter  ECG  Bloodpressure monitoring 

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Recovery room 2h

Medication 

Benzodiazepines Anxiolytic  Sedation  Anticonvulsant  Muscle relaxation  Retrograde amnesia 

Benzodiazepines    

Very short: Short: Long: Anxiolytic:

midazolam(Dormicum® 0.5-2.5mg) lorazepam (Temesta® 1–2.5 mg) nitrazepam (Mogadon® 2.5 mg) alprazolam (Xanax Retard 1-2 mg)

Anesthesy techniques    

Local anesthesy Loco-regional Loco-regional + sedation General anesthesy

Anesthesy technique 

General anesthesia: day-clinic Classic operation room setting  Preoperative screening (>40 year or ASA score >1) 

ASA Score  A normal healthy patient.  A patient with mild systemic disease.  A patient with severe systemic disease.  A patient with severe systemic disease that is a constant threat to life.  A moribund patient who is not expected to survive without the operation.  A declared brain-dead patient whose organs are being removed for donor purposes.

Overview   

Anesthesy techniques Surgery Postoperative care

Zygoma implant Surgery 

Incision Lefort I  Crestal  10 mm palatal 

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Distal relieving incision

Zygoma Implant Surgery 

Prelevation of buccal flap Up to the infraorbital nerve  Distally up the inferolateral border (try to avoid Bichat fat)  Laterally up to the zygomatic bone 

Zygoma Implant Surgery 

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Prelevation of palatal flap sometimes section of the incisal nerve Palatal entry point for the drill must be visible

Zygoma Implant Surgery 

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Anterior maxillary antrotomy (10 x 5 mm) Far enough laterally and cranially Maxillary surface of the zygomatic bone must be visible Ideally Schneiderian membrane kept intact

Zygoma Implant Surgery 

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Handpiece zygoma 20:1 Max 2000 r/min

Zygoma Implant Surgery 

Select entry point Close to the dentoalveolar border  2 mm round drill 

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Select emergence point on the zygoma

Zygoma Implant Surgery ď Ž

ď Ž

Check intended drilling direction using a special retractor Implant follows inferolateral border

Zygoma Implant Surgery 

Mark drill Round  Ø 2,9 mm 

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Protect overlying soft tissues Recheck drilling position

Zygoma Implant Surgery   

Twist drill Ø 2,9 mm Pilot drill Ø 3,5 mm Twist drill Ø 3,5 mm

Zygoma Implant Surgery Depth gauge to select correct implant length ď Ž

Implant lengths: 30 35 40 42,5 45 47,5 50 52,5 ď Ž

Zygoma Implant Surgery 

Machined zygoma

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TiUnite zygoma

Zygoma Implant Surgery  

Installation of implants 3 important points: Insert implant following drilled trajectory  If drilling unit blocks before reaching depth: consider redrilling  Consider rotation of the implant head 

Zygoma Implant Surgery ď Ž

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Connection to handpiece Engage the implant and bring it intraorally

Zygoma Implant Surgery ď Ž

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Use slow speed drilling to engage the implant Continue with manual insertion with the handle

Zygoma Implant Surgery 

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Connect handle with adapter to the implant Rotate manually clockwise Do no apply bending forces

Zygoma Implant Surgery 

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Check correct implant head position Remove implant mount Place cover screw with hexagonal driver

Zygoma Implant Surgery 

Suturing Vicryl 4/00 resorbable sutures  Single and matrass sutures 

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Abutments connection After 6 months  Two lengths of zygoma abutments 

Overview   

Anesthesy techniques Surgery Postoperative care

Postoperative care    

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Cold pack application Pain killer: Dafalgan®, paracetamol /6h Nasal decongestive: Vibrocyl® spray 3/d Antihistaminic: dexchloorfeniramine Polaramine® repetab 1 x / d Antibiotics: Clindamycin DalacinC 300 mg 3X/day

Postoperative care 

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No prosthesis wearing until postoperative swelling has disapeared (10-14 days) Prothesis is released on implantation sites Aplication of soft relining in the prothesis eg CoeSoft (GC) to be repeated until definitive relining Inadequate adaptation of the prothesis may cause rotation of the implants !!

Where can we place long implants?   

Zygoma Pterygoid/Sphenoid Skull base

Zygomatic bone

Maximum 4

Pterygoid

Sphenoid

Maximum 2

Maximum 2

Where can we place long implants? 

Zygoma Intrasinusal Brånemark  Perforating ant maxillary wall Stella  Extramaxillary Miglioranca / Malo  External sinus lifting Hinze/ Vrielinck  Quad zygoma 

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Pterygoid Skull base bone

Vrielinck Vrielinck

Intrasinusal zygoma

Where can we place long implants? 

Zygoma Intrasinusal Brånemark  Perforating ant maxillary wall Stella  Extramaxillary Miglioranca / Malo  External sinus lifting Hinze/ Vrielinck  Quad zygoma 

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Pterygoid Skull base bone

Vrielinck Vrielinck

Anterior slot technique Stella

Where can we place long implants? 

Zygoma Intrasinusal Brånemark  Perforating ant maxillary wall Stella  Extramaxillary Miglioranca / Malo  External sinus lifting Hinze/ Vrielinck  Quad zygoma 

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Pterygoid Skull base bone

Vrielinck Vrielinck

Extramaxillary

Where can we place long implants? 

Zygoma Intrasinusal Brånemark  Perforating ant maxillary wall Stella  Extramaxillary Miglioranca / Malo  External sinus lifting Hinze/ Vrielinck  Quad zygoma 

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Pterygoid Skull base bone

Vrielinck Vrielinck

External sinus lifting

Where can we place long implants? 

Zygoma Intrasinusal Brånemark  Perforating ant maxillary wall Stella  Extramaxillary Miglioranca / Malo  External sinus lifting Hinze/ Vrielinck  Quad zygoma 

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Pterygoid Skull base bone

Vrielinck Vrielinck

Quad zygoma

Where can we place long implants? 

Zygoma Intrasinusal Brånemark  Perforating ant maxillary wall Stella  Extramaxillary Miglioranca / Malo  External sinus lifting Hinze/ Vrielinck  Quad zygoma 

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Pterygoid Skull base bone

Vrielinck Vrielinck

Pterygoid / Sphenoid

Where can we place long implants? 

Zygoma Intrasinusal Brånemark  Perforating ant maxillary wall Stella  Extramaxillary Miglioranca / Malo  External sinus lifting Hinze/ Vrielinck  Quad zygoma 

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Pterygoid Skull base bone

Vrielinck Vrielinck

Skull base