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 stumpImpacted tooth Bone removalLessMore Surgical skillsLessMore Nature of boneLess DenseDenser (Mandibular third Molar)
Lower third molar Surgery Step1 – Adequate flaps for surgery Incisions Flap Types Envelop flap Relaxing incision
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
Take home points Use finesse not force Dont 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 Ss) Negative pressure – Three Ss No Smoking No Sucking (on a straw) No Spitting No Strenuous exercises
Control of Pain Pain is expected Normal PO3-5 days PO Cessation of pain by 7 days Severe pain within first 24 hrsavg. 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 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
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