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Dental Notes

Mandible Fracture

PREOPERATIVE DIAGNOSIS: Mandible fracture.

POSTOPERATIVE DIAGNOSIS: Mandible fracture.

OPERATION: Examination under anesthesia of mandible. Extraction of nonviable/exfoliating teeth.

ANESTHESIA: General endotracheal anesthesia.

INTRAVENOUS FLUIDS: See nurse’s records.

ESTIMATED BLOOD LOSS: See nurse’s records.

COMPLICATIONS: None.

FINDINGS: Reproducible occlusion, several lower jaw exfoliating teeth and nonviable teeth.

INDICATIONS: The patient is an 8-year-old girl who fell 1 flight of stairs. She fell onto her jaw. The patient presented to the Emergency Department with pain, open bite deformity, and decreased sensation of the right lower lip. A CT scan was obtained and it demonstrated evidence of bilateral condylar fractures as well as potential greenstick fractures of the body.

On examination, however, the patient was difficult to exam secondary to pain related to the examination. As a result, the patient was planned for examination under anesthesia, possible open reduction and internal fixation of mandible fracture. Risks, benefits, and alternatives were discussed with the patient’s parents who wished to proceed with surgery.

PROCEDURE: The patient was taken to the operating room and placed on the operating table in the supine position. Once general endotracheal anesthesia was obtained via a nasotracheal intubation, the patient was draped in the usual manner. There was no mobility of the mandible at the apparent fracture lines. This was consistent with perhaps a greenstick fracture. Furthermore, there was reproducible occlusion. We did find several lower jaw exfoliating/nonviable teeth, particularly, there were 2 deciduous molars on the left and bilateral canines that needed to be removed secondary to either exfoliating or non-viability. We debrided the wound. We elevated gingival mucosa. We then placed Gelfoam in the socket. We sutured Vicryl over the socket to reapproximate the gingival mucosa. The patient was then extubated and taken to PACU in stable condition breathing spontaneously.

Mandible Fx (multiple)

PREOPERATIVE DIAGNOSIS: Multiple facial fractures including:
1. Comminuted mandible fracture.
2. Mandibular alveolar ridge fracture.
3. Bilateral LeFort II fractures.
4. Nasal complex bone fracture.

POSTOPERATIVE DIAGNOSIS: Multiple facial fractures including:
1. Comminuted mandible fracture.
2. Mandibular alveolar ridge fracture.
3. Bilateral LeFort II fractures.
4. Nasal complex bone fracture.

OPERATION:
1. Open reduction and internal fixation comminuted mandibular fracture.
2. Closed reduction alveolar ridge fracture with fixation with wires.
3. Placement intramaxillary fixation.
4. Bilateral LeFort II open reduction and internal fixation via multiple approaches.
5. Closed reduction of nasal fracture.
6. Complex closure lip laceration.

ANESTHESIA: General.

INDICATIONS: This is a 23-year-old gentleman who was involved in an incident in which there was an explosion of a pool filter pump; this hit him square in the face. He had significant trauma and was seen and evaluated in the ER, had a CT scan which showed the aforementioned injuries.

We discussed at length with the patient, operative repair of these. He was amendable and understood the risks and benefits of surgery including but not limited to bleeding, infection, malocclusion, remaining fractures requiring further surgical intervention, possible injury to teeth, nerves, and eyes, including but not limited to blindness. Given this, the patient signed informed consent and we proceeded with surgery today.

PROCEDURE: The patient was brought into the operating room, placed in a supine position. SCDs were placed on the lower extremities. General anesthesia was then induced, and a #7 endotracheal tube was placed via the left nares and directed down into appropriate position. This was then sutured into place with an 0 silk suture through the septum.

Next, the entire face was prepped and draped in the usual sterile fashion. Lidocaine 1% with epinephrine was then used to infiltrate along the upper and lower buccal sulci as well as both of the conjunctival areas down to the orbital rim. A total of 20 ml of 1% lidocaine with epinephrine was utilized for this.

Next, attention was turned towards the mandibular fracture. Incision was made along the lower buccal sulcus with a 15 blade followed by Bovie cautery directly on down to the bone. This was taken out in the symphyseal portion of the mandible leaving a cuff of approximately 5 to 7 mm in length and tracking it from that point approximately 3 cm in each direction coming up short of the expected position of the nerve on both sides. This dissection revealed a comminuted fracture over the symphyseal region extending more to the patient’s left side. There was also noted to be an alveolar ridge fracture involving the 4 lower incisors.

At this point, the first segment was identified to be fixated. This was the one on the most upper and right portion of it. This was a vertically/diagonally oriented fracture. This was opened up with a Freer elevator and then curetted with a microcurette along both edges to allow good approximation. At this point, there was good approximation, this by a combination of reduction manually from above, below, and within the mouth as well. Next, an X-plate of 1.7 in size was utilized. A total of 4 holes were used, placing it running in the direction of the fracture.

Once this was secured with 4 screws, attention was turned towards reducing the other fractures. The other fracture was a continuation of this fracture as well as along the other side of this fragment, which was approximately 1 cm in width. Another  X-type plate was placed. This was also 1.7 mm in size, fixating it with 4 screws, again with the plate direction run over the length of the fracture with screws on each side of it.

At this point there was good approximation and good strength to this. Along the mandibular border a 2.3 plate, 4-hole, was placed. This was placed with screws in the standard fashion. At this point, there was good fixation of this comminuted fracture. It was stable and appeared to be in good alignment.

Next, the alveolar ridge fell into what appeared to be good position and then fixated with #26 wires, first on the right and then on the left side via interdental wiring. At this point this was fixated quite well. The patient was then brought up into occlusion. This did not show perfect occlusion at this point as the midface was still somewhat impacted. The screws for maxillomandibular fixation were then placed. They were placed just posterior and just above the depth of the canine. First in the mandible, 14-mm screws were placed here followed by re-dissection on the maxillary side and placement of 8-mm screws there. Again, in the same position just posterior and just above the expected end of the canine. At this point the nasal Forceps were placed intranasally taking care along the now nasotracheal tube and via gentle rocking motion, the mid face was disimpacted, brought both down towards the patient’s feet and then as well as anteriorly pulling the patient’s head up toward the sky, off the table. At this point the segments did move, somewhat, and did appear to be free throughout. The patient was then able to be brought up into maxillomandibular fixation, at which point it appeared that there was a good occlusion hitting along all of the wear facets as expected. The wires were then placed, 24 gauge, and tightened down bringing the patient into good fixation.

At this point the upper buccal sulcus incision was made, again, leaving us approximately a 7-mm cuff. This was made with Bovie cautery through and then directly on down to the bone.

Just prior to opening the upper buccal sulcus, the lower buccal sulcus was closed. This was irrigated with a dilute Betadine solution followed by closure with a running 4-0 chromic suture.

Now, with the upper buccal sulcus incision made, periosteal Freer elevators were utilized along the periosteum to elevate, disclosing the fractures. There was a fracture quite posterior on the left side across the zygomaticomaxillary buttress as well as one on the medial side extending to the piriform aperture, involving the maxillonasal buttress. This was a free-floating segment, approximately a centimeter and half in diameter. Lateral to this on the left side, there was a free-floating segment which was depressed down which extended all the way through the zygomaticomaxillary buttress as well. This had essentially no support at this time.

Next, attention was turned on the right side again, dissected up to the piriform sinus and then across. Again, there was a fracture on the zygomaticomaxillary buttress on the right side, again quite lateral. There was also noted to be a fragmental fracture of the anterior maxillary sinus area, extending up into the area of the nasomaxillary buttress as well. At this point, both of the nerves had been identified of the infraorbital nerves, and both appeared to be intact and both were preserved during this dissection.

Attention was then turned towards transconjunctival approaches to get to the orbital rims. On the left side, the gray line was tacked with a 5-0 silk followed by 1 in the fornix area. Incision was then made with the Bovie cautery approximately 5 mm below the tarso border. This was then bluntly dissected with a hemostat down to the infraorbital rim and a combination of blunt dissection using malleable retractors and q-tips was utilized to expose the orbital rim.

At the orbital rim, all the fat had been retracted and this was then incised again with the Bovie pinpoint cautery through this. The fracture could be seen. It was quite medial and significantly displaced on the nasal side. This was then dissected in a subperiosteal plane. The orbital floor did have a fracture in it, but did not have a defect. All the bone was there, but a fracture running longitudinally within it. The dissection was carried laterally and then medially. This exposed that medial segment of the nasal bone, which did need fixation.

Attention was then turned to the right side. On this side, a similar approach was used to get down to the orbital rim, displaying once again a fracture. This was also at about the midportion to slightly medial in nature. This was dissected well using the Freer elevator to elevate the periosteum and had good exposure.

At this point attention was turned towards reapproximating and elevating all fractures. They were manually manipulated using a combination of skin hooks, Freer elevators, using both a transconjunctival as well as infraorbital approach along the upper buccal sulcus to line up the fragments. At this point, the patient was in maxillomandibular fixation with good occlusion as well the bones lined up well at the fracture segments, at the zygomaticomaxillary, and nasomaxillary buttress on the right side, the nasomaxillary buttress on the left side with the area in between the maxillary in the zygomatic area being with still a defect.

At this point plates were placed. First, an L-plate was placed, first on the left side, putting approximately 3 screws on each side of it, spanning the large area of defect from the maxillary to the zygoma area. Next, one was placed on the right side, again, in the same position over the zygomaticomaxillary area to support this. This was also a smaller L-shaped as there was a defect to span. On the nasomaxillary area, medially, plates were once again place, and again L-shaped plates were used, first on the left and then on the right. These were secured all with screws. A total of 2 screws were placed minimum on each side of each fracture. This had good reduction of all fragments. The free-floating fragment on the left side was pulled up into place and tacked down with a second plate. This was screwed into place. At this point we returned to the transconjunctival exposures.

The area was overall pretty good alignment of both as well as good general fixation on the right side. On the right side there was a 4-hole plate placed across the infraorbital rim, 2 screws were placed on each side of the fracture followed by on the left side with only 1 screw being able to be placed in the medial segment as this was quite far over. Prior to fixating the fracture on the left side, we did test it, and it did appear there was some laxity in the area of the naso-orbital ethmoidal area, however, after fixation, this was fixated well revealing simply only nasal bone fractures which were segments that would need fixation. At this point all plates were in place. A 5-0 PDS was used to resuspend the midface area by suturing with a figure-of-eight, closed the periosteum at both the subconjunctival areas. Eye protection was then removed at this point. Nasal bone fractures were then reduced with the back edge of a knife handle bringing them back up into position.

The patient had a lower lip laceration which was quite irregular, approximately 4 cm in length. This was trimmed, taking approximately 5 mm off each end including a triangular piece which allowed better closure. This was closed with a 4-0 chromic suture. The upper buccal sulcus was then closed with a 4-0 chromic. Two of them, each run from the end to the midportion. All areas had been irrigated well. There was generally good hemostasis at the end of this part of the procedure. The nasal tube was then cut free. The patient then emerged from anesthesia and a Denver splint was placed over the nasal area

 

Dental Restorations and Extractions

PREOPERATIVE DIAGNOSIS: Moderate-to-extensive dental caries.

POSTOPERATIVE DIAGNOSIS: Moderate-to-extensive dental caries, tooth B abscess.  

OPERATION: Dental examination, dental prophylaxis, fluoride treatment, extractions times 4, pulpotomies times 7, dental restorations times 12.

ANESTHESIA: General via nasotracheal intubation.

ESTIMATED BLOOD LOSS: Less than 20 ml.  

INDICATIONS: This 3-year 5-month old male was brought to the XXX to treat his dental caries. The patient has an unremarkable medical history but was uncooperative in a regular dental setting. Due to the extent of the patient’s treatment plan and the patient’s young age, the decision was made to treat the patient under general anesthesia.

PROCEDURE: The patient was brought into the OR at 1212 hours and placed on the table in the supine position. The patient was induced nasally at 1225 hours. The patient was then draped. A throat pack consisting of moistened sterile gauze was placed deep within the oropharynx. An intraoral examination was then performed. The patient was then given a prophylaxis with hand scalers and a fluoridated prophylaxis paste. The teeth were then rinsed and dried.

The left side of the mouth was then isolated with a rubber dam. Clamps were placed on teeth J and K. Extensive caries was then removed from teeth G, H, I, K, and L. The caries extended into the pulpal chambers of all 5 teeth. Pulpotomies were performed with formocresol and IRM. Teeth G and H were restored with dental composite. Teeth I, K, and L were restored with stainless steel crowns. Moderate caries was then removed from teeth M and J. Tooth J was restored with dental amalgam and tooth M was restored with dental composite. The left side of the mouth was then rinsed and dried and the rubber dam was removed.

The right side of the mouth was then isolated with the rubber dam. Teeth clamps were placed on teeth A and T. Extensive caries was then removed from teeth R and S. The caries extended into the pulpal chambers of both teeth. Pulpotomies were performed with formocresol and IRM. Tooth R was restored with dental composite. Tooth S was restored with a stainless steel crown. Moderate caries was then removed from teeth A and C. Tooth A was restored with dental amalgam. Tooth C was restored with dental composite. Moderate-to-extensive caries was then removed from tooth T. There was insufficient supported enamel to place an internal restoration, so the tooth was restored with a stainless steel crown. The right side of the mouth was then rinsed and dried the rubber dam was removed.

Topical fluoride was then applied to the dentition for 1 minute. The excess fluoride was then suctioned out. Tooth B was determined to be abscessed and nonrestorable. Teeth D, E, and F were determined to be nonrestorable. The decision was made to remove all 4 teeth and 1.8 ml of 2% lidocaine with 1:100,000 epinephrine was infiltrated around the 4 teeth. The teeth were then removed with dental forceps. The extraction sites were curetted and firm pressure was applied to the alveolars to obtain hemostasis.

The entire mouth was then suctioned free of all blood and secretions and the throat pack was removed. The patient was extubated at 1440 hours. There were no complications. The patient was in stable condition upon transport to postoperative recovery. 

 

Dental Extractions

PREOPERATIVE DIAGNOSIS: Moderate dental caries.

POSTOPERATIVE DIAGNOSIS: Moderate dental caries, retained assiduous teeth, excessive root recession, teeth M and R.  

OPERATION: Dental examination, dental prophylaxis, fluoride treatment, pulpotomies times 1, restoration times 11, extractions times 6.

ANESTHESIA: General via nasotracheal intubations.

ESTIMATED BLOOD LOSS: Less than 10 ml.  

INDICATIONS: This 8-year 4-month old Hispanic female was brought to the XXX to treat her dental caries. The patient is autistic and was uncooperative in a regular dental setting. Due to the extent of the patient’s treatment plan, the decision was made to treat the patient under general anesthesia.

PROCEDURE: The patient was brought into the OR at 1218 hours and placed on the table in the supine position. The patient was induced nasally at 1235 hours. The patient was then draped. A throat pack consisting of moistened sterile gauze was placed deep within the oropharynx. An intraoral examination was then performed. The mouth was then given a dental prophylaxis with hand scalers and a fluoridated prophylaxis paste. The teeth were then rinsed and dried.

The left side of the dentition was then isolated with a rubber dam. Clamps were placed on teeth 14 and 19. Extensive caries was removed from tooth I. The caries extended into the pulpal chamber of the tooth. A pulpotomy was performed with formocresol and IRM. The tooth was then restored with a stainless steel crown. Moderate caries was then removed from teeth J, 14, 19, K, and L. Teeth J, K, and L were restored with dental amalgam. Teeth 14 and 19 were restored with dental composite. The left side of the dentition was then rinsed and dried and the rubber dam was removed.

The right side of the dentition was then isolated with a rubber dam. Clamps were placed on teeth #3 and 30. Moderate caries was then removed from teeth 3, A, S, T, and 30. Teeth #3 and 30 were restored with dental composite. Teeth A, S, and T were restored with dental amalgam. The right side of the dentition was then rinsed and dried and the rubber dam was removed. The decision was made to remove teeth D, E, F, and G due to the eruption of the permanent teeth. The decision was made to remove teeth M and R due to excessive abrasion on the cervical areas; 1.8 ml of 2% lidocaine with 1:100,000 epinephrine was infiltrated around the 6 teeth. The teeth were then removed with dental forceps. Extraction sites were curetted and firm pressure was applied to the alveolus for 1 minute.

The entire mouth was then suctioned to remove all blood and secretions and the throat pack was removed. The patient was extubated at 1530 hours. There were no complications. The patient was in stable condition upon transport to postoperative recovery.

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