Technique Surgical Anatomy Procedure Basics Perioperative management Post operative management

Mandible

Applied Anatomy Flap design Distal incision –Direct it laterally Buccal incision-Facial artery and vein Lingual Nerve Close proximity to mandibular third molars

Surgical Anatomy Surgical Location Applied Anatomy Distal end of body of mandible Embedded between thick buccal alveolar bone and narrow inner cortical plate. Transverse direction Applied Anatomy Flap design

Applied Anatomy Flap design Lingual Nerve Distal incision –Direct it laterally Buccal incision-Facial artery and vein Lingual Nerve Close proximity to mandibular third molars

Surgical Anatomy Inferior alveolar nerve External Oblique ridge Lingual Alveolus Lingual pouch Loose connective tissue Tendinous insertion of the temporalis muscle

Upper third molar Location- Tuberosity region Close proximity to maxillary sinus Conical rooted Maxillary molar Tuberosity fracture Infratemporal fossa

Technique-Basic Procedure Adequate exposure for accessibility Removal of overlying bone Sectioning of the tooth Delivery of the sectioned tooth with an elevator Debridement and wound closure

General differences between bone removal while extracting a root stump vs. impacted tooth Less More Surgical skills Nature of bone Less Dense Denser (Mandibular third Molar) 10

Lower third molar Surgery Step1 – Adequate flaps for surgery Incisions Flap Types Envelop flap Relaxing incision

Step1 – Adequate flaps for surgery

Step1 – Adequate flaps for surgery

Step1 – Adequate flaps for surgery

Step1 – Adequate flaps for surgery

Tearing – the most common error Failure to cleanly elevate the flap Too much tension and stretching of the flap because the flap is too small for the access needed 18

Bone Removal

Bone Removal

Step 2- Bone Removal

Step 2- Bone Removal Chisel and Mallet Types Use Strokes are a succession of short, sharp taps sustained by wrist movement

Sectioning of the tooth Assess the need for sectioning Direction of sectioning depends on the angulation of impaction Procedure Section tooth until ¾of the way towards lingual aspect Split the tooth using a straight elevator

Sectioning of the tooth

Sectioning of the tooth

Sectioning of the tooth Elevators Straight elevator #301, #304 Cryer Crane pick

Sectioning of the tooth Mesioangular least difficult (Class 1 Position A) Followed by Horizontal and Vertical impactions Distoangular is most difficult Lot of distal bone removal Crown is sectioned

Example of Sectioning- Distoangular Impacted

Example of Maxillary Third Molar

Releasing Incision

Exposure of Maxillary third molar

Removal of thin Buccal plate

Application of Elevator

Application of Elevator

Follicle removal

Suturing

Extracted Maxillary third molar

Take home points Use finesse not force Don’t loose your handle Watch the adjoining tooth Deeper Buccal troughing ( Drill at the expense of the tooth instead of bone) Conserves Bone Avoid proximity to vital structures

Take home points (contd.) Use purchase point on root component Use of small or large root picks depending on the size of the root Inter-radicular bone removal to gain access to a root Leaving the root tip Not infected Document it

Take home points (contd.) Use a good light source No indiscriminate deep drilling in the socket No surgery without radiographs Take additional radiographs when in doubt Lingual plate is thin and tooth fragments can slip in to ‘lingual pouch’

Perioperative patient management Patient anxiety control Goals Achieve a level of patient consciousness that allows the surgeon to work efficiently Achieved by Long acting anesthetics Nitrous oxide IV sedation

Perioperative patient management Pain control (Analgesics) Best achieved before the effect of LA wears off Doses to be prescribed to last 3-4 days (Beat the pain before it beats you) Swelling Control Parental corticosteroids Ice packs

Perioperative patient management Infection control (Antibiotics) Pre existing pericoronitis Periapical abscess Systemic disease Other Topical Antibiotic (Tetracycline) Effective in prevention of dry socket

Trismus Mild to moderate Resolves in 7 to 10 days If does not resolve -Investigate

Post operative management Prevention of complications Give Proper Instructions Verbal Written

Post operative complications Hemorrhage- Controlled by Pressure gauze 15 minutes Placement of gelfoam/sutures Debridement of site with subsequent placement of gelfoam/sutures Placement of surgicel (oxidized cellulose) Topical thrombin with sutures, Pressure!! Pressure!!! Further work-up may be indicated if above measures do not achieve adequate hemostasis.

Factors that Aggravate bleeding (Four S’s) Negative pressure – Three S’s No Smoking No Sucking (on a straw) No Spitting No Strenuous exercises

Control of Pain Pain is expected Normal PO—3-5 days PO Cessation of pain by 7 days Severe pain within first 24 hrs—avg. pain tolerable Most quit taking meds within 4-7 days Direct correlation between Operating time and resultant pain Pain and trismus Appropriate analgesics Codeine –Acetamenophen Oxycodone-Acetaminophen etc.

Dry Socket Pre op regimen for prevention of dry sockets Antibiotics Chlorhexidine rinses Placement of antibiotics in site of tooth extraction Copious irrigation (dilution of the pollution) Occurs 3-5 days PO up to 2-3 weeks Pt. Presents c/o pain (radiates to my ear) malodorous breath foul taste intraorally

Dry Socket Clinically No tissue/clot in site of extraction, or appear as non healing site with bone exposed Fibrinolysis, bacterial content of saliva? Treat with irrigation of site placement of topical dressing, or just placement of plain gauze to cover bony margins Alvogyl BIPS dressing Most dressing will contain some form of eugenol, and a carrier medium.

Post operative diet High calorie, high liquid diet for 12- 24hours Adequate intake of fluids 2L (Milk, Juices etc.) Soft and cold foods (ice creams, shakes,smoothies) Multiple extractions Soft diet for several days Diabetics Normal diet and insulin ASAP

Oral Hygiene On the day of surgery Next day of Surgery Keep wound clean-heals faster Gentle brushing away from wound site Avoid disturbing wound site Next day of Surgery Gentle rinses with warm water Resume oral hygiene methods 3-4 days PO (flossing etc.)

Other Edema Ecchymosis Operative notes Blood ooze submucosally/subcutaneously Common in elderly(decresed tissue tone, increase capillary fragility, weaker intrcellular attachment) Onset 2-4 days PO Resolves in 7-10days Warn the patient Operative notes

Complications

Oro Antral Communication Size <2mm=spontaneous closure 2-6mm=suture over site and sinus precautions >6mm=closure with flap Local tissue advancement Palatal rotation BFP

Incomplete root removal Occurs when root fragment would require excessive destruction of bone/adjacent structures during removal. Size <5mm Deeply embedded in bone No pathology is associated with root tip Inform the pt., take radiographs, follow up.

Displacement of tooth Maxillary teeth Displacement into Max. Sinus Attempt recovery through site Caldwell-Luc Displacement into infratemporal fossa Cause Excessive Posterior pressure Single attempt with suction Return to site 2-4 wks PO to allow for fibrosis Consider leaving in place if asymptomatic

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