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BDS4 Oral surgery > Third Molars > Flashcards

Third Molars Flashcards

1
Q

When do third molars erupt into mouth?

A
  • Between 18-24y
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2
Q

When does crown calcification of third molar begin and completes?

A
  • Begins between 7-10yrs
  • Completes age 18yrs
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3
Q

When is root calcification complete of third molars?

A
  • 18-25yrs
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4
Q

What is the probability that at least 1 third molar is missing?

A

1 in 4

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5
Q

What is Molar agenesis?

A

Third molar never forms
- More common in Maxilla and in females

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6
Q

At what age would we say a third molar is never going to form if missing on radiograph?

A
  • Age 14
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7
Q

What does M3M mean?

A
  • Mandibular third molar
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8
Q

What does Impacted mean?

A
  • Tooths eruption is blocked
  • Blocked by adjacent tooth, alveolar bone, surrounding mucosal soft tissue or a combo of these factors
  • Can be unerupted , partially erupted or fully erupted
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9
Q

If a third molar is impacted does that mean surgery?

A
  • Not indication for surgery
  • That is balanced by many other factors
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10
Q

Define partially erupted?

A
  • When some of the tooth has erupted into oral cavity
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11
Q

Define unerupted

A
  • Tooth completely buried
  • Has not erupted into oral cavity
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12
Q

What is the incidence of impacted M3M’s?

A
  • 36-59%
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13
Q

What are some consequences of impaction?

A
  • Caries
  • Pericorinitis
  • Cyst formation
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14
Q

What nerves are at risk during third molar surgery?

A
  • Inferior alveolar nerve
  • Lingual nerve
  • Nerve to mylohyoid
  • Long buccal nerve
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15
Q

Label this diagram

A
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16
Q

Where does the inferior alveolar nerve come from?

A
  • Peripheral sensory nerve
  • Derived from V3 mandibular division of trigeminal nerve
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17
Q

What does the inferior alveolar nerve supply?

A
  • Mandibular teeth on that side
  • Lower lip and chin on that side
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18
Q

What is the location of lingual nerve?

A
  • Close relationship to lingual plate in mandibular and retromolar area
  • At or above level of lingual plate in 15%-18% of cases
  • Between 0-3.5mm medial to mandible
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19
Q

What does the lingual nerve innovate?

A
  • Branch of the mandibular division of trigeminal nerve
  • Anterior 2/3rds of the dorsal and ventral mucosa of tongue
  • Lingual gingivae and floor of mouth
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20
Q

What guidelines can we look at at for third molars?

A
  • NICE
  • SIGN publication number 43
  • FDS, RCS 2020
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21
Q

What did the NICE guidlines state in 2000 that was confirmed by SIGN about XLA wisdom teeth?

A
  • Any justified to remove if visible pathology
  • Caries, periodontal disease, infection, cyst formation etc
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22
Q

What are some therapeutic indications for extraction?

A
  • Infection (caries, pericorinitis, periodontal disease or local bone infection
  • Cysts
  • Tumours
  • External resorption of 7 or 8
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23
Q

What type of impaction is particularly prone to periodontal disease of distal of 7?

A
  • Horizontal medio-angle impaction
  • Early extraction
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24
Q

What type of cysts is most commonly associated with impacted third molars?

A
  • Dentigerous cyst
  • Arises from reduced enamel epithelium separation from crown
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25
Q

What are some other non therapeutic reasons for extraction?

A
  • surgical indications i.e. within surgical field (orthognathic , fractured mandible, in resection of diseased tissue)
  • High risk of disease
  • Medical indications e.g. awaiting cardiac surgery, immunosuppressed or to prevent osteonecrosis
  • Accessibility - limited access
  • Pt age , complications and recovery time increase with age
  • Autotransplantation
  • GA (consider emoval of opposing and contralateral)
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26
Q

Why might a third molar be extracted post fractured mandible?

A
  • To allow for adequate open reduction internal fixation
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27
Q

Why might an extraction of third molar be accepted in pts awaiting cardiac surgery?

A
  • Required to be signed off as dentally fit to avoid complications
  • If dentist suspects the 8 may cause issues in the future might opt to have removed prophylactically
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28
Q

If pt is immunosuppressed or about to be immunosuppressed why might be a good idea to remove third molar before starting txt?

A
  • Reduced ability to heal due to immunosuppression
  • **
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29
Q

Why might you consider removing third molar if pt going to start bisphophonates?

A
  • Remove poor or doubtful prognosis teeth before starting txt
  • Reducing chance of getting MRONJ
  • Medicated related osteonecrosis of the jaw
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30
Q

What is pericorinitis?

A
  • Inflammation around crown of partially erupted tooth
  • Sometimes you need to probe distal to second molar to show there is a small communication
  • Food and debris get trapped under the operculum resulting in inflammation and infection
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31
Q

When does pericornitis occur?

A
  • 20-40yrs
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32
Q

What health condition has been found to be related to incidences of pericoronitis?

A
  • Upper respiratory tract infections
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33
Q

What anaerobic microbes have been found in pericoronitis?

A
  • Streptococci
  • Actinomyces
  • Propionibacterium
  • Prevotella
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34
Q

What are the signs of pericoronitis?

A
  • Throbbing Pain
  • Swelling intra and extra
  • bad taste
  • Pus discharge
  • Hard to open their mputh
  • Difficulty chewing
  • Malaise
  • Transient and intermittent pain
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35
Q

What symptoms are common to pericoronitis?

A
  • Occlusal trauma to operculum
  • Ulceration of operculum
  • Evidence of cheek biting (traumatic ulceration)
  • Foetor oris
  • Lim mouth opening
  • Dysphagia
  • Pyrexia (fever)
  • Malaise
    Regional lymphadenopathy
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36
Q

What is the txt for pericoronitis?

A
  • Incision of localised pericoronal abscess if required
  • LA if the pt wants it depening on pain and pt
  • irrigate with warm saline or chlorhexidine mouthwash using 10-20ml syringe with blunt needle under operculum
  • XLA upper third molar if traumatising operculum
  • Pt instructed on frequent warm salty mouth rinse or chlorhexidine mouthwash
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37
Q

Why do some health boards not authorise the use of chlorhexidine in irrigation of pericoronitis?

A
  • Very rare but some cases of anaphylaxis
  • Check your health board
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38
Q

What pt advice would you give for pericoronitis?

A
  • Analgesia pt can take , do not exceed recommended dose on back of packet
  • paracetamol 4g , ibuprofen 2.4g
  • Keep fluid levels up and keep eating soft/liquid diet if necessary
  • Warm salty mouth rinse frequently
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39
Q

When would you prescribe antibiotics for pericoronitis?

A
  • Severe pericoronitis
  • Systemically unwell
  • E/O swelling
  • immunocompromised e.g. diabetic
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40
Q

If pt present with large extra/oral swelling, systemically unwell, trismus, dysphagia with pericoronitis what should you do?

A
  • Refer to maxillofacial unit or A&E
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41
Q

What are some predisposing factors to pericoronitis?

A
  • PE and vertical or distoangular impaction
  • Opposing maxillary third molar or second molar causing mechanical trauma contributing to infection
  • Poor oral hygiene
  • Insufficient space between ascending ramus of lower jaw and distal aspect of mandib second molar
  • White race
  • URTI and stress and fatigue
  • Full dentition
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42
Q

During extra-oral exam what features are you assessing?

A
  • TMJ
  • Limited mouth opening
  • Facial symmetry
  • Lymphodenopathy (unilateral, bilateral)
  • MOM
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43
Q

When assessing the third molar what thinhs do you need to note ?

A
  • PE or UE
  • How much of the crown can be seen i.e. 2/3rds
  • Is there operculum covering
  • Is there pus
  • Is there food trap
  • State of margins i.e. any erythema
  • Caries
  • Bleeding
  • Impaction
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44
Q

When are you to take a radiograph?

A
  • Only if surgical intervention is being considered
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45
Q

What radiograph do you take for third molar extraction?

A
  • OPT
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46
Q

Upon the radiographic report of OPT for third molar what should you note?

A
  • Presence or abscence of disease in 3M or anywhere else
  • Anatomy of 3M (crown size, shape, condition, root morhpology)
  • Depth of impaction
  • Orientation of impaction
  • Working distance (distal of lower 7 to ramus of mandible
  • Follicular width (2.5-3mm considered pathology)
  • Periodontal status
  • Relationship or proximity of upper third molar to maxillary antrum and of lower third molars to Inferior dental canal
  • Any other assoc pathology
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47
Q

What are some radiographic signs that the third molar is close to the inferior alveolar nerve canal?

A
  • Interruption of white lines/lamina dura of canal
  • Darkening of root where crosses by canal
  • Diversion/ deflection of inferior dental canal
  • Defelction of root
  • Narrowing of IANC
  • Narrowing of root
  • Dark and bifid root
  • Juxta apical area
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48
Q

What are the 3 signs that have been demonstrated to be significantly increased risk of nerve injury during 3M surgery?

A
  • Diversion of IANC
  • Darkening of root where crossed by canal
  • Interruption of white lines of canal
  • SIGN guidelines and FDS guidelines
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49
Q

What does this image show?

A
  • Normal root morphology of IANC
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50
Q

What does this image show ?

A
  • Diversion/ deflection of IANC
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51
Q

What does this image show?

A
  • Darkening of the root where crossed by the IANC
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52
Q

What does this image show?

A
  • Interruption of the white lines/ lamina dura of IANC
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53
Q

What does this image show?

A
  • Deflection of root
54
Q

What does this image show?

A

Narrowing of IANC

55
Q

What does this image show?

A
  • Narrowing of root of 3M
56
Q

What change to 3M does this image show?

A
  • Dark and bifid root
57
Q

What change to 3M does this image show?

A
  • Juxta apical area
  • A well circumcised area lateral to root
  • Not usually found at apex of tooth
58
Q

If you suspect a close relationship to IANC what radiograph other than OPT can yiu get?

A
  • CBCT
59
Q

What does transverse angulation of 3M mean?

A
  • Crown is buccally placed and roots are lingually placed or vice versa
60
Q

What does aberrant angulation of 3M mean?

A
  • Tooth positioned in odd place
61
Q

In what order does different types of angulation in lower 8’s most commonly occur?

A
  • Mesial 40%
  • Vertical 30-38%
  • Distal 6-15% (most likely to be reffered to specialist as hardest to XLA)
  • Horizontal 3-15%
  • Transverse or aberrant (less common - quite rare)
62
Q

How is the angulation / orientation of 3M measured?

A
  • Measured against curve of spee
  • On an OPT draw the curve of spee
  • Draw a straight line through the 8 from the furcation and straight line through the 7
  • Assess how they meet
63
Q

How would you classify these lower molars?

A
  • Lower right 48 mesially impacted on 47
  • Lower left 38 horizontally impacted
64
Q

How would you classify this impaction of lower molars?

A
  • Lower right 48 horizontally impacted
  • Lower left 38 distally impacted
65
Q

Why are distally impacted lower molars hard to remove and require specialist referral?

A
  • Need to remove distal bone of ramus of mandible to remove 8
  • Roots lie close to the 7s roots meaning hard to get an application point and need to be careful do not damage 7
66
Q

How would you classify these lower third molars ?

A
  • True vertical impaction 48
  • Distal impaction 38
67
Q

How would you classify this molar?

A
  • Transverse impaction 48
68
Q

How would you classify this third molar?

A
  • Aberrant position 38
69
Q

What feature of a third molar gives us an indication of the amount of bone removal required during surgery?

A
  • Depth of impaction
70
Q

What are the 3 ways Depth of impaction can be described?

A
  • Superficial
  • Moderate
  • Deep
71
Q

What does superficial depth of imoaction mean?

A
  • Crown of 8 related to crown of 7
72
Q

What does moderate depth of impaction mean?

A
  • Crown of 8 related to crown and root of 7
73
Q

What does deep depth of impaction mean?

A
  • Crown of 8 related to root of 7
74
Q

How would you classify the depth of the lower m olars?

A
  • 48 moderate impaction
  • 38 superficial impaction
75
Q

How would you classify this lower molar in terms of depth?

A
  • Superficial impaction 38
76
Q

How would you classify this depth of impaction of lower molar?

A
  • Moderate impaction 48
77
Q

What are the txt options for third molars (common pathways)?

A
  • Referral to specialist/ dental hospital with oral surgery unit/ MFS
  • Clinical review
  • Removal of 3M
  • XLA maxillary third molar
  • Coronectomy
78
Q

What is a clinical review?

A
  • Assessing the pts signs and symptoms at check ups
79
Q

What is a coronectomy?

A
  • Removal of the crown of the tooth and roots left in situ
  • Done with 3M if thought to have close relationship to IANC
80
Q

What other rare txt options are available for 3M?

A
  • Operculectomy
  • Surgical exposure
  • Pre-surgical orthidontics
  • Surgical reimplantation/ autotransplantation
81
Q

If tooth is asymptomatic but is diseased or at high risk of disease developing what is the management of M3Ms?

A
  • If risk high surgical intervention considered
  • If tooth at higher risk of surgical complications ( close approximation to IANC) then active surveillance recommended until symptoms develop or early disease progression proven
82
Q

If tooth is asymptomatic and non-diseased or at low risk of disease devlopment what is the management of M3M?

A
  • Clinical review supplemented with radiographic assessment at appropriate intervals
83
Q

If tooth is symptomatic and is diseases or at high risk of disease devlopment what is the management of M3M?

A

Consider therapeutic XLA indicated for
- Single sever acute or recurrent subacute pericornitis
- Unrestorable caries M3M or assist restoration of adjcent tooth
- Periodontal disease compromising M3M and/or adjacent tooth
- Resorption of M3M and/or adjacent tooth
- Fractured M3M
- M3M PA abscess, irreversible pulpitis, or acute spreading infection
- Surrounding pathology

84
Q

What medical factors do you need to consider when determining prophylactic removal txt option?

A
  • Pt undergoing planned medical txt that may complicate likely surgery of M3M
  • Bisphosphonates
  • Antiangiogenics
  • Chemotherapy
  • Radiotherapy to head and neck
  • Immunosuppresant therapy
85
Q

What surgical factors do you need to consider when considering prophylactic removal of M3M?

A
  • Third molar lies within the perimeter of surgical field
  • Mandibular fractures
  • Orthognathic surgery
  • Resection of disease ( benign and mlaignant lesions)
86
Q

What to do if tooth is symptomatic but no assiocated disease?

A
  • Leave deeply impacted M3M with no associated disease
  • Txt other diagnoses causing pain in that region
  • TMD disorders
  • Parotid disease
  • Skin lesions
  • Migraines
87
Q

What methods of anaesthesia available?

A
  • LA
  • GA
  • Conscious sedation (IV with midazolam)
88
Q

What consent do you require for surgical management?

A
  • Written and verbal
  • Form listing risks and warnings
89
Q

When gaining consent for the procedure what do you need to explain to the pt in order to get informed consent?

A
  • Explain procedure to pt in words they will know
  • If tooth is needing sectioned explain this
  • Give pt ide what to expect during , no pain but will feel vibrations
  • Explain minor surgical procedure, may need flap, possible drilling, sutures (stitches help gum to heal)
  • Risk to adjacent restoration but will place temp and replace at later date
90
Q

in edentulous / atrophic mandible pt what is the risk associated even if it is small?

A
  • Aberrant lower 8 closer to lower border of mandible
  • Large cystic lesion associated with wisdom tooth
  • Risk of jaw fracture
  • Very rare
  • Arranged to have this fixed in a hosiptal at the time
91
Q

What post op complications do you need to tell the pt in order to gte consent?

A
  • Pain
  • Swelling , normal to see up to two weeks after
  • Brusiing , varies but is normal and setlle within a week or two
  • Jaw stiffness/ limited mouth opening so may need to have soft diet for up to two weeks, if sever contact us
  • Bleeding - normal to see a little bits of blood on pillow or when brushing teeth - bite down on guaze for 15mins if a lot
  • Infection - signs and symptoms of infection
  • Dry socket (most common in 3M)
92
Q

What would you say to pt when consenting them for nerve damage?

A
  • May experience sensory deficit
  • Numbness or tingling of the lower lip, chin, side of tongue
  • 10-20% will experience temporary numbness or tingling lower lip and chin from IAN and may take weeks /months to improve
  • Most healing takes place first 9 months , unlikely to heal after 18-24 months
  • <1% experience permanent numbness or tingling
  • Lingual nerve alters one of tongue, taste
  • Altered sense of taste (rare)
  • Painful sensation (dysaesthesia)
  • Rudeced sensation (hypoaestheisa) or increased sensation
93
Q

How does the Chorda tympani relate to altered taste in surgical extractions?

A
94
Q

What acroynym is useful for referral?

A
  • SBAR
    Situation
    Background
    Assessment - extra and intra / MH etc
    Recommendation - your opinion
95
Q

What are the basic principles of surgical removal?

A
  • Risk assessment
  • Verbal and written consent in terms pt can confirm
  • Medical history
  • Aseptic technique
  • Minimal trauma to hard and soft tissues
96
Q

What is the step by step of how to surgically remove third molar?

A
  • Anaesthesia
  • Access
  • Bone removal if necessary
  • Tooth division as necessary
  • Debridement
  • Suture
  • Achieve haemostatis
  • Post op instructions v+w
97
Q

Step by step how do you gain access for surgical removal? 6 points

A
  • Access to tooth gained by raising buccal mucoperiosteal flap
  • +/- raising a lingual flap (controversial)
  • Maximum access with minimal trauma
  • Larger flap heal as quick as smaller one
  • Use scalpel in firm continuous stroke around gingival margin of 7
  • Minimise trauma to dental papillae
98
Q

Step by step approach for reflection of the tissues during surgical removal of third molar?

A
  • Relieving incision from mesial 5
  • Raise flap at base of relieving incision where it is already gaping / bone is visible
  • Undermine / free anterior papilla before proceeding with reflection distally to avoid tears with a Warwick James elevator
  • Reflect with periosteal elevator firmly on bone (raise in one piece)
99
Q

What instruments are used during reflection of flap off the bone?

A
  • Mitchells trimmer
  • Howarths periosteal elevator
  • Ash periosteal elevator
100
Q

What are the most difficult areas to reflect?

A
  • Papilla
  • Mucogingival junction
101
Q

Label the instruments highlighted

A
  • Left is Howarths periosteal elevator
  • Middle is Mitchells trimmer
  • Right is Ash periosteal elevator
102
Q

What is this instrument?

A
  • Rake retractor
103
Q

What is this instrument?

A
  • Minnesota retractor
104
Q

Step by step for retraction during surgical removal of 8?

A
  • Use Howarths periosteal elevator, rake retractor or Minnesota retractor for :
  • Access to operative field
  • Protection of soft tissues
  • Flap design facilitates retraction
  • Done with care
  • Atraumatic / passive retraction
105
Q

What is atraumatic / passive retraction?

A
  • Rest retractor firmly on bone
  • Be aware of adjacent structure like the mental nerve
  • Minimise trauma
106
Q

What do we use when doing bone removal of lower molar?

A
  • Electrical straight handpiece with saline cooled bur
  • Round or fissure stainless steel and tungsten carbide burs
107
Q

What can air driven handpieces lead to during bone removal?

A
  • Surgical emphysema
108
Q

What site is the bone gutter carried out?

A
  • Buccal aspect of the tooth beginning at distal aspect of impaction
  • Do not start mesial as if you loose control of drill and it plunges into soft tissue distal of 8 then lingual nerve may be damaged
109
Q

How would you describe the bone gutter required?

A
  • Deep narrow gutter around crown of wisdom tooth
  • To allow correct application of elevators on mesial and bucaal aspects of tooth
110
Q

Why is irrigation vital in bone removal?

A
  • maintain visibility
  • Avid bony necrosis
111
Q
A
112
Q

When would be appropriate to decide if the tooth needs dividing upon removal?

A
  • If adequate bone has been removed and tooth cannot be removed in its entirety with elevators or a combo of elevators and forceps
113
Q

How can the tooth by divided for surgical removal?

A
  • Either section the crown of the tooth from the roots and then elevate each in turn (horizontal crown section)
  • Or vertical divide the tooth with a bur at the bifurcation and elevate each section
114
Q

What are the 3 methods of debridement?

A
  • Physical
  • Irrigation
  • Suction
115
Q

What do you do for Physical debridement?

A
  • Bone file or handpiece to remove sharp bony edges
  • Mitchells trimmer or Victoria curette to remove soft tissue debris
116
Q

What do you do for Irrigation?

A
  • Sterile saline into socket and under mucoperiosteal flap
117
Q

What must you do after removal of tooth?

A
  • Aspirate under flap to remove debris
  • Check socket for retained apices etc
  • When the tooth is removed any debris must be cleaned out and any follicular tissue or granulation tissue from chronic infection should be curetted – especially that hidden behind the second molar
118
Q

What instrument is highlighted

A
  • bone file
119
Q

What are the aims of auturing?

A
  • Reposition tissues (approximate tissues)
  • Cover bone
  • Prevent wound breakdown
  • Achieve haemostasis
120
Q

Describe this 3 sided suture placement

A
  • 3 sided mucoperiosteal flap with distal and mesial relieving incision
  • Sutures placed distal of 8 and buccal aspect of 7 to reposition tissues
121
Q

Describe this 3 sided suture placement

A
  • 3 sided mucoperiosteal flap with distal and mesial relieving incision
  • Sutures placed distal of 8 and buccal aspect of 7 to reposition tissues
  • Another suture placed more buccal along mesial incision as still a gap in the tissues (clinical decision)
122
Q

Describe this 3 sided suture placement

A
  • 3 sided mucoperiosteal flap with distal and mesial relieving incision
  • Sutures placed distal of 8 and buccal aspect of 7 to reposition tissues
  • Another suture placed through papilla from buccal to lingual aspect distal of 7 (papilla loose or not approximated enough)
123
Q

Describe this envelope suture placement

A
  • Distal relieving incision but no mesial relieving incision
  • Place interupted suture distal of 8 and buccal to lingual distal of 7 through dental papilla
124
Q

Post op instructions given verbally and written to pt?

A
  • No smoking for 48hrs and consider cessation
  • No alcohol at least 24 hrs
  • No rigorous exercise , take it easy
  • Avoid eating until LA wears off
  • Keep diet soft foods esp that evening and eat on other side
  • Try and avoid touching socket with tongue or finger as this increases bacteria introduction or dislodges the blood clot
  • Take painkillers before LA wears off and regularly to keep on top of the pain, do not exceed recommended dose
  • Pain is worse 24-48hrs then should start to receed so take analgesia when required
  • Swelling expected and is normal , can use ice pack to reduce swelling
  • If any swelling becomes present under jaw , down neck or up to the eye and you feel eye is closing over then contact us asap
  • Bleeding normal for next 72hrs , just a little bit on you pillow or when youre brushing - give gauze and instructions ot stop bleeding
  • Brusijng normal but if gets worse after 3 days contact us
  • Signs and symptoms of infection are if pain or swelling getting worse after 3 days tor notice ous or bad tatse then contact us or own dentist
  • Jaw stiffness to be expected , usual for this to occur for 2-3 weeks after
  • Limiting mouth opneing can be helpful
  • IDB lasts for 3 hours but if they feel sensation has returned to most areas except a little bit then ocntact us
  • Warm salty mouthrinse helpful 3-4 times a day beginning tommorow or may dislodge blood clot and increases chance of dry docket
  • Contact details for practice or hospital or NHS 24 (111)
125
Q

Why perform a coronectomy instead of surgical removal?

A
  • Alternative when there appears to be increased risk of IAN damage with surgical removal
  • Aim is to reduce risk of IAN damage
126
Q

What is the process of Coronectomy?

A
  • 3 sided / envelope mucoperiosteal flap
  • Transection of tooth 3-4mm below enamel of crown into dentine
  • Elevate/ lever crown off without mobilising roots
  • Pulp left in place untreated
  • If needed further reduction of roots with rose head bur to 3-4mm below alveolar crest (not always poss)
  • Irrigate socket with saliner
  • Replace flap (can leave socket open or close flap)
  • AB not prescribed routinely
127
Q

What is the follow up for a coronectomy?

A
  • Review 1-2 weeks
  • Further review 3-6 months then 1 year (discharge back to GDP)
  • Radiographic review 6months ,1yr and thereafter if symptomatic
128
Q

What are the risks assoicated with Coronectomy?

A
  • If root is mobilised during crown removal then entire tooth must be removed (more likely wiht ocnical fused roots)
  • Leaving roots behind can result in infection
  • Can get a slow healing/painful sockety
  • Root may migrate later and begin to erupt through mucosa and may require XLA
129
Q

Are upper third molars easier to remove than lowers?

A
  • Yes
  • Althouggh occasionally difficult due to dense cortical bone
130
Q

How are upper third molras removed?

A
  • Removed by elevation only or elevtaion and forceps
  • Elevation with straight or curved Warwick James elevators or couplands
  • care taken that tooth doesnt pop out and go down pt throat
  • Forceps like the Boynets upper third molras used
131
Q

How do you take care in not causing maxillary tuberosity fracture?

A
  • Support tuberosity with finger and thumb
  • Excessive force can fracture it , use forceps and supporting tuberosity helps
132
Q
A

BDS4 Oral surgery (15 decks)

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