Technique

Surgical AnatomyProcedure Basics

Perioperative managementPost operative management

Mandible

Applied AnatomyFlap design

Applied Anatomy Flap design

Distal incision –Direct it laterally

Buccal incision-Facial artery and vein

Lingual NerveClose proximity to

mandibular third molars

Surgical Anatomy Surgical Location

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 Distal incision –

Direct it laterally Buccal incision-

Facial artery and vein

Lingual NerveClose 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

Root stump Impacted tooth

Bone removal Less More

Surgical skills Less More

Nature of bone Less Dense Denser(Mandibular third Molar)

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

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 trismusAppropriate 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 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

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

Have a wonderful weekend!