5. Surgery overview

Surgery

Luc Vrielinck

Afdeling Mond-,Kaak- en Aangezichtsheelkunde

Ziekenhuis Oost-Limburg, Genk

Overview

Anesthesy techniques

Surgery

Postoperative care


Local anesthesy

Loco-regional

Loco-regional + sedation

General anesthesy

NB 30 min before surgery glucocorticoid IM

or IV


Local anesthesy

Loco-regional


General anesthesy

Local anesthesy

Buccally up to

infraorbital nerve

Palatal infiltration

incl. palatine nerve

and incisal canal

Externally: zygomatic

region


Local anesthesy

Loco-regional


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


Local anesthesy

Loco-regional


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: midazolam(Dormicum®0.5-2.5mg)

Short: lorazepam (Temesta® 1–2.5 mg)

Long: nitrazepam (Mogadon® 2.5 mg)

Anxiolytic: alprazolam (Xanax Retard 1-2 mg)


Local anesthesy

Loco-regional


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


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


Prelevation of

palatal flap

sometimes section

of the incisal nerve

Palatal entry point

for the drill must be

visible


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


Handpiece zygoma

20:1

Max 2000 r/min


Select entry point

Close to the dento-

alveolar border

2 mm round drill

Select emergence

point on the zygoma


Check intended

drilling direction

using a special

retractor

Implant follows

inferolateral border


Mark drill

Round

Ø 2,9 mm

Protect overlying soft

tissues

Recheck drilling

position


Twist drill Ø 2,9 mm

Pilot drill Ø 3,5 mm

Twist drill Ø 3,5 mm


Depth gauge to select

correct implant length

Implant lengths:

30 35 40 42,5 45 47,5 50 52,5


Machined zygoma

TiUnite zygoma


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


Connection to

handpiece

Engage the implant

and bring it

intraorally


Use slow speed

drilling to engage

the implant

Continue with

manual insertion

with the handle


Connect handle

with adapter to the

implant

Rotate manually

clockwise

Do no apply

bending forces


Check correct

implant head position

Remove implant

mount

Place cover screw

with hexagonal driver


Suturing

Vicryl 4/00 resorbable sutures

Single and matrass sutures

Abutments connection

After 6 months

Two lengths of zygoma abutments

Overview


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

Maximum 2

Sphenoid

Maximum 2


implants? Zygoma

Intrasinusal Brånemark

Perforating ant maxillary wall Stella

Extramaxillary Miglioranca / Malo

External sinus lifting Hinze/ Vrielinck

Quad zygoma

Pterygoid Vrielinck

Skull base bone Vrielinck

Intrasinusal zygoma