Surgical Removal of Impacted Third Molars Flashcards
What are the principles of surgical ACCESS?
Gained by raising mucoperiosteal flap (buccal)
- Wide based incision
- Scalpel in one continuous stroke
- No sharp angles
- Adequate sized flap (big and small flaps heal the same)
- Reflection should be cleanly and down to bone
- Minimum trauma = to papillae and soft tissues
- Keep tissues moist
- Ensure flap margins and suture lie on sound bone
- Wound not closed under tension
- Healing by primary intention (minimise scarring)
What type of flap designs are there?
- 3-sided
- 2-sided
- Envelope
- Semilunar
What are the principles of surgical BONE REMOVAL?
- Electrical straight handpiece with saline cooled bur
- -> Air driven -> surgical emphysema (creating ‘dead space’ room for infection)
- Round/fissure SS and tungsten carbide burs
- Protect soft tissues
- Create gutter around crown of 8 (allows application of elevators)
What are the principles of surgical TOOTH DIVISION?
- Horizontal section if oddly shaped roots
- Vertical section if 2 distinct roots
What is the ‘lingual split technique’?
- Younger pt = sedated or GA
- Lingual flap
- Lingual wall of 8 removed (mallet & chisel)
- Whole tooth removed by lingual rotation
What are the principles of elevator use?
- Avoid excessive force
- Support; avoid injury
- Ensure applied force away from major structures
- Use under direct vision
- Never use adj teeth as fulcrum unless being taken out too
- Establish effective point of application
- Keep sharp, if bunt discard
What are the uses of elevators?
- Provide point of application for forceps
- Loosen teeth prior forceps use
- Extract tooth (w/o forceps)
- Removal of root stumps
What are the mechanics of elevators?
- Wheel and axel (scooping)
- Wedge (wriggling)
- Lever (see-saw)
What are the types of forceps used?
LOWER
- Lower universals
- Lower roots
- Lower molars (L & R)
- Cowhorns
UPPER
- Upper straight anterior
- Upper universal
- Upper molars (L & R)
- Upper 8s (bayonet third molars)
- Upper bayonet root
What are the principles of surgical DEBRIDEMENT?
PHYSICAL
- Bone file/ handpiece smooth sharp bone
- Mitchell’s trimmer/ Victoria curette to remove soft tissue debris (incl follicular/ granulation tissue)
IRRIGATION
- Sterile saline into socket (before repositioning)
SUCTION
- Aspiration under flap
What are the principles of surgical SUTURING?
- Suture flap across socket
- Anatomical closure (return to original position)
What are the AIMS of suturing?
- Reposition tissues (‘apporximate’)
- Cover bone
- Prevent wound breakdown
- Achieve haemostasis (compress BVs)
- Encourage healing by primary intention?
What POST-OP advice should be given following surgical removal of wisdom teeth?
- PAIN: expect it, analgesia
- SWELLING: peaks 48hrs after, resolves 10 days, ice packs helpful
- BRUISING: variable
- JAW STIFFNESS: usually settles in 2 weeks, must eat and drink normally
- BLEEDING: damp gauze -> bite 30 mins -> if still bleeding contact surgery, out of hours, A&E
- DON’T RINSE out: for several hours
- DONT’ EXPLORE SOCKET: dry socket risk
- AVOID SMOKING: longer healing, dry socket risk
- AVOID ALCOHOL & EXERCISE (increase BP -> bleed)
- SOFT, COOLER DIET: hard food traumatise, hot -> bleed, eat to other side
- NUMB LIP: careful don’t bite
- KEEP AREA CLEAN: brush as normal, HSMW
- SUTURE advice: resorbable 2 weeks, or non-resorbable come back to remove
What POST-OP medication advice should be given following surgical removal of wisdom teeth?
- AB not routine; consider for prolonged procedures or immunocomp (diabetes)
- IBUPROFEN: 200/400mg x3 daily 6 hourly
- -> AVOID in asthmatics (sensitivity to NSAIDs and aspirin), Warfarin, on other NSAIDs
- PARACETAMOL: 1,000mg x4 daily 4 hourly
- COCODAMOL: 8mg codeine, 500mg paracetamol (8/500 2 tablets 4x daily 4 hourly)
What risks are associated with coronectomies?
- If roots mobilised during procedure –> entire tooth must be removed
- Leaving roots behind may –> infection
- Roots may migrate later and erupt –> requires extr
