4Applied Anatomy Flap design Distal incision –Direct it laterallyBuccal incision-Facial artery and veinLingual NerveClose proximity to mandibular third molars
5Surgical Anatomy Surgical Location Applied Anatomy Distal end of body of mandibleEmbedded between thick buccal alveolar bone and narrow inner cortical plate.Transverse directionApplied AnatomyFlap design
6Applied Anatomy Flap design Lingual Nerve Distal incision –Direct it laterallyBuccal incision-Facial artery and veinLingual NerveClose proximity to mandibular third molars
7Surgical Anatomy Inferior alveolar nerve External Oblique ridge Lingual AlveolusLingual pouchLoose connective tissueTendinous insertion of the temporalis muscle
8Upper third molar Location- Tuberosity region Close proximity to maxillary sinusConical rooted Maxillary molarTuberosity fractureInfratemporal fossa
9Technique-Basic Procedure Adequate exposure for accessibilityRemoval of overlying boneSectioning of the toothDelivery of the sectioned tooth with an elevatorDebridement and wound closure
10General differences between bone removal while extracting a root stump vs. impacted tooth LessMoreSurgical skillsNature of boneLess DenseDenser(Mandibular third Molar)10
11Lower third molar Surgery Step1 – Adequate flaps for surgeryIncisionsFlap TypesEnvelop flapRelaxing incision
22Step 2- Bone Removal Chisel and Mallet Types Use Strokes are a succession of short, sharp taps sustained by wrist movement
23Sectioning of the tooth Assess the need for sectioningDirection of sectioning depends on the angulation of impactionProcedureSection tooth until ¾of the way towards lingual aspectSplit the tooth using a straight elevator
39Take home points Use finesse not force Don’t loose your handle Watch the adjoining toothDeeper Buccal troughing ( Drill at the expense of the tooth instead of bone)Conserves BoneAvoid proximity to vital structures
40Take home points (contd.) Use purchase point on root componentUse of small or large root picks depending on the size of the rootInter-radicular bone removal to gain access to a rootLeaving the root tipNot infectedDocument it
41Take home points (contd.) Use a good light sourceNo indiscriminate deep drilling in the socketNo surgery without radiographsTake additional radiographs when in doubtLingual plate is thin and tooth fragments can slip in to ‘lingual pouch’
42Perioperative patient management Patient anxiety controlGoalsAchieve a level of patient consciousness that allows the surgeon to work efficientlyAchieved byLong acting anestheticsNitrous oxideIV sedation
43Perioperative patient management Pain control (Analgesics)Best achieved before the effect of LA wears offDoses to be prescribed to last 3-4 days(Beat the pain before it beats you)Swelling ControlParental corticosteroidsIce packs
44Perioperative patient management Infection control (Antibiotics)Pre existing pericoronitisPeriapical abscessSystemic diseaseOtherTopical Antibiotic (Tetracycline)Effective in prevention of dry socket
45Trismus Mild to moderate Resolves in 7 to 10 days If does not resolve -Investigate
46Post operative management Prevention of complicationsGive Proper InstructionsVerbalWritten
47Post operative complications Hemorrhage- Controlled byPressure gauze 15 minutesPlacement of gelfoam/suturesDebridement of site with subsequent placement of gelfoam/suturesPlacement of surgicel (oxidized cellulose)Topical thrombin with sutures,Pressure!!Pressure!!!Further work-up may be indicated if above measures do not achieve adequate hemostasis.
48Factors that Aggravate bleeding (Four S’s) Negative pressure – Three S’sNo SmokingNo Sucking (on a straw)No SpittingNo Strenuous exercises
49Control of Pain Pain is expected Normal PO—3-5 days PO Cessation of pain by 7 daysSevere pain within first 24 hrs—avg. pain tolerableMost quit taking meds within 4-7 daysDirect correlation betweenOperating time and resultant painPain and trismusAppropriate analgesicsCodeine –AcetamenophenOxycodone-Acetaminophen etc.
50Dry Socket Pre op regimen for prevention of dry sockets Antibiotics Chlorhexidine rinsesPlacement of antibiotics in site of tooth extractionCopious irrigation (dilution of the pollution)Occurs 3-5 days PO up to 2-3 weeksPt. Presents c/o pain (radiates to my ear)malodorous breathfoul taste intraorally
51Dry SocketClinicallyNo tissue/clot in site of extraction,or appear as non healing site with bone exposedFibrinolysis, bacterial content of saliva?Treat with irrigation of site placement of topical dressing, or just placement of plain gauze to cover bony marginsAlvogylBIPS dressingMost dressing will contain some form of eugenol, and a carrier medium.
52Post 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 extractionsSoft diet for several daysDiabeticsNormal diet and insulin ASAP
53Oral Hygiene On the day of surgery Next day of Surgery Keep wound clean-heals fasterGentle brushing away from wound siteAvoid disturbing wound siteNext day of SurgeryGentle rinses with warm waterResume oral hygiene methods 3-4 days PO(flossing etc.)
54Other Edema Ecchymosis Operative notes Blood ooze submucosally/subcutaneouslyCommon in elderly(decresed tissue tone, increase capillary fragility, weaker intrcellular attachment)Onset 2-4 days POResolves in 7-10daysWarn the patientOperative notes
56Oro Antral Communication Size<2mm=spontaneous closure2-6mm=suture over site and sinus precautions>6mm=closure with flapLocal tissue advancementPalatal rotationBFP
57Incomplete root removal Occurs when root fragment would require excessive destruction of bone/adjacent structures during removal.Size <5mmDeeply embedded in boneNo pathology is associated with root tipInform the pt., take radiographs, follow up.
58Displacement of tooth Maxillary teeth Displacement into Max. Sinus Attempt recovery through siteCaldwell-LucDisplacement into infratemporal fossaCauseExcessive Posterior pressureSingle attempt with suctionReturn to site 2-4 wks PO to allow for fibrosisConsider leaving in place if asymptomatic