FOREWORD

Praise to God for His blessings so that this group report could be finished well. This report is the result of Group 10 discussion for the seventh scenario in this Block 10. Authors have tried to do our best through this report. However, as a mere human being, this report that we create may have some mistakes. Therefore, authors will be glad to receive critics and suggestions from information providers, all lecturers, friends and all readers. Authors would also like to thank Group 10 facilitator for this scenario, drg. Bramma Kiswanjaya, Ph.D and all who have contributed in the making of this group report. Lastly, we hope this report would be beneficial for the education in Indonesia, especially in the Faculty of Dentistry University of Indonesia. We sincerely apologize if there are mistakes in this paper or mistakes during the writing process.

Jakarta, March 31th 2013 Authors

Group 10

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BAB I
Description Mr Laode 35 years old, comes to RSGMP FKGUI with complain of eating trouble since she has a sharp tooth that thrust into the tongue. From anamnesis, Mrs Laode explain that she is on her 3rd month of pregnancy. Her sister sisi, 17 years old, who also comes, wants to make her tooth alignment. Clinical examination shows that 13 is unerupted but planted on the jawbone in vertical position. On anemsis, the patients says that for the previous month she was easily getting tired, often felt thirsty and hungry eventhough she has already taken her meals, and also loose her height. Key words: Female 35 years old : Eating rouble due to sharp tooth that thrust into the tongue 3rd month of pregnancy

Female 17 years ols Wants her tooth aligned 13 is unerupted Lump on the gum 13 is planted in the jawbone in the vertical position 2 month of easily getting tired, often feel thisty and hungry and also loose weight

Problems 1. Why does mrs laode has sharp teeth ? 2. What is the treatment for mrs laode condition, considering her first trimester of pregnancy ? 3. What do the symptoms sisis indicate ? 4. What is the treatment for sisi problem ? considering her systemic conditions ? 5. What is the diagnosis for sisis problem ?
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Hypothesis 1. The cause for mrs laode sharp tooth is unknown because there is not enough information. The treatment plan for mrs laode is preprosthetic surgery followed by prosthetic treatment that has to be done after her labour. 2. Sisis is suffering from insulin dependent diabetes mellitus 3. Sisis suffering from canine impaction 4. Tretment plan for sisi is to undergo preorthodontic surgery then followed by orthodontic treatment that has to be done when her DM is controlled. Mind map

Examination: Radiology Clinical examination

Pretreatment surgery

Indication and contraindication

Diagnosis (e,g abnormalities)

types

Consideration Pregnancy DM

Pre-orthodontic

Pre-prosthetic

Procedure and technique for: Frenectomy Alveolectomy Vestibuloplasty Sulces deepening windowing

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Learning objective 1. Examination for pre-prosthetic and pre-othrodontic surgery 2. Diagnosis for pre-othrodontic and prosthetic surgery 3. Consideration for pre-prosthetic and pre-othrodontic surgery 4. Indication and contraindication for pre-prosthetic and pre-othrodontic surgery 5. Procedure and technique for the following surgery: A. Frenectomy B. Alveolectomy C. Vestibuloplasty D. Sulcus deepening E. Windowing

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BAB 2 CONTENT Preprosthetic surgery Preprosthetic surgery involves operations aiming to eliminate certain lesions or abnormalities of the hard and soft tissues of the jaws, so that the subsequent placement of prosthetic appliances is successful.

Examination A. Examination for pre-prosthetic treatment 1. Anamnesis Chief complaint and goal of treatment (aesthetic and function) Physiologic adaptation and denture wearing experience General medical conditions and medications taken

2. Intra oral examination Vestibulum: check for presence of inflammation Attachment of muscle and frenum on alveolar crest Pathologic condition of soft tissue and bone Gag reflex on palate

3. Radiographic examination Orthopantomograph (OPG): digital panoramic Lateral cephalogram 3D CT Scan Important anatomic structure that should be examined: o Tooth radices o Impacted tooth o Cyst and tumor o Position of mental foramen o Bone density in maxilla and mandibula

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B. Examination for pre-orthodontic treatment (Exposure of impacted canine) Radiographic examination: Combination of periapical, occlusal, panoramic radiograph with tube shift method Buccal object rule: SLOB (same side lingual, opposite side buccal) Periapical occlusal technique

Diagnosis for Pre-Treatment Surgery A. Pre-prosthetic Surgery Definition: procedures designed to optimize the stability, retention, support, and comfort of removable dentures through the selective modification of soft and hard tissues. Conditions and Diagnosis for Pre-prosthetic Surgery: a. Dental caries and periodontal disease Extraction is not always thought of as a pre-prosthetic procedure nor is it usually thought of as a preventative procedure. The removal of teeth is the definitive preprosthetic surgical procedure particularly if the patient is being edentulated. Care is needed to minimize bone loss and create an optimal ridge form. The timely extraction of non-restorable or periodontally doomed teeth prevents the ongoing bone loss that would be associated with the infection or surgical extraction of decayed teeth or uncontrolled periodontal disease. b. Ridge irregularities The elimination of protruding spicules or points of bone allows for more uniform loading of the ridge. While somewhat more technically demanding, the removal of tori eliminates point loading in the area of the torus. In the case of lingual tori, removal often allows for extension of the lingual flange with increased retention and resistance. c. Undercuts Elimination of bony undercuts allows for more intimate contact of denture base to bone and therefore more uniform loading of the ridge. d. Flabby ridge tissue

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The trimming of flabby ridges allows for more intimate adaptation of denture to mucosa and more uniform loading of ridges. This reduces denture movement and reduces resultant "rubbing" of the mucosa. e. Hyperplastic tuberosities f. Occasionally, posterior interarch space may be reduced by hyperplasia (usually soft tissue but occasionally osseous) of the tuberosity. This reduces the space available for the placement of a denture base over the tuberosity or the retro-molar pad. This results in denture heel interference. Soft tissue hyperplasia can be reduced by wedge excision of the tissue followed by undermining of the wound edges and primary closure. Hard tissue reduction is carried out essentially the same way, with osseous reduction done prior to closure. The amount of bone reduction allowed is a function of the level of the floor of the sinus. g. Decreased retention: Loss of retention as a function of ongoing atrophy is difficult to regain. Vestibuloplasty: With time and bone atrophy, there is a relative loss of vestibular depth. This is a function of resorption of the ridge crest in a sulcular direction, toward the attachment of the sulcular muscles (mentalis, buccinator, etc.). In a fashion similar to the excision of epulis fissuratum, the sulcus depth can be regained and maintained by the creation of a partial thickness wound (leaving periosteum intact and on the bone) and then relining the defect with palatal mucosa or a partial thickness skin graft. This procedure is technically demanding and carries with it increased morbidity (pain, swelling and potential complications. This requires wiring of the denture in place for approximately two weeks. This is usually done with fixation screws or circummandibular / circumzygomatic wires. Bone grafting to the ridge from hip (iliac crest) or rib is technically very demanding, and carries with it a high level of morbidity (pain, swelling, risk of complications). Furthermore, it also has a relatively poor prognosis, with a return to pre-op bone levels within five years.

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B. Pre-orthodontic Surgery (Orthognatic) Most permanent teeth erupt into occlusion. In some individuals, however, the permanent teeth may fail to erupt and become impacted within the alveolus.

The timing of orthodontic treatment, type of surgical procedure to uncover the impacted tooth, orthodontic mechanics necessary, and potential problems with treatment vary, depending on which tooth has become impacted.

The most commonly impacted tooth is the maxillary canine, followed by the maxillary central incisor. The usual cause of impaction of the maxillary central incisor is the presence of a supernumerary tooth or mesiodens. If the supernumerary tooth is discovered early and extracted, the central incisor may erupt spontaneously. If the root of the impacted incisor forms completely and the mesiodens has not been removed, however, then the central incisor may not erupt spontaneously. Labial impaction of the maxillary canine over the maxillary lateral incisor occurs occasionally. This type of impaction is due to one of two causes. Either the canine moves ectopically over the labial surface of the maxillary lateral incisor root and fails to erupt, or the maxillary dental midline may shift toward the canine, causing it to be impacted labially.

Indication and Contraindication of pre-treatment surgery

Hard Tissue Lesions or Abnormalities The abnormalities associated with hard tissues are classified into two categories: a. Those that may be smoothed with alveoloplasty immediately after extraction of the teeth (sharp spicules, bone edges),or those detected an drecontoured in an edentulous alveolar ridge. b. Congenital abnormalities, such as torus palatinus, torus mandibularis, multiple exostoses.

After the natural dentition is lost, the patient can have an alveolar ridge with irregularities, undercuts, scarring, and insertion of perioral muscles that interfere with the stability of the prosthesis. Changes in the soft tissues are related to the degree of underlying jaw atrophy. Subsequent to extractions, nature steps in to begin the process of alveolar ridge resorption. This
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process is rapid following extractions and then slows down to achieve a balance between osteoblastic and osteoclastic activity. Over a period of years, patients often end up with an edentulous bony ridge that lacks adequate prosthetic support. Immediate and late consequences of edentulism require a careful evaluation of the intraoral supporting structures in order to provide proper rehabilitation and to minimize the ongoing process of bone loss. Irregular alveolar ridges, undercuts, tori, large maxillary tuberosities, and shallow vestibules are some of the problems that can interfere with dental prosthetic rehabilitation. 1. Indication a. Complete or partial edentulism secondary to early tooth loss b. Naturally occurring reduction of the residual bony ridge Jaw atrophy (Class II - VI) Mucosal atrophy Interarch changes (vertical, anterior/posterior, transverse) Reduction of denture bearing are Muscle hypotonia Facial changes

c. Pain (not remedial by conventional prosthetic measures) due to : Mucositis (a burning discomfort of the mucosa membrane) Neuropathy (alteration of sensation of the lips varying from objective/subjective paraesthesia to anaesthesia or pain arising from traumatized nerve trunks) Local recurrent ulceration of unsupported crestal soft tissues and thin atrophic mucosa Temporomandibular join pain Dental roots or unerupted teeth

d. Dysfunction (not remediable by conventional prosthetic means) of Mastication Speech Deglutition

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e. Disproportionate growth of the jaws of facial skeleton producing mechanically impossible conditions for mastication and denture retention. This skeletal deformity may be : Class II or relative mandibular retrusion or maxillary protrusion Class III or relative mandibular protrusion or maxillary retrusion

f. Craniofacial deformity which results from abnormal growth patterns of the skull base and facial skeleton g. Oligodontia, anodontia a naturally occurring failure of tooth development h. Enhanced gag reflex patient have an excessive sensitivity of the soft palate which if contacted produces retching.

2. Contraindication a. Uncontrolled diabetes b. Leukemia c. Heart failure d. Renal Failure e. Liver disease f. Pregnancy

COMPROMISED CONDITION Diabetes Mellitus Diabetes mellitus is caused by and underproduction of insulin, a resistance of insulin receptors in end-organs to the effect of insulin, or both. Diabetes is divided into insulin-dependent and noninsulin-dependent. 1. Insulin dependent usually begins in children or teenagers. Effect: The major problem of insulin dependent DM is the inability of the patient to use glucose. The serum glucose rises above the level that the renal can reabsorb normally and causing glucosuria. The osmotic effect of the glucouse solute results in polyuria, stimulating the patient thirst and causing polydypsia. The carbohydrate metabolism is

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altered, leading to fat breakdown and production of ketone bodies. This can produce ketoacidosis and tachypnea with somnolence (sleepy) and eventually coma. People with insulin-dependent DM must strike a balance among caloric intake, exercise, and insulin administration. Any decrease in regular caloric intake or increase in activity, metabolic rare, or insulin dose can lead to hypoglycemia and vice versa. 2. Non-insulin-dependent produce insulin but in insufficient amounts because of decreased insulin activity, insulin receptor resistance, or both. This form of diabetes begins in adulthood, is exacerbated by obesity, and usually does not require insulin therapy. It is treated by weight control, dietary restriction, and the use of oral hypoglycemics. Insulin is required only if the patient is unable to maintain acceptable serum glucose label s using the usual therapeutic measures. Severe hypoglycemia in noninsulin-dependent diabetic patients rarely produces ketoacidosis but leads to a hyperosmolar state with altered levels of consciousness. Consideration to diabetes mellitus Hypoglycemic patient Untreated insulin-dependent diabetes patient has a risk of ketoacidosis and its attendant alteration of consciousness require the emergency treatment. Short-term mild-to-moderate hyperglycemia usually is not a significant problem for people with diabetes. Therefore when an oral surgical procedure is planned it is best to err on the side of hyperglycemia rather than hypoglycemia. It is good to avoid an excessive insulin dose and to give a glucose source. Ambulatory oral surgery procedures should be performed early in the day, using an anxiety-reduction program. If intravenous sedation is not being used, the patient should be asked to eat a normal meal and take the usual morning amount of regular insulin and a half dose of NPH (neutral protamine Hagedorn) insulin. The patients vital signs should be monitored, and, if signs of hypoglycemia, such as hypotension, hunger, drowsiness, nausea, diaphoresis, tachycardia, or a mood change occur, an oral or intravenous supply of glucose should be administered. If the patient temporarily will be unable to eat after surgery, any delayed-action (most commonly NPH) insulin normally taken in the morning should be eliminated and restarted only after normal caloric intake resumes. The patient should be advised to monitored urine of serum glucose closely for the first 24 hours postoperatively. Some dental offices have their own serum glucose11 | P a g e

monitoring equipment to use to quickly test diabetic patients while in the office. If a patient must miss a meal before an oral surgical procedure, the patient should be told not to take any morning insulin until intravenous glucose in water is started in the office. One half of the usual dose of regular insulin and no NPH insulin should be used in this situation. Regular insulin should then be used, with the dose based on serum or urinary glucose monitoring and as directed by the patients physician. Emergency Procedure also can be stopped if the patient has the symptom of hypoglycemia and allow the patient to consume a high-caloric carbohydrate (e.g: packets of sugar, a glass of fruit juice, or sugar containing carbonated soda). If the patient falls rapidly into unconsciousness or unable to take the sugar from the mouth access, intra venous access can be applied with an ampule (50 ml) of 50% glucose (dextrose) in water administered 2 to 3 minutes. If intravenous cannot be accessed, the intramuscularly access can be applied with 50% of glucose and glucagon, or subcutaneously with 0.5 ml dose of 1:1000 epinephrine that repeated every 15 minutes. Body defense People with well-controlled diabetes are no more susceptible to infections than people without diabetes, but they have more difficulty containing infections. This is caused by altered leukocyte function, as well as by other factors that affect the bodys ability to control an infection. Difficulty in containing infections is more significant in people with poorly controlled diabetes. Therefore elective oral surgery should be deferred in patients with poorly controlled diabetes until control is accomplished. However, if an emergency situation or a serious oral infection exists in any person with diabetes, consideration should be given to hospital admission to allow for acute control of the hyperglycemia and aggressive management of the infection. Many clinicians also believe that prophylactic antibiotics should be given routinely to patients with diabetes undergoing any surgical procedure. However, this position is controversial. Management Insulin-dependent 1. Defer surgery until diabetes is well controlled, consult to the physician 2. Schedule an early morning appointment, avoid lengthy appointments
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3. Use anxiety reduction protocol, but avoid deep sedation techniques in outpatients 4. Monitor pulse, respiration, and blood pressure before, during, and after surgery 5. Maintain verbal contact with patient during surgery 6. If patient must not eat or drink before treatment, instruct the patient not to take the usual dose of regular or NPH insulin 7. If allowed, have the patient eat normal breakfast before surgery and take usual dose of regular insulin but only half dose of NPH insulin 8. Advise the patient not to resume normal insulin dosage until they are able to return to usual level caloric intake and activity level 9. Consult to the physician if any question concerning modification of the insulin regimen arise 10. Watch the sign of hypoglycemia 11. Treat infections aggressively Non-insulin-dependent 1. Defer surgery until the diabetes is well controlled 2. Schedule an early morning appointment, avoid lengthy appointment 3. Use an anxiety-reduction protocol 4. Monitor pulse, respiration, and blood pressure before, during, and after the treatment 5. Maintain verbal contact with patient during surgery 6. If patient must not eat or drink before treatment and will have difficulty eating after surgery, instruct the patient to skip any oral hypoglycemic that day 7. If the patient can eat normal breakfast before surgery, instruct the patient to eat normal breakfast and to take the usual dose of hypoglycemic agent. 8. Watch for sign of ypoglycemia 9. Treat infections aggressively

Dental treatment for diabetes based on fingerstick blood glucose testing Finger stick blood glucose (mg/dL %) Dental treatment

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Less than 85

Administer treatment

glucose;

postpone

elective

85-200

Stress

reduction;

consider

antibiotic

prophylaxis for extraction 200-300 Stress reduction; antibiotic prophylaxis;

referral to primary care physician 300-400 Avoid elective treatment; referral to primary care physician or emergency room at nearby hospital Greater than 400 Avoid elective treatment; send to emergency room at nearby hospital

PREGNANT A pregnant patient, although not considered medically compromised, poses a unique set of management considerations for the dentist. Dental care must be rendered to the mother without adversely affecting the developing fetus, and although routine dental care generally is safe for the pregnant patient, the delivery of such care involves some potentially harmful elements, including the use of ionizing radiation and certain drugs. Thus, the prudent practitioner must balance the beneficial aspects of dentistry with potentially harmful procedures by minimizing or avoiding exposure of the patient (and the developing fetus). DENTAL MANAGEMENT Medical Considerations Management recommendations during pregnancy should be viewed as general guidelinesnot as definitive rules. The dentist should assess the general health of the patient through a thorough medical history. Information to ascertain includes current physician, medications taken, use of tobacco, alcohol, or illicit drugs, history of gestational diabetes, miscarriage, hypertension, and morning sickness. If the need arises, the patients obstetrician should be consulted. Pregnancy is a special event in a womans life; hence, it is an emotionally charged experience. Establishing a good patient-dentist relationship that encourages openness, honesty,

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and trust is an integral part of successful management. This kind of relationship greatly reduces stress and anxiety for both patient and dentist. As with all patients, measuring vital signs is important for identifying undiagnosed abnormalities and the need for corrective action. At a minimum, blood pressure and pulse should be measured. Systolic pressure at or above 140 mm Hg and diastolic pressure at or above 90 mm Hg are signs of hypertension. Also, clinical concern is appropriate if the patients blood pressure increases 30 mm Hg or more in systolic or increases 15 mm Hg in diastolic blood pressure over pre-pregnancy values, because these changes can be a sign of preeclampsia. 16 Confirmed hypertensive values dictate that the patient be referred to a physician to ensure that preeclampsia and other cardiovascular disorders are properly diagnosed and managed. Preventive Program. An important objective in planning dental treatment for a pregnant patient is to establish a healthy oral environment and an optimum level of oral hygiene. This essentially consists of a plaque control program that minimizes the exaggerated inflammatory response of gingival tissues to local irritants that commonly accompany the hormonal changes of pregnancy. Acceptable oral hygiene techniques should be taught, reinforced, and monitored. Diet counseling, with emphasis on limiting the intake of refined carbohydrates and carbonated soft drinks, should be provided. Coronal scaling and polishing or root curettage may be performed whenever necessary. Preventive plaque control measures should be provided and emphasized throughout pregnancy, including the first trimester, for benefit to the pregnant mother and the developing baby.

Treatment Timing Other than as part of a good plaque control program, elective dental care is best avoided during the first trimester because of the potential vulnerability of the fetus. The second trimester is the safest period during which to provide routine dental care. Emphasis should be placed on controlling active disease and eliminating potential problems that could occur later in pregnancy or during the immediate postpartum period, because providing dental care during these periods often is difficult. Extensive reconstruction or significant surgical procedures are best postponed until after delivery.

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The early part of the third trimester is still a good time to provide routine dental care. After the middle of the third trimester, however, elective dental care is best postponed. This is because of the increasing feeling of discomfort that many expectant mothers may experience. Prolonged time in the dental chair should be avoided, to prevent the complication of supine hypotension. If supine hypotension develops, rolling the patient onto her left side affords return of circulation to the heart. Scheduling short appointments, allowing the patient to assume a semireclining position, and encouraging frequent changes of position can help to minimize problems.

Dental Radiographs Dental radiography is one of the more controversial areas in the management of a pregnant patient. Pregnant patients who require radiographs often have anxiety about the adverse effects of x-rays on their baby. In some instances, their obstetrician or primary care physician may reinforce these fears. In almost all cases involving dental radiography, these fears are unfounded. The safety of dental radiography has been well established, provided that features such as fast exposure techniques (e.g., high-speed film or digital imaging), filtration, collimation, lead aprons, and thyroid collars are used. Of all aids, the most important for the pregnant patient are the protective lead apron and the thyroid collar. In addition, the use of digital radiography markedly reduces radiation exposure to no more than that with the use of F-speed film. In spite of the safety of dental radiography, ionizing radiation should be avoided, if possible, during pregnancy, especially during the first trimester, because the developing fetus is particularly susceptible to radiation damage. However, should dental treatment become necessary, radiographs may be required for accurate diagnosis and treatment. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have published guidelines stating: Diagnostic radiologic procedures should not be performed during pregnancy unless the information to be obtained from them is necessary for the care of the
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patient andcannot be obtained by other means. Therefore, the dentist should understand the risks of ionizing radiation and know how to proceed as safely as possible in the event that radiographs are needed. Bitewing, panoramic, or selected periapical films are recommended for minimizing patient dose.

Drug Administration Another controversial area in the treatment of the pregnant dental patient is drug administration. The principal concern is that a drug may cross the placenta, with the potential for toxic or teratogenic effects on the fetus. Additionally, any drug that is a respiratory depressant may cause maternal hypoxia, resulting in fetal hypoxia, injury, or death. Ideally, no drug should be administered during pregnancy, especially during the first trimester. Strict adherence to this rule, however, is sometimes impossible. Fortunately, most of the commonly used drugs in dental practice can be given during pregnancy with relative safety, although a few exceptions are notable. Table available below presents a suggested approach to drug usage for pregnant patients.

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Local Anesthetics. Local anesthetics administered with epinephrine generally are considered safe for use during pregnancy. Although both the local anesthetic and the vasoconstrictor cross
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the placenta, subtoxic threshold doses have not been shown to cause fetal abnormalities. Because of adverse effects associated with high levels of local anesthetics, it is important not to exceed the manufacturers recommended maximum dose. Analgesics. The analgesic of choice during pregnancy is acetaminophen. Aspirin and nonsteroidal antiinflammatory drugs convey risks for constriction of the ductus arteriosus, as well as for postpartum hemorrhage and delayed labor. The risk of these adverse events increases when agents are administered during the third trimester. Risk also is more closely associated with prolonged administration, high dosage, and selectively potent anti-inflammatory drugs, such as indomethacin. Codeine and propoxyphene are associated with multiple congenital defects and should be used cautiously and only if needed. The safety of hydrocodone and oxycodone is unclear. Antibiotics. Penicillins (including amoxicillin), erythromycin (except in estolate form), cephalosporins, metronidazole, and clindamycin are generally considered to be safe for the expectant mother and the developing child. The use of tetracycline, including doxycycline is contraindicated during pregnancy. Tetracyclines bind to hydroxyapatite, causing brown discoloration of teeth, hypoplastic enamel, inhibition of bone growth, and other skeletal abnormalities. Anxiolytics. Few anxiolytics are considered safe to use during pregnancy. if N2O-O2 is used during pregnancy: Use of N2O-O2 inhalation should be minimized to 30 minutes. At least 50% oxygen should be delivered to ensure adequate oxygenation at all times. Appropriate oxygenation should be provided to avoid diffusion hypoxia at the termination of administration. Repeated and prolonged exposures to nitrous oxide are to be avoided. The second and third trimesters are safer periods for treatment because organogenesis occurs during the first trimester.

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PRE-PROSTHETIC SURGERY ALVEOPLASTY Alveoplasty is contouring of the alveolar ridge to remove any irregularities and undercuts. Most alveoplasties are performed on the maxilla and anterior mandible. The goals are to provide a stable base for the prosthesis and preserve as much alveolar bone as possible. Always be conservative when removing bone. Surgical Technique for an Alveoplasty in an Edentulous Patient 1. After adequate local anesthesia is obtained, a crestal incision is made over the area. A vertical release incision should be made when there is a risk of tearing the soft tissue flap. An ellips incision also can be made for single alveoplasty. Be careful with anatomical structures such as the mental nerve and always maintain a wide-base flap. A thin ridge in the anterior mandible presents a challenge because it is possible to end up in the floor of the mouth. 2. Use a periosteal elevator to raise a fullthickness flap. Keep the pointed edge of the elevator against bone at all times to minimize tissue perforation. If a vertical release incision was made, start the reflection where it joins the crestal incision. 3. Reflect the flap enough to identify the areas needing to be smoothed. When the fullthickness flap is reflected, use a Seldin or Minnesota retractor to retract and protect the flap. 4. Contour the bone with a bone file, rongeurs, and/or round bur mounted on a slow-speed handpiece. Undercuts and sharp edges are eliminated, but the contouring does not have to be perfectly smooth. Frequently reposition the flap and try to feel the bone (with a gloved finger through soft tissue) for irregularities. Never perform digital palpation of the bone directly because some irregularities are minimal and will not be noticeable or significant enough to remove with the flap in position. 5. Use the bone file for final contouring and smoothing of the bone. 6. Irrigate the areaespecially at the bottom of the flap, where bone debris frequently accumulates. Normal saline irrigation is used to keep bony temperatures < 47C to maintain bone viability. 7. Reposition the flap to its original position
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8. Suture with interrupted or continuous sutures. 9. Analgesics should be prescribed, but antibiotics are usually not necessary

Figure. The arrow in the picture shows a severe loss of inter-ridge distance. There is no space to restore the edentulous span.

Figure. Increased inter-ridge distance after alveoloplasty.

ALVEOLECTOMY AND ALVEOLOTOMY According to Pedersen, Alveolectomy is a radical surgery to reduce or take alveolar processus , so mucosa apposition can be done, which is a procedure that is done to prepare the ridge before radiation therapy. Alveolotomy is partial taking of alveolar processus or the bone between roots in order to get molding and contouring.

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The indications for these procedures are rare but may be of value where excessive anterior projection of the ridge in the upper premaxillary area might pose problems for future denture aesthetics or stability. Management Alveolectomy involves reduction in both the height and width of the ridge and is mainly accomplished by reduction of the labial plate. The mucoperiosteum is best raised with a 'U'shaped incision to allow access. Bone rongeurs or larger 'acrylic' burs can be used to reduce the labial plate prominence and, on occasion, also the interdental septae. The bony margin is then smoothed with a file and the wound closed with sutures. Transeptal or interseptal alveolotomy reduces the labial prominence but maintains the height of the ridge. Following extraction of the incisors and canines, the interdental septum is removed between each socket and the labial plate is then fractured inwards with firm digital pressure. A vertical cut may be needed over the canine prominence labially to facilitate this fracture. The labial plate will still be attached to its overlying periosteum and should therefore remain viable. These operations may be facilitated by cooperation with the prosthodontist, who can provide the surgeon with a template of acrylic that is made on the cast trimmed to the desired contour. Unless the patient desires an aesthetic change, these procedures are becoming less frequent.
Treatment of the Labial and Lingual Frenum Labial Frenectomy Labial frenum attachments consist of thin bands of fibrous tissue covered with mucosa extending from the lip and cheek to the alveolar periosteum. The height of this attachment varies from individual to individual; however, in dentate individuals frenum attachments rarely cause a prob- lem. In edentulous individuals frenum attachments may interfere with fit and sta- bility, produce discomfort, and dislodge the overlying prostheses. Several surgical methods are effective in excising these attachments. Simple exci- sion and Z-plasty are effective for narrow frenum attachments. Vestibuloplasty is often indicated for frenum attachments with a wide base. Local anesthetic infiltration is per- formed in a regional fashion that avoids direct infiltration into the frenum itself; such an infiltration distorts the anatomy and leads to misidentification of the frenum. Eversion of the lip also helps one identify the anatomic frenum and assists with the excision. An elliptic 22 | P a g e

incision around the proposed frenum is completed in a supraperiosteal fashion. Sharp dissec- tion of the frenum using curved scissors removes mucosa and underlying connec- tive tissue leading to a broad base of periosteum attached to the underlying bone. Once tissue margins are under- mined and wound edges are approximat- ed, closure can proceed with resorbable sutures in an interrupted fashion. Sutures should encounter the periosteum, espe- cially at the depth of the vestibule to main- tain alveolar ridge height. This also reduces hematoma formation and allows for the preservation of alveolar anatomy. In the Z-plasty technique, excision of the connective tissue is done similar to that described previously. Two releasing incisions creating a Z shape precede undermining of the flaps. The two flaps are eventually undermined and rotated to close the initial vertical incision horizon- tally. By using the transposition flaps, this technique virtually increases vestibular depth and should be used when alveolar height is in question.

Wide-based frenum attachments may best be treated with a localized vestibulo- plasty technique. A supraperiosteal dissec- tion is used to expose the underlying perios- teum. Superior repositioning of the mucosa is completed, and the wound margin is sutured to the underlying periosteum at the depth of the vestibule. Healing proceeds by secondary intention. A preexisting denture or stent may be used for patient comfort in the initial postoperative period. Lingual Frenectomy High lingual frenum attachments may consist of different tissue types including mucosa, connective tissue, and superficial genioglossus muscle fibers. This attach- ment can interfere with denture stability, speech, and the tongues range of motion. Bilateral lingual blocks and local infiltra- tion in the anterior mandible provide ade- quate anesthesia for the lingual frenum excision. To provide adequate traction, a suture is placed through the tip of the tongue. Surgical release of the lingual frenum requires dividing the attachment of the fibrous connective tissue at the base of the tongue in a transverse fashion, fol- lowed by closure in a linear direction, which completely releases the ventral aspect of the tongue from the alveolar ridge Electrocautery or a hemostat can be used to minimize blood loss and improve visibility. After removal of the hemostat, an incision is created through the area previously closed within the hemostat. Careful attention must be given to Whartons ducts and superficial blood vessels in the floor of the mouth and ventral tongue. The edges of the incision are undermined, and the wound edges are approximated and closed with a running resorbable suture, burying the knots to minimize patient discomfort.

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RIDGE EXTENSION VESTIBULOPLASTY Vestibuloplasty A surgical procedure to restore alveolar ridge height by lowering muscles attaching to the buccal, labial, and lingual aspects of the jaws Maxillary alveolar bone resorption frequently results in mucosal and muscle attachments that interfere with denture construction, stability, and retention. Excess soft tissue may accompany bony resorption, or soft tissue may require modification. Several techniques provide additional fixed mucosa and vestibular depth in the maxillary denture-bearing area

Traditional Flap Vestibuloplasty (Lip Switch) In this procedure a mucosal flap pedicled from the alveolar ridge is elevated from the underlying tissue and sutured to the depth of the vestibule. The inner portion of the lip is allowed to heal by secondary epithelialization. When adequate mandibular height exists, this procedure increases the anterior vestibular area, which improves denture retention and stability. The primary indications for the procedure include adequate anterior mandibular height (at least 15 mm), inadequate facial vestibular depth from mucosal and muscular attachments in the anterior mandible, and the presence of an adequate vestibular depth on the lingual aspect of the mandible. These techniques provide adequate results in many cases and generally do not require hospitalization, donor-site surgery, or prolonged periods without a denture. Disadvantages include unpredictability of the amount of relapse of the vestibular depth, scarring in the depth of the vestibule, and problems with adaptation of the peripheral flange area of the denture to the depth of the vestibule.

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Vestibule and Floor of Mouth Extension Procedures

In addition to the attachment of labial muscles and soft tissues to the denture-bearing area, the mylohyoid and genioglossus muscles in the floor of the mouth present similar problems on the lingual aspect of the mandible. Trauner described detaching the mylohyoid muscles from the mylohyoid ridge area and repositioning them interiorly, effectively deepening the floor of the mouth area and relieving the influence of the mylohyoid muscle on the denture. After the two vestibular extension techniques, a skin graft can be used to cover the area of denuded periosteum. The combination procedure effectively eliminates the dislodging forces of the mucosa and muscle attachments and provides a broad base of fixed keratinized tissue on the primary denture-bearing area.

Split-thickness skin grafting with the buccal vestibuloplasty and floor-of-mouth procedure is indicated when adequate alveolar ridge for a denture-bearing area is lost but at least 15 mm of
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mandibular bone height remains. The remaining bone must have adequate contour so that the form of the alveolar ridge exposed after the procedure is adequate for denture construction. Endosteal implants are generally a much more suitable treatment and therefore vestibuloplasty with skin grafting is not commonly performed. If gross bony irregularities exist, such as large concavities in the superior aspect of the posterior mandible, they should be corrected through grafting or minor alveoloplasty procedures before the soft tissue procedure.

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The advantage of early covering of the exposed periosteal bed improves patient comfort and allows earlier denture construction, the long-term results of vestibular extension are predictable. Disadvantage need for hospitalization and donorsite surgery combined with the moderate swelling and discomfort experienced by the patient. Patients rarely complain about the appearance or function of skin in the oral cavity. If the skin graft is too thick at the time of
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harvesting, hair follicles may not totally degenerate, and hair growth may occasionally be seen in isolated areas of the graft. Tissue other than skin has been used effectively for grafting over the alveolar ridge. Palatal tissue offers the potential advantages of providing a firm, resilient tissue, with minimal contraction of the grafted area. Although palatal tissue is relatively easy to obtain at the time of surgery, the limited amount of tissue and the discomfort associated with donor-site harvest-ing are the primary drawbacks. In areas where only a small localized graft is required, palatal tissue is usually adequate. Full-thickness buccal mucosa harvested from the inner aspect of the cheek provides advantages similar to those of palatal tissue. However, the need for specialized mucotomes to harvest buccal mucosa and extensive buccal mucosa scarring after harvesting of a full-thickness graft are disadvantages. This mucosa does not become kera-tinized, is generally mobile, and often results in an inade-quate denture-bearing surface.

Maxillary Submucosal Vestibuloplasty The submucosal vestibuloplasty may be the procedure of choice for correction of soft tissue attachment on or near the crest of the alveolar ridge of the maxilla. This technique is particularly useful when maxillary alveolar ridge resorption has occurred but the residual bony maxilla is adequate for proper denture support. Underlying submucosal tissue is either excised or repositioned to allow direct apposition of the labiovestibular mucosa to the periosteum of the remaining maxilla.

To provide adequate vestibular depth without producing an abnormal appearance of the upper lip, adequate mucosal length must be available in this area. A simple test to determine whether adequate labiovestibular mucosa is present is performed by placing a dental mouth mirror under the upper lip and elevating the superior aspect of the vestibule to the desired postoperative depth. If no inversion or shortening of the lip occurs, then adequate mucosa is present to perform a proper submucosal vestibuloplasty.

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The submucosal vestibuloplasty can generally be performed with local anesthetic and intravenous (IV) sedation in an outpatient setting. A midline incision is made in the anterior
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maxilla, and the mucosa is undermined and separated from the underlying submucosal tissue. A supraperiosteal tunnel is then developed by dissecting the muscular and submucosal attachments from the periosteum. The intermediate layer of tissue created by the two tunneling dissections is incised at its attachment area near the crest of the alveolar ridge. This submucosal and muscular tissue can be repositioned superiorly or excised. After closure of the midline incision, a preexisting denture or prefabricated splint is modified to extend into the vestibular areas and is secured with palatal screws for 7 to 10 days to hold the mucosa over the ridge in close apposition to the periosteum. When healing takes place, usually within 3 weeks, the mucosa is closely adapted to the anterior and lateral walls of the maxilla at the required depth of the vestibule.

The maxillary submucosal vestibuloplasty can also be combined with HA augmentation of the alveolar ridge area. A subperiosteal tunnel can be created using a tech-nique similar to standard maxillary HA augmentation procedures.33 By incising the periosteum high on the lat-eral aspect of the mandible, the periosteal envelope can be enlarged to allow greater HA augmentation in this area.

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Increasing the size of the alveolar ridge

There are two aspects to surgically increasing the denture bearing area: Sulcus deepening Ridge augmentation

Sulcus deepening
The size of the denture-bearing area can be increased by deepening the sulci providing there is adequate underlying bone. That this is difflcult to do satisfactorily is proved by the number of operations designed to this end, of which only a few are described here. Deepening of the buccal sulcus in the maxilla is seldom necessary as the palate provides a large denture-bearing area. Retention and support for the lower denture would often benefit from deepening of the sulci particularly where muscle attachments have come to lie near the crest of the ridge: Anteriorly the mentalis muscle laterally the buccinators muscle and lingually the mylohyoid muscle are involved.

To deepen the sulci effectively, these muscles must be detached from the mandible and the mucosa made to heal with a new reflection at a lower level. This last is the most difficult part of the operation. It is complicated by the presence of the mental nerve which must be located and preserved from accidental damage. The procedures available can be considered in four groups.

1. Mucosa is advanced to line both sides of an extended sulcus (submucosal vestibuloplasty) An example of this group is obwegeser's operation. This attempts to divide the muscle attachments and deepen the buccal sulcus without making a flap or leaving raw areas. The procedure is usually performed in the maxilla. Two vertical incisions 1cm long are made in the buccals sulcus of the canine regions or a single incision in the mid-line. Scissors or a scalpel are then passed between mucosa and periosteum. The muscle attachments on the buccal aspect are cut, as far back and upwards as possible to free the mucosa. This is drawn up and the sulcus maintained by using a denture lined with gutta percha.one or two bones crewsin the palate retain the denture for 2 weeks.

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Obwegeser's operation has the disadvantage that it is performed blind and if bleeding occurs the new sulcus may be obliterated.

2. skin is transplanted to line both sides of an extended sulcus (buccal inlay) In this operation a pouch is made in the mandibular buccal sulcus which is lined with a splitthickness skin graft from the patient's arm or thigh. An incision is made in the mandibular labial sulcus and a pouch dissected to the required size. This must leave the periosteum intact and attached to bone. An acrylic splint with a gutta percha mould, larger than will eventually be required, is made. where the skin graft and mucous membrane meet, the mould is grooved so that on healing the ring scar contracts into the groove. The mould is chilled and the skin graft attached to it with the raw surface outwards. This is then placed in the pouch and the splint secured to the mandible with circumferential wires for two weeks. 3. skin is transplanted to line one side of an extended sulcus (lower labial vestibuloplasty) An incision is made along the mandibular alveolar crest from canine to canine. The incision goes through the mucosa bur not through the mentalis muscle or the periosteum. The mucosal flap is dissected off periosteum and muscles. care must be taken not to tear the mucosa. Dissection is continued past the reflection just short of the inner margin of the lip. The mentalis muscle is then divided with a scapel close to the periosteum which is left undisturbed. The muscle will retract into the deepert issues. The mucosal flap is repositioned to cover the labial side of the new sulcus and held in position by sutures through the periosteum. A split thickness skin graft is placed against the raw area of the periosteum with a gutta percha mould on an acrylic splint. In this way,the labial aspect of the new sulcus is lined with mucosa, and the periosteum with the skin graft. 4. Lowering of floor of mouth and vestibuloplasty. This operation, described by Obwegeser, combines a buccal vestibuloplasty skin graft with a vestibuloplasty on the lingual aspect of the ridge which heals by secondary epithelialisation. The mucosal flaps on the buccal and lingual sides are held down in the depths of the new sulci by sutures passing under the mandible.

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In the vestibuloplasty procedures, the splint or modifled denture must maintained in place for 2-3 weeks to allow initial healing. During this period, a high standard of oral hygiene is vital. Following removal of the splint, there is a marked tendency for the sulcus to contract. To reduce this, the denture must be modifled to extend into the full depth of the sulcus and be worn contiously for several weeks.

PRE-ORTHODONTHY SURGERY Surgical exposure of impacted teeth In general, there are 2 basic approaches to surgically exposing impacted teeth: 1. The open eruption technique In this method, the teeth is exposed to the oral environment, while surrounded by freshly trimmed soft tissue of the palate or labial oral mucosa, following the removal of the mucosa and bone which is actually covering the tooth. Divided into 2 method: a. The window technique Window technique involves the surgical removal of a circular section of the overlying mucosa and the thin bony recovering. For most labially displaced teeth, due to their height, this entire surgical procedure would most likely only be possible above the level of attached gingival, in the mobile area of the mucosa.

This is the simplest, most conservative and most direct manner to expose a tooth which is palpable immediately under the oral mucosa and it may often be accomplished with surface anaesthetic spray only. An attachment may then be bonded to the tooth and orthodontically encouraged eruption may proceed without delay, to complete its alignment within a very short time.

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The only situation in which this exposure procedure is clinically advantageous is when there is a very wide band of attached gingival and where a labially impacted tooth is situated well down in this band, such that a simple removal of the tissue overlying the crown will still leave 1-2 mm of bound epithelial attachment inferior to the free, movable, oral mucosal lining of the sulcus. The palatal mucosa is very thick and thighly bound down to the underlying bone. Thus, no parallel precausions need to be made to ensure a good attachment for the final periodontal status of a palatally impacted tooth, following its eruption into the palate. When the window technique is used on the palatal side, the cut edges of the wound need to be substantially trimmed back and the dental follicle removed to prevent re-closure of the very considerable width of palatal soft tissue over the exposed tooth. For a deeply buried palatal canine, the exposure will additionally need to be maintained using a surgical pack.

b. The apically repositioned flap The apically repositioned flap is an alternative way of performing an open exposure technique on the buccal side. It is aimed at improving the periodontal outcome by ensuring that attached gingival covers the labial aspect of the erupted tooth in the final instance. This is done by raising a labial flap, taken from the crest of the ridge, and relocating it higher up on the crown of the newly exposed tooth. This particular method of exposure is best situated above the band of
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attached gingival, but which are not displaced mesially or distally from their place in the dental arch.

2. The closed eruption technique The closed eruption technique has an attachment placed at the time of the exposure and the tissues fully replaced and sutured to their former place, to re-cover the impacted tooth. For a buccally impacted tooth, a surgical flap is raised from the attached gingival at the crest of the ridge, with suitable vertical releasing cuts, and elevated as high as is necessary to expose the unerupted tooth. An attachment is then bonded and the flap fully sutured back to its former place. The twisted stainless steel ligature wire or gold chain, which is preferred by some clinicians, which has been tied or linked to the attachment, is then drawn inferiorly and through the sutured edges of the fully replaced flap. The surgical wound is, therefore, completely closed and the exposed tooth and its new attachment are sealed off from the oral environment. Traction is then applied to the twisted stainless steel ligature or gold chain to bring about the full eruption of the tooth. In this method, the tooth progresses towards and through the area of the attached gingiva several weeks or months after complete healing of the repositioned surgical flap has occurred and it creates its own portal through which it exits the tissues and erupts into the mouth. As such, it very closely simulates normal eruption and the clinical outcome will usually be difficult to distinguish from any normally and spontaneously erupting tooth, in terms of its clinical appearance and objective periodontal parameters.

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BAB III CLOSING Hypothesis The cause for mrs laode sharp tooth is unknown because there is not enough information. The treatment plan for mrs laode is preprosthetic surgery followed by prosthetic treatment that has to be done after her labour. Accepted, mrs Laode will undergo selective tooth grinding. Tooth extraction is not indicate to prevent changes on her arch Sisis is suffering from insulin dependent diabetes mellitus Accepted, obvious systemic condition can be observed with her being hungry despite shes already taken meal just before. Ketoacidosis examination can be done to determine her DM type by smelling her breath. Sisis suffering from canine impaction Accepted Tretment plan for sisi is to undergo preorthodontic surgery then followed by orthodontic treatment that has to be done when her DM is controlled. Accepted, the pre-orthodontic surgery is done with windowing technique to expose the impacted technique, when the canine is exposed, surgeon will put bracket at the buccal site of the canine crowns then refer it to the orthodontist for activations. The proper time for her surgery is when her blood glucoe is on the range of 85<x<300. Conclsions Compromised condition like pregnant patient has to be treat carefully to prevent injury to the patient or her fetus, especially surgical operations this should be done after the baby has been delivered. Routine oral prophylaxis to maintain oral hygiene should be done. Patient with diabetes mellitus is prone to infection due to lower immune response, before any kind of
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treatment, patient glucose blood level should be measured, for patient with blood glucose level around 85-300 mg/dl treatment can be done but always monitor for his/her blood glucose level during and after surgery. If hypoglycemia occurred during treatment, stop the treatment and have the patient ingest glucose containing food/drink immidietly. If hyperglycemia occurred, IV injection of insulin should be administered, treatment can be continued when the glucose blood level is lowering.

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