1. Technique Surgical Anatomy Procedure Basics Perioperative management
Post operative management

2. Mandible

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

5. 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

6. 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

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

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

9. 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

10. 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

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

12. Step1 – Adequate flaps for surgery

13. Step1 – Adequate flaps for surgery

14. Step1 – Adequate flaps for surgery

15. Step1 – Adequate flaps for surgery

18. 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

19. Bone Removal

20. Bone Removal

21. Step 2- Bone Removal

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

23. 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

24. Sectioning of the tooth

25. Sectioning of the tooth

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

28. 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

29. Example of Sectioning- Distoangular Impacted

30. Example of Maxillary Third Molar

31. Releasing Incision

32. Exposure of Maxillary third molar

33. Removal of thin Buccal plate

34. Application of Elevator

35. Application of Elevator

36. Follicle removal

37. Suturing

38. Extracted Maxillary third molar

39. 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

40. 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

41. 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’

42. 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

43. 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

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

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

46. Post operative management
Prevention of complications
Give Proper Instructions
Verbal
Written

47. 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.

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

49. 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.

50. 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

51. 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.

52. 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

53. 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.)

54. 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

55. Complications

56. 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

57. 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.

58. 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

59. Have a wonderful weekend!