Technique

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

2. Mandible

4. Applied AnatomyFlap design • 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 • 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 • 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

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

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

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