11 - Third molars 4 Flashcards
What are the basic principles of of surgical removal?
- risk assessment
- aseptic technique
- minimal trauma to hard and soft tissues
What are the steps of surgical removal?
- anaesthesia
- access
- bone removal
- tooth division
- debridement
- suture
- haemostasis
- POI
Describe access for surgical removal.
- raise a buccal mucoperiosteal flap
+/- raise a lingual flap (high risk) - open a larger slap than you may think, as minimal trauma required
- use scalpel with one firm continuous stroke
- minimise trauma to dental papilla
How do you reflect a flap?
- begin raising flap at base of relieving incision
- undermine and free papilla before proceeding distally
- reflect with elevator firmly on bone
What instruments can be used to reflect a flap?
- Mitchell’s trimmer
- Howarth’s periosteal elevator
- Ash periosteal elevator
- Curved Warwick James elevator
Why do you retract a flap?
- access to operative field
- protection of soft tissues
Describe how to retract a flap.
- the flap design facilitates retraction
- atraumatic and passive retraction s done by resting the instrument firmly on bone
- be aware a adjacent structures
What instruments can be used to retract a flap?
- Howarth’s periosteal elevator
- rake retractor
- Minnesota retractor
Describe a rake retractor.
Has small “teeth” at the end to grip the tissue
Describe a Minnesota retractor.
- wide application point
- reflects light into surgical field
What is used to remove bone?
Electrical straight handpiece with saline cooled bur
Why can you not use air driven handpieces in oral surgery?
- can cause surgical emphysema
- air is driven into soft tissues and can cause severe infection
Which burs are used for bone removal?
- round or fissure
- stainless steel
- tungsten carbide
Describe bone removal for third molar extraction.
- buccal aspect drilled and onto distal aspect of impaction
- deep but narrow gutter
- bone removed to allow application of elevators on mesial and buccal aspect
Describe tooth division.
- most common to section the crown from the roots
- occasionally roots require sectioning
How do you section a tooth horizontally for removal?
- placed bur horizontally and begin to cut above the CEJ
- once initial cut is made, insert elevator and rotate to crack tooth
- warn patient about noise
How do you section a tooth horizontally for a coronectomy?
- placed bur horizontally and begin to cut below the CEJ
- once initial cut is made, insert elevator and rotate to crack tooth
- warn patient about noise
How do you section a tooth vertically?
- cut along crown
- feel for a drop into the furcation
- elevate roots and crown, distal first then mesial
Describe the debridement of the extraction socket.
- physical debridement can be carried out using a bone file or handpiece
- irrigate the socket with saline and under flap
- aspirate under flap to remove any debris
What instruments are used to physically debride the socket?
- Mitchells trimmer
- Victoria curette
What is the purpose of suturing?
- approximate tissues
- compress blood vessels
- cover bone
- prevent wound breakdown
- achieve haemostasis
What POI should be given to the patient after a surgical extraction?
- avoid disturbing socket
- no smoking for as long as possible
- no alcohol for >24 hours
- no vigorous exercise for >24 hours
- optimal pain relief advice
What is a coronectomy?
- alternative to removal of entire tooth when the roots are in close proximity to the ID canal
- crown is removed with deliberate retention of roots
Describe the coronectomy procedure.
- flap design as necessary for access
- transaction of tooth 3-4mm below enamel of crown into dentine
- elevate/lever crown without mobilising roots
- pulp left in place and untreated
- socket irrigated
- flap repositioned
Describe the follow for a coronectomy.
- review 1-2 weeks
- further review 6-12 months then discharge to GDP
What are the risks you must inform the patient of regarding coronectomy?
- if roots mobilised the entire tooth must be removed
- leaving roots behind can result in infection although rare
- can heal slowly and painfully
- roots may migrate after surgery and begin to erupt, these would require extraction although would now be safer
How are upper third molars extracted?
- generally easier
- can be removed by elevation only or with forceps
What instruments are used to remove upper third molars?
- straight or curved Warwick James elevator
- couplands
- Bayonet forceps
