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
Buccally up to infraorbital nerve Palatal infiltration
incl. palatine nerve and incisal canal
Externally: zygomatic region
Anesthesy techniques
Local anesthesy Loco-regional Loco-regional + sedation General anesthesy
Regional anesthesy
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
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
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
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
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
Prelevation of palatal flap sometimes section of the incisal nerve Palatal entry point for the drill must be visible
Zygoma Implant Surgery
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
Handpiece zygoma 20:1 Max 2000 r/min
Zygoma Implant Surgery
Select entry point Close to the dentoalveolar border 2 mm round drill
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
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
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
ď Ž
Connection to handpiece Engage the implant and bring it intraorally
Zygoma Implant Surgery ď Ž
ď Ž
Use slow speed drilling to engage the implant Continue with manual insertion with the handle
Zygoma Implant Surgery
Connect handle with adapter to the implant Rotate manually clockwise Do no apply bending forces
Zygoma Implant Surgery
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
Abutments connection After 6 months Two lengths of zygoma abutments
Overview
Anesthesy techniques Surgery Postoperative care
Postoperative care
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
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
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
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
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
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
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
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
Pterygoid Skull base bone
Vrielinck Vrielinck
Skull base