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minor oral surgical procedures final.pptx
1. GUIDED BY :- SUBMITTED BY :-
Dr. MALLIKA REDDY MDS PRIYADHARSHANI CHALAM. D
Dr. SREE VIDYA MDS FINAL YEAR – BDS
Dr. SADANANDA MDS 19D2310
Dr. KUMARI RATNA MDS KGFCDS
Dr. SENDHIL KUMAR MDS
2. A surgical procedure that can be comfortably done by competent
non specialized dental surgeon within 30 minutes under LA with
or without sedation.
PROCEDURES :-
*Soft tissues
1. Frenectomy
2. Removal of fibrous epulis
*Hard tissues
1. Removal of impacted tooth
2. Canine transplantation
3. Trans alveolar extractions
3. Definition - A tooth has not erupted to the functional position with
in expected time period due to Malpositioning / Lack of space in
the dental arch/ Obstruction (Soft tissues or hard tissues)
ETIOLOGY:-
*Hereditary
*Acquired
*Jaw size tooth number discrepancy
*Supernumerary tooth
*Early loss of deciduous
*Retention of deciduous more than expected time
*Damage to the tooth bud
4. *Unrestorable caries
*Untreatable pulpal pathology/ periapical pathology
*Fracture of tooth
*Tooth associated with fracture lines
*Internal or External resorption of tooth or adjacent tooth
*Tooth impeding a surgery
*Orthodontic purposes
*Recurrent infection of that region/ Cellulitis/ Abscess or osteomyelitis
*Cyst or tumor
*Prophylactic removal or in combine surgeries.
6. Physiologic Contraindications
* Pregnancy: First and last trimester are more crucial period.
During the first 3 months of pregnancy, process of
organogenesis/fetal development takes place. 3rd week to
8th week during differentiation, all the drugs should be
avoided for the potential risk. All dental invasive procedures
should be avoided, unless severe infection warrants the
emergency treatment. 3rd trimester patient may develop
supine hypotension syndrome during dental treatment in a
flat position. Left lateral position will allow the venous
return.
*Extraction during menstruation period: Painful and stressful
condition along with mood swings for many women. High
circulating estrogen levels may cause excessive bleeding. Not
the best time to undertake extraction unless it is a must.
* Extreme old age: Compromised body physiology as well as
fragile physical and mental conditions should be handled with
utmost care.
7. Absolute Contraindications :-
1. Teeth in recent irradiated area: Within 6 months to 1 year
Within 6 months of myocardial infarction (after bypass
surgery or stents)
2. Teeth in the area of central hemangioma, arteriovenous
(AV) malformation, aneurysm
3. Pregnancy: 1st and last trimester Site of malignant tumor:
Hastens metastasis.
Relative Local Contraindications :-
1. Acute generalized periodontitis, acute necrotizing
ulcerative gingivitis (ANUG)
2. Acute dentoalveolar abscess, acute cellulitis
3. Acute pericoronitis.
8. MAXILLARY FORCEPS:-
* In all the maxillary extraction forceps, handles and beaks are at 180° to each other, i.e. in
a straight line
* Maxillary anterior forceps: They have identical beaks that are closed, straight, flat and
broad. The handles are straight, not curved. They are used for extraction of the maxillary
incisors and the canines. Basic forces:
* ■ Maxillary central incisors: Labial movement, mesial rotation
* ■ Maxillary lateral incisors: Labiopalatal movements, removal in the labial direction
* ■ Maxillary canine: Labiopalatal movements, removal in the labial direction. Maxillary
premolar forceps: They have identical beaks that are concave on the side facing the
operator. The beaks are broad and open. They are used for extraction of the maxillary
premolars. The curvature of the blade is to give access to the premolars placed posteriorly
in the arch. Rotational and buccal movements are given for the maxillary second premolar,
while only buccopalatal movements are given for the first premolar.
Basic forces:
* ■ First premolar: Buccopalatal movements and removal in the buccal direction
* ■ Second premolar: Buccopalatal movements and removal in the buccal or palatal
direction
9. DENTAL FORCEPS USED FOR EXTRACTION OF THE TEETH
(A) Olden type of dental forceps (B) Modern design of Lower Forceps and(C) Upper
forceps
12. Maxillary Molars (Right and Left)
*The beaks of these forceps are not identical. One beak is rounded
and the other one is pointed. The pointed beak engages the groove
between the buccal roots and the other beak engages the palatal
surface above the CEJ.
*The beaks also have a curvature towards the operator, like the
premolar forceps. When viewed, if the pointed beak is to the lvice-
versa. The handles have concavity on the inner side and convexity on
the outer side.
Basic forces:
■ The first and the second molars are extracted by giving buccopalatal
movements and removal in the buccal direction
■ The third molar is extracted by giving buccal movements and distal
rotation.
*Maxillary cowhorn forceps: These forceps have unidentical beaks,
one of which has a single pointed tip and the other, a bifid pointed
tip (resembling horns of a cow). The single pointed tip engages the
furcation between the two buccal roots and the other tip engages
the palatal root. It is a paired forceps. The beaks are curved towards
the operator.
13. Maxillary anterior root forceps: They have identical, straight,
slender and closed beaks. They are used primarily for the
extraction of the root stumps of the maxillary anterior teeth.
Maxillary posterior root forceps: They are similar to the
anterior root forceps, but like the premolar forceps, they have a
curvature towards the operator for access posteriorly. They are
used for removing single molar root pieces and premolar root
stumps.
Bayonet forceps: They have identical, pointed, angulated and
closed beaks. The length of the beaks varies from long to short.
According to the thickness of the beaks, they can be classified
into thick beak and thin beak bayonet forceps. The thick beak
bayonet forceps are used to remove maxillary posterior root
stumps that are not separated, while the thin beak forceps are
used to remove single roots.
Maxillary third molar forceps: The handles are extra long and
the beaks are angulated shaped, when viewed from sides.
15. Mandibular Forceps
*They are designed such that handles and beaks are at right
angle to each other to facilitate easy access to the mandibular
teeth.
*Mandibular anterior forceps: They have identical broad, short
and closed beaks. The joint is a rivet joint unlike most forceps
that have a box joint. They are used for extracting mandibular
anterior teeth.
Basic forces:
■ Central and lateral incisors: Labiolingual and mesiodistal
movements and removal in the labial direction.
■ Cuspid: Labiolingual movement and removal in the labial
direction.
* Mandibular premolar forceps: They have identical broad
open beaks that are longer than the beaks of the anterior
forceps. They are used for extraction of the mandibular
premolar teeth.
16. Basic forces:
*■ Both the premolars are extracted with buccolingual
*and mesiodistal movements.
Mandibular molar forceps: They have identical, broad, stout open
beaks with a pointed tip. The sharp pointed tips can engage the
bifurcation both at buccal and lingual surfaces. They are used for the
extraction of mandibular molar teeth.
Basic forces: All the molars are extracted by buccolingual movements
and removal in the buccal direction.
Mandibular cowhorn forceps: They have identical, open, short and
pointed beaks that resemble the horns of a cow. The beaks are round
and taper to a point.
The forceps grips the tooth at the bifurcation between the mesial and
distal roots. When pressure is applied the beaks are closed using the
buccal and the lingual plates as the fulcrum, the tooth is luxated or
literally squeezed out of the socket, provided the root morphology is
favorable. They are used to remove grossly carious mandibular molars
with extensive destruction of the crown.
18. *
Elevators
*The dental elevators are used to luxate/elevate the teeth from the
socket prior to application of the forceps. In addition to luxation of
the teeth, the elevators also expand the bony socket facilitating tooth
extraction. They are also used to remove root remnants from the
extraction socket.
The elevator has three components: (1) handle, (2) shank and (3) blade.
*1. Handle: This is usually large in size to facilitate a good grip on the
instrument while working. It may be 180° to the shank or at right
angles to the shank. The latter is known as crossbar elevators. The
crossbar elevators can generate tremendous amount of force.
*2. Shank: It connects the handle to the blade. The shank should be
strong enough to withstand and transmit the forces applied to the
handle.
*3. Blade: The blade of the elevator is the working tip of the elevator,
which is used to transmit forces to the tooth, root and bone.
20. Elevator has no joint, needs a fulcrum to work, has to be wedged between the
interdental bone and the tooth. They are available in different sizes and shapes.
Blades can vary in size and shape and depending on that the elevators are
classified as:
■ Depending on the working tip shape:
1. The straight or the gouge type
2. The triangular type
3. The pick type
■ According to the use of the elevator designed to remove:
1. The entire tooth: Straight elevator hospital pattern, coupland elevator
2. The roots broken at gingival margin: Apexo elevator, coupland elevator
3. The roots broken off halfway to the apex: Curved hospital pattern, winter
elevators
4. Apical third of the root.
22. According to form:
1. ■ Straight or gouge type: All types, wedge type, Miller, Pott elevator
2. ■ Curved right and left Cryer’s Apexo elevator
3. ■ Angulated or triangular: Right and left Cryer or pennant type
4. ■ Cross bar: Handle at right angle to the shank; winter elevators
5. ■ Pick type:crane pick,root tip pick
Choice of Elevator Choice of elevator will depend on the condition of the
tooth to be removed and its mobility, how much tooth structure is remaining,
availability and position of solid fulcrum, direction of the movement required
and space available for elevation Crane pick, root tip pick.
23. Commonly Used Elevators
*Straight Elevators (Coupland, London Hospital Pattern)
*They are the most common types used for the luxation of teeth. The
blade has a concave surface on one side that faces the tooth to be
elevated. Sometimes the blade can be at an angle to the shank,
allowing the instrument to reach the posterior areas of the oral
cavity easily.
Common examples of these elevators are: the Miller and the Pott’s
elevator .
*Hockey Stick or London Hospital Elevator
This elevator is similar to the Cryer’s elevator, with the working blade
at an angulation to the shank, but the blade is straight, rather than
triangular, and has a convex and a flat surface. The flat surface is the
working surface and has transverse serrations on it for better contact
with the root stump. When viewed, the instrument looks like a Hockey
stick and hence the name. The principles and functions are similar to
the Cryer’s elevator
24. Apexo Elevators
* These are straight elevators that resemble the Cryer’s elevators, but have a
biangulated and sharp, straight working tip. They are paired elevators for the
mesial and the distal roots. Their uses and work principles are same as for the
Cryer’s elevators. They can also be used to remove the maxillary root stumps.
Cryer’s Elevator
* Cryer’s elevator is a straight elevator with a triangular blade. The working tip is
angulated, with one convex and another flat surface. The flat surface is the
working side. It is based on the lever and the wedge principle .
Uses:-
* For extraction of root stump of mandibular molars when one root is removed and
the other is to be removed.
* For extraction of mandibular molar root stumps when both the roots are present
but one is fractured at a lower level than the other or when the bifurcation is
intact.
* Two separate elevators are available for the mesial and distal roots. The working
blade is introduced into the empty socket and moved towards the remaining root
piece.
* In this technique, the interradicular bone is fractured prior to removal of the root
stump.
26. Winter’s Elevator
*Winter’s elevator is a crossbar elevator. The shank is at right
angles to the handle.
*The working tip is at an angle to the shank. The blade has a
convex and a flat surface.
*The flat surface is the working surface and placed facing the
tooth to be elevated.
* It works on the wheel and axle principle.
Uses
*To luxate the mandibular molar teeth.
*Winter Cryer’s Elevator
*As the name suggests, the elevator is a crossbar elevator with a
triangular blade. The uses and the applications of this
instrument are similar to the Cryer’s elevator. It works on the
wheel and axle and wedge principles
27. *There are three work principles applicable to the dental
elevators.
They are:
*(1) Lever principle
*(2) Wedge principle
*(3) Wheel and axle principle.
28. Lever Principle
*This is the most commonly used principle. Lever is the simple machine
used to lift heavy objects by exerting small amount of force. The
elevator is a lever of the first order.
*In this, the fulcrum is located between the input effort and the output
load/resistance. In order to gain mechanical advantage, the effort
arm must be longer than the resistance arm.
*Use of lever principle while using forceps: While extracting a tooth,
controlled force is delivered in a predetermined direction. The effort
or power is represented by handles of the forceps, and the resistance
or weight is represented by the beaks.
*Fulcrum is at the hinge joint.
Use of lever principle while using elevators:
*This principle is also used when elevators are used, where modest
force is transmitted at long power arm or the handle, so that the
mechanical advantage is derived at the short-weight arm, i.e. the
working end/blade, which engages the tooth, e.g. coupland elevator.
*Maximum mechanical advantage is gained in using elevator is by
keeping the effort arm longer than the resistant arm
30. WEDGE PRINCIPLE
It consists of two movable inclined planes, which meet and form a sharp
angle. The wedge is a movable inclined plane which overcomes a large
resistance at right angles to the applied effort. The effort is applied to
the base of the plane and the resistance has its effect on the slant side.
It is usually used in conjunction with the lever principle. It is an
established physics principle that a wedge can be used to split, expand
or displace the portion of a substance that receives force. The sharper
the angle of the wedge, the less A B
Mechanical advantage using wedge principle to split, expand or displace
the substanceeffort is required to overcome the resistance.
Mechanical advantage of wedge is 2.5. The mechanical advantage is
calculated by dividing the length of the slope by the wedge’s width .
* The wedge elevator is forced between the root and the bone, parallel
to the long-axis of the tooth.
* A small Apexo or Warwick James elevator can displace the roots
towards the occlusal plane out of socket, similarly a straight elevator
is applied between the tooth and interdental bone to separate the
periodontal ligament attachment
32. Wheel and Axle Principle
*The mechanical device consists of a wheel attached to an axle or
central pole, where torque is applied to the wheel winds a rope
or chain onto the axle. The wheel and axle principle is actually a
modified form of lever principle, but it can move a load farther
than a lever can.
*A light force applied to a crank handle onto the side of a wheel
creates a torque about the axle centerline (the fulcrum) to lift a
heavy load.
33. (A and B) Mechanical principle of wheel and axle to gain advantage and (C and
D) Clinical application of wheel and axle principle by using: (C) Cryer elevator;
(D) Maxillary forceps
34. Indications for the Use of Elevators
* To luxate multirooted teeth prior to the forceps application.
* To luxate, remove teeth that cannot be engaged by the beaks of the
forceps, e.g. impacted teeth, malposed teeth, badly carious teeth,
firm teeth.
* To remove fractured root stumps, apical tips.
Rules to be Followed While Using the Elevators
* Hold the elevator with palm grip .
* Never use the adjacent tooth as the fulcrum, unless that the
adjacent tooth is also to be extracted.
* Never use the buccal or lingual plate as the fulcrum.
* Always use finger guards to protect the soft tissues if the elevator
slips.
* Support the shank of the elevator with the index finger to control
the forces applied to the elevator.
* Always elevate from the mesial side of the tooth.
* The concave or flat surface of the elevator faces the tooth/root to
be elevated, follow the root curvature.
35. Handling application of elevator:
(A and B) Proper grip of the elevator
(C to E) Rotation of elevator around its long-axis
36. Basic Requirements for Carrying Out Dental Procedures
1. Extraction
* A good radiograph
* Adequate anesthesia: Local, local with sedation or general anesthesia
* Proper instruments
* Adequate illumination
* Efficient assistance
* Good suction apparatus
* Proper position of dental chair, specific to the tooth which is to be extracted
* Proper position of a patient
* Proper position of the operator
* Selection of proper dental forceps/elevators
* Proper different extraction movements.
* Proper position of dental chair, specific to the tooth, which is to be extracted
* Best chair position is the position, which is the most comfortable for the patient as
well as for the operators and assistant.
Angulation of the Dental Chair
* For maxillary teeth: Chair is tilted backwards and maxillary occlusal plane is
adjusted to 45–60° to the floor, when the mouth is fully opened.
* For mandibular teeth: Chair is made straight and mandibular occlusal plane with
mouth open, is adjusted parallel to the floor or 10° to the floor.
37. Height of the Dental Chair:-
* For maxillary teeth extraction:
Occlusal level should be 8 cm/3-
inches below the shoulder level of
the operator: 16 cm/6-inches below
the elbow of the operator .
* Height of the patient’s mouth is at
or slightly below the operator’s
elbow and operator’s arms are
inclined downward at an angle of
120° at elbow.
Position of the Patient:-
*Patient should be seated
comfortably in a dental chair with
proper adjustment of the head rest.
Patient’s head, neck and trunk
should be in one line.
* For the extraction in the maxillary
and mandibular right and left
quadrants, patient’s head is turned
towards the operator. For maxillary
and mandibula
Position of the operator for various
extraction procedures
38. Adjusting the height of a dental chair for extraction of a tooth:
Height adjusted for :-
(A) Maxillary teeth extraction and (B) Mandibular teeth extraction
39. Requirements for Closed Extractions:-
* Adequate access and visibility: Good illumination via light source
* Unimpeded pathway of removal of a tooth
* Use of controlled force to luxate and extract the tooth.
Operator’s Preparation
* Operator should take universal precautions for prevention of transmission of infection.
Patient’s Preparation:-
* Sterile disposable drape should be used
* Proper oral hygiene instructions should be followed by the patient
* Gross scaling should be carried out prior to extraction, if indicated
* Oral antiseptic mouthwash rinses are advised.
* Clinical Procedure for Intra-alveolar/Simple
Extraction of a Tooth:-
* Positioning of the patient
* Administration of local anesthesia
* Separation of soft-tissue attachments from the tooth
* Adaptation of forceps to the tooth
* Luxation of the tooth by elevator or forceps
* Removal or extraction of a tooth.
Common Technique Carried Out by Using Dental Forceps and Elevators Applying displacing force to a tooth:
* ■ Direct application of a forceps: Alveolar purchase
* ■ Indirect via a fulcrum: Use of elevators
* Expansion of socket: Wedging by forceps beaks
* Forceps beaks should be held parallel to the long-axis of the tooth,below the CEJ.
40. Severing the soft-tissue attachment around the tooth to be extracted prior
to introducing the beaks of forceps
41. Major movement of a forceps for luxation of a tooth:
(A) Apical force application (B) Buccal or labial movement
(B) (C) Lingual movement and (D) Fully luxated tooth in the socket
42. REASONS FOR BREAKAGE OF A TOOTH/INCOMPLETE REMOVAL OF A TOOTH
* Wrong selection of a forceps
* Faulty grip of the forceps/elevator
* Excessive jerky or inadequate extraction movements
* Gripping of a crown instead of root
* Uncooperative patient.
COMPLICATIONS OF TOOTH EXTRACTION
* Intraoperative complications (immediate):
*■ Failure to luxate/remove the tooth
*■ Fracture of a tooth, alveolus, mandible, maxillary tuberosity
*■ Mucosal laceration/puncture wounds on gums, lips, tongue, floor of the
mouth
*■ Luxation/removal of adjacent tooth
*■ Displacement of root/tooth in facial space, maxillary sinus, lingual pouch
*■ Aspiration of a tooth/root
*■ Nerve injury
*■ Hemorrhage-primary
*■ Temporomandibular joint (TMJ) dislocation/
43. Postoperative (delayed complications):
*■ Hemorrhage: Reactionary, secondary
*■ Pain
*■ Dry socket: Alveolar osteitis
*■ Postoperative edema/swelling
*■ Hematoma/ecchymosis
*■ Infection
*■ Trismus
Late complications:
*■ Chronic osteomyelitis/osteoradionecrosis
*■ Nerve damage: Anesthesia/paresthesia
*■ Chronic pain
* Systemic complications:
*■ Syncope, fits, respiratory obstruction, hyperventilation, myocardial
infarction, etc.
*■ Management of complications is given in appendix 1 at the end of
the book.
44. POST-EXTRACTION CARE
*Inspect the socket: Remove the debris/bone/tooth fragments
*Irrigate the site with saline
*Compress the alveolar bone with firm finger pressure
*Curette out the granulation tissue from the socket and excess
granulation tissue around gingival cuff
*Trim/smoothen any sharp edges from alveolar margin with bone file
*Ensure hemostasis.
Instructions to the Patient:-
* Moist pressure pack to be held with gentle pressure for
*at least 30 minutes
* No spitting/gargling/smoking
* Avoid hot food/alcohol for at least 24 hours
* Liquid/semisolid/soft diet.
45. *Pell & Gregory classification
*Winter's line Penderson scale
*Parents scale
*WHARFE scale
*Classify according to angulation of the tooth.
1. Mesio-angular
2. Disto-angular
3. Horizontal
4. Vertical
5. Transverse
6. Inverted
47. Depth
As per the relationship to the occlusal surface of the adjoining
second molar of the impacted maxillary or mandibular third
molar, the depth can be judged :
* Position A: The highest position of the tooth is on a level with
or above the occlusal line.
* Position B: The highest position of the tooth is below the
occlusal plane, but above the cervical level of the second
molar.
* Position C: The highest position of the tooth is below the
cervical level of the second molar.
The deeper the impacted tooth, the more overlying bone is
present and the more the angulation of impaction deviates from
parallel to the long-axis of the adjacent tooth, the more
difficult it is to remove the impacted tooth.
49. Maxillary Third Molars’ Classification:-
*Angulation and depth classification is same as mandibular third
molars
*Classification of the maxillary third molar in relation to the
floor of maxillary sinus :
Sinus approximation (SA): No bone or a thin bony partition
present between impacted maxillary third molar and the floor of
the maxillary sinus.
No sinus approximation (NSA): 2 mm or more bone is present
between the sinus floor and the impacted maxillary third molar.
51. Impacted maxillary canine position:
(A)Palatally placed
(B) Labially placed
(C) Partly on the labial side and partly on palatal side
(D) Canine locked between the roots of adjacent teeth and
(E) Canine in the edentulous maxillary
Labial or palatal placement of impacted maxillary canine :-
Intermediate position:
■ Crown between the lateral incisors and premolar
■ Crown above the root tip with labial/palatal orientation of the lateral incisor or
premolar.
Aberrant position: Impacted maxillary canines lie in the maxillary sinus or nasal cavity
■ ClassI: Palatally placed maxillary canine: Horizontal Vertical Semivertical
■ Class II: Labially or buccally placed maxillary canine: Horizontal Vertical Semivertical
■ Class III: Involving both buccal and palatal bone, e.g. crown is placed on the palatal
aspect and the root is towards the buccal alveolar process.
■ Class IV: Impacted in the alveolar process between the incisors and first premolar
Class V: Impacted in the edentulous maxilla.
52. Impacted maxillary canine position: (A) Palatally placed; (B) Labially placed; (C)
Partly on the labial side and partly on palatal side; (D) Canine locked between
the roots of adjacent teeth and (E) Canine in the edentulous maxilla
53. Cone beam computed tomography (CBCT) views of impacted maxillary and
mandibular canines:
(A and B) Labially placed canine (C and D) Palatally placed canine (E)
Completely horizontally placed canine (F to H) Mandibular impacted canine
54. Pell and Gregory Classification (1933)
Relationship of the impacted lower third molar to the ramus of
the mandible and the second molar [based on the space
available distal to the second molar :
■ Class I: Sufficient space available between the anterior border
of the ascending ramus and the distal side of the second molar
for the eruption of the third molar.
■ Class II: The space available between the anterior border of
the ramus and the distal side of the second molar is less than the
mesiodistal width of the crown of the third molar. It denotes
that the distal portion of the third molar crown is covered by the
bone from the ascending ramus.
■ Class III: The third molar is totally embedded in the bone from
the ascending ramus, because of absolute lack of space.
56. *White line - Indicate the depth of impaction
*Amber line - Indicate the bone cover to the
third molar
*Red line - Indicate degree of difficulty in
elevation
Perents scale
*Easy 1 - Extraction require forceps only
*Easy 2 - forceps + osteotomy
*Difficult 1 - Osteotomy + coronal section
*Difficult 2 - Root sectioning
58. Mostly - IOPA
1. OPG
2. Lateral oblique
* In IOPA radiograph there should be ½ Of the 1st molar, second molar & third molar, ID canal, Roots, Distal bone
Third molar analysis:-
1. Angulation
2. Crown - size, shape, caries, restorations
3. Roots- Number, shape, curvatures
4. Relationship with IDN
5. Roots
6. Darkening of the roots
7. Dark & bifid roots
8. Narrowing of the roots
9. Deflected roots
10. Canals
11. Interruption of white line
12. Narrowing of the canal
13. Diverted canals
14. Depth of tooth in alveolar bone.
2"' molar analysis
1. Crown - Restorations,
Caries,
2. Resorption
3. Roots- Number,
Shape, Periodontal
status of tooth, Apical
tissues
4. Surrounding bone
5. Density
6. Infections
59. *Eruption status of third molar
* presence of local infection caries in or resorption of the third
molar or adjacent tooth
* periodontal status
*orientation and relationship of the tooth to the inferior dental
canal .
*occlusal relationship
*temporomandibular joint function
* regional lymph nodes
*Any associated pathology should be noted.
60. *Fracture of the mandible or maxilla:Treat at time of surgery or
arrange immediate referral.
*Oro-antral communication: Repair at time of surgery, usually
with a buccal advancement flap. Antibiotic therapy is advisable
and the patient should avoid nose blowing.
*Broken instrument: Remove at time of surgery. If not
retrievable, inform the patient and record in notes
*Nerve damage: For complete transection of lingual or inferior
dental nerves, arrange immediate nerve repair by experienced
surgeon. For partial damage, debride gently and maintain good
apposition of the ends
61. Haemorrhage:
*Control at time of surgery. Soft tissue bleeding may require haemostatic
agents, bipolar diathermy and/or sutures.
*Bruising:
*Patients should be informed that bruising is common and will usually
resolve within two weeks
Displacement:
*Appropriate instruments should be in place prior to elevation to help
prevent displacement.
*Recover any displaced tooth at time of surgery if possible, or arrange
referral to a specialist centre
*Wound dehiscence:If no pain or infection, advise patients to continue
wound toilet (e.g. hot salty mouthwashes, socket syringing).
*Damage to adjacent teeth: Inform patient at time of surgery (or when fully
conscious). Record in notes and arrange repair if required.
64. Transalveolar extraction is the method used for recovering the roots that are
fractured during routine extraction of teeth (routine closed extraction method)
for a variety of reasons. It consists of removal of some amount of the bone
investing the roots, if required, and using the forceps or elevators to deliver a
tooth/root.
Indications for transalveolar surgical extraction:
* ■ Any tooth, which offers a lot of resistance for elevation technique
* ■ Retained roots, which cannot be grasped by the forceps or delivered with an
elevationtechnique
* ■ Previous history of difficult or attempted and failed extraction technique
* ■ Any large restoration with root canal therapy—brittle teeth
* ■ Hypercementosis/ankylosis of a tooth
* ■ Geminated/dilacerated tooth
* ■ Radiographic evidence of complicated/difficult root pattern or roots with
unfavorable or conflicting lines of withdrawal
* ■ Sclerosis of the bone
* ■ Teeth associated with pathology—periapical granuloma, cyst, tumor, etc.
* ■ Impacted teeth, embedded teeth.
65. Pre-extraction Radiological Evaluation
Relationship with associated vital structures:
*■ Maxillary sinus
*■ Inferior alveolar canal
*■ Mental nerve
*■ Adjacent teeth roots.
Configuration of roots:
*■ Number of roots
*■ Width—greater below cementoenamel junction (CEJ) than at the CEJ
*■ Size of roots
*■ Curvature of roots, divergence of roots
*■ Length—thin, tapered roots
*■ Resorption of roots
*■ Shape of the individual root
*■ Hypercementosis, ankylosis, root caries/root resorption
*■ Previous endodontic therapy.
Condition of surrounding bone:
*■ Density of bone surrounding the tooth
*■ Dense bone—condensing osteitis, sclerosis will increase the difficulty.
66. Preoperative radiograph is helpful to detect these conditions: (A) Hypercementosis; (B)
Extra-roots; (C) Dilacerated roots; (D) Curved, long root; (E) Roots in the maxillary
sinus and (F) Approximity to the inferior alveolar nerve
67. Multiple Extractions
*Single sitting procedure for multiple adjacent teeth with slight
modification of routine extraction pattern facilitates a smooth transition
from a dentulous to an edentulous state:
* Soft tissue reflection is extended slightly to form a small envelop flap,
exposing a crestal bone prior to extractions
*After extractions, the ridge is checked for any sharp bony spicules or
undercuts
*Alveolectomy/plasty—suturing.
Order of Multiple Teeth Extractions:-
* Maxillary posterior teeth except first molar
* Maxillary anterior teeth except the canines
* Maxillary first molar
* Maxillary canine
* Mandibular posterior teeth except the first molar
* Mandibular anterior teeth except the canines
* Mandibular first molar
* Mandibular canine
68. Difficult Extraction/Breakage of the Root
* Reposition the patient.
* Visualize the root directly or with the help of a mouth mirror.
* Irrigate the socket forcibly
* Suction the area.
* Probe with an explorer, endo file or an apexo elevator.
* Sometimes it is prudent to leave very small root tip behind, but the risk/benefit
ratio should be in patient’s favor and patient should be informed about it.
Surgical Extractions (Complicated Extractions)
* Unplanned extractions—an event that can convert an uncomplicated extraction into
a complicated one.
* Proper pre-extraction assessment of a difficult case.
* Any premonition or suspicion that the tooth/bone will break—think and plan.
* Properly planned surgical extraction is always less traumatic (people attack the
tooth—the hardest structure in the body, but hesitate, when it comes to soft tissue
incision).
* Do not shy away from complicated extraction.
* Proceed as predicted with fewer surprises.
69. Effect of root morphology in impaction surgery
*Root morphology plays a major role in deter-mining the degree
of difficulty of the impacted tooth's removal.
*The first consideration is the length of the root when the root is
one third to two thirds formed, the ends of the roots are blunt
and almost never fracture.
*If the tooth is not removed during the formative stage and the
entire length of the root develops, the possibility increases for
abnormal root
*morphology and for fracture of the root tips during extraction.
*If the root development is insufficient (i.e., less than one third
complete), the tooth is more difficult to remove, because it
tends to roll in its crypt like a ball in a socket, which prevents
easy elevation.
*The curvature of the tooth roots also plays a role in the
difficulty of the extraction.
70. Basic Necessities for Surgery
The main requirements for any surgery are adequate visibility and assistance. Adequate visibility will depend
on the following:
* Adequate access/good visibility
* Adequate light source
* A clean surgical field (free from excessive bleeding).
Adequate Access:-
* Adequate access will require:
* Comfortable patient
* Adequate oral opening
* Adequate flap design to expose the field of surgery
* Proper retraction of the tissues by assistant High-volume suction, hemostasis of the operating field
Patient:-
* Comfortable, mentally and physically Alleviation of fear, anxiety, avoidance of pain/discomfort, assurance Informed
consent
* Minimum amount of draping
* Rinsing with antiseptic mouth wash.
Equipment:-
* The proper adequate instrument kit should be prepared and sterilized
* Effective light source and suction.
Assistant:-
* Four handed surgery with the help of a skilled assistant.
* The assistant should be familiar with the procedure being performed to anticipate the surgeon’s needs
71. Flap
Definition:- A unit of skin & Subcutaneous tissues that transferred from donor site to the
recipient site, while surviving it's own intravascular circulation.
* Graft
* Does not carry it's own blood supply survive by the blood supply of the recipient site.
Mucoperiosteal flap
* Definition: A unit of mucosa & periosteal elevated by surgical incision for exposure of an
underlying pathology of bone (jaws)
* Main principles
* Preserve blood supply
* Good accessibility
* Easy to repositioning
* Margins should be lying on the intact bone
* Prevent damage to the vital structures
* In 3"' molar removal surgery when suturing the suture distal to the 2nd molar should be
very tight. Otherwise it causes post-operative sensitivity.
* Also most of the time when raising flap in the edentulous mandible we have to take extra
precautions to not to damage the periosteum, Because due to no teeth ID artery blood
supply reduced though most of the time edentulous arch depend on the periosteal blood
supply. So we have to raise supraperiosteal flap.
72. Principles of Flap Designing
*Intraoral surgical flaps are made to gain surgical access to the area to
be operated or to move tissues from one place to another.
Indications:-
*For basic oral surgical procedures to allow complete visualization of
the operative field and to access osseous tissues, whenever required.
Types of Flaps:-
A. Full thickness—mucoperiosteal flap
*■ Partial thickness
B. Envelope flap
*■ Two-sided triangular flap
*■ Three-sided rhomboid flap
*■ Semilunar flap.
C. Labial, buccal flaps
*■ Palatal, lingual flaps
73. Types of flaps: (A) Gingival margin crevicular incision (B) Two-sided
triangular flap (C) Three-sided rhomboid flap. Note that the base should be
wider than height and (D) Semilunar flap
74. Envelope Flap
The most common type of flap.
*The incision is made to any length (depending on the amount of
exposure needed) intraorally around the necks of the teeth along the
free gingival margin on the buccal or lingual aspect including the
interdental papillae
*The entire mucoperiosteal flap is raised by using periosteal elevator
to a point to the apical one-third of the tooth.
*This is mainly used for the surgical extraction of a tooth or roots.
*Two-sided triangular flap: In addition to the envelope flap, a vertical
releasing incision is used in order to havebetter access to the area.
This vertical releasing incision is made on one side of the envelope
flap (at the proximal or distal end) going divergent towards the
buccal vestibule forming an obtuse angle at the free gingival margin.
The vertical incision should be made in the interproximal area, as the
tissues here are thick.
* To avoid periodontal defect, the incision should never lie directly on
the facial aspect of the tooth. Once the incision is taken, then the
two sided triangular flap is reflected towards the base of the flap by
using periosteal elevator.
76. Three-sided rhomboid flap:
This is the modification ofthe earlier flap to improve the visibility and
access.
*An additional vertical incision is added in the opposite direction
from the earlier release. Here, care should be taken that the base
of the flap must be wider than the apex to ensure good blood
supply.
Semilunar flap:
Whenever the periapical area is required to be exposed to carry out
periapical surgery, this flap is designed. Again the base of the flap
should be broader than the apex and the suture line should not lie on
the bony defect.
*The incision is taken at least 5 mm away from the free gingival
margin. This flap is useful to avoid damage to interdental papilla
and to prevent periodontal postsurgical defects. In case of crowding
of the teeth, the suturing is not a problem with this flap. The only
disadvantage of this flap is that it often lies on the bony defect.
77. It is described originally by Sir William Kelsey Fry in
1933 .
Later popularized by T Ward Quick and clean technique .
1. Creates a saucerization of the socket, thereby reduces the
size of the residual blood clot
2. Used for mandibular third molar removal, especially those
which are placed lingually
3. Support the mandible at the inferior border
78. Steps:-
*1. Vertical stop cut is made by placing the chisel with the bevel facing
posteriorly, distal to the second molar.
*2. With the chisel bevel downward, a horizontal cut is made backward
from the lower end of the vertical limiting stop cut.
*3. The buccal bone plate is removed above the horizontal cut.
*4. The distolingual bone is then fractured inward by placing the cutting
edge of the chisel along the dotted line. Bevel side of the chisel is facing
upward and cutting edge is parallel to the external oblique ridge.
The chisel is held at 45° to the bone surface.
*5. Finally, small wedge of bone, which then remaining distal to the tooth
and between the buccal and lingual cut, is excised and removed.
*6. A sharp straight elevator is then applied and minimum force is used to
elevate the tooth. As the tooth moves upward and backward, the lingual
plate gets fractured and facilitates the delivery of the tooth.
*7. After the tooth is removed, the lingual plate is grasped with the
hemostat and freed from the soft tissue and removed.
*8. Smoothening of the edges is done with bone file.
Wound irrigated and sutured.
80. TOOTH/ROOT SECTIONING: SPLITTING OF
TOOTH/ROOT-ODONTECTOMY
* Reduces the amount of bone removal (conserves the bone) required prior to elevation
of the tooth .
* Reduces the risk of damage to the neighboring teeth/ inadvertent luxation .
* Avoids inadvertent jaw fracture .
* Reduces total surgery time .
* Reduces postoperative edema .
* Planned sectioning permits the parts of the tooth to be removed separately in an
atraumatic manner by creating space into which it is displaced and the remaining
crown or root segments removed.
* The direction in which the impacted tooth should be sectioned is dependent on the
angulation of the impacted tooth, based on the line of draw of the segments Can be
performed either with a bur or chisel. Bur use is preferable. Mallet blows may give
psychological discomfort to the patient.
* The bur is used in a controlled fashion to avoid damage to the vital structures and
surrounding teeth and soft tissues .
* The tooth is usually sectioned one-half to three-fourths with the bur and then it is
completely sectioned with the elevator While sectioning care should be taken that the
segment at the top should be bigger than at the bottom Purchase points also can be
placed at the time of sectioning Fissure bur size—1.5 mm in diameter and at least 7
mm in head length.
81. Indications for Odontectomy
*Deep impacted tooth, with lot of bone coverage.
*Large bulbous crown, locked under second molar .
*Unfavorable root anatomy: divergent, dilacerated, hooked,
curved, extra roots, hypercementosis .
*Roots with close proximity to IAN .
*Extensively carious tooth,
*Bulbous roots with mesiodistal diameter more than the tooth
diameter at the cervical line .
*Narrow periodontal ligament space: Difficult placement for
elevators.
82. Hemostasis
*Hemostasis should be achieved during surgery for the following
reasons:
*To minimize the intraoperative total blood loss
* Increase visibility.
*To increase the speed of the surgery and to cut down the total
operating time.
*To minimize the postsurgical hematoma.
*Hematoma decreases the vascularity, increases the wound
tension, acts as a culture media and makes it susceptible for
the development of postoperative wound infection.
83. Various Procedures to Achieve Hemostasis
* Intermittent pressure: With cotton/gauze sponges or with hemostat
clamping. Pressure is usually applied for 20–30 seconds, for smaller
tiny vessels, while large vessels require about 5–10 minutes of
continuous pressure.
*Use of electrocautery: For this judicious thermal coagulation, the
area around the vessel should be dried thoroughly. Avoid unnecessary
burning the tissue.
*Suture ligation: Whenever large vessel is severed, the ends are
grasped with a hemostat. Nonabsorbable suture (linen) is used to
ligate the ends of the vessels.
*Placement of compression dressing over the wound:
Many times there is oozing over a large area and hemostasis is difficult.
A cotton pad or folded ribbon gauze is stabilized over the wound and
secured with tie over sutures and left in place for 2–3 days.
* Use of vasoconstrictor agents: Such as epinephrine, commercial
thrombin or collagen gelfoam, surgical oxidized cellulose, etc
84. Dead Space Elimination
Dead space is the area that remains devoid of tissue after closure of the
wound. It is created as a result of removal of tissue in the depths of a
wound or by not suturing in multiple layers (single layer approximation).
Dead space is usually filled with hematoma.
How to Avoid a Dead Space?
1. Multiple layer suturing from the depth to the surface .
2. Use of pressure dressing over the wound in the postoperative period
for 12–18 hours .
3. Use of surgical packing of the defect. Whenever proper approximation
of the margins is not possible the strip or the ribbon gauze
impregnated with an antibacterial medication can be used .
4. Use of drains alone or along with the pressure dressings .
5. Nonsuction drains or suction drains can be used.
Decontamination and Debridement
*Irrigation during surgery y Irrigation at the end of surgery .
* Careful debridement of necrotic tissue, foreign bodies, severely injured
tissues .
*Antibiotic prophylaxis
85. It is an acute infection with associated inflammation of gingival and
contiguous soft tissue, covering the crown of the partially erupted
impacted mandibular third molar and its associated follicle (the gingival
tissue covering is also called as operculum).
Pericoronitis is reported to be common in vertical (23%), followed by
mesioangular (15%), and distoangular (8%) and horizontal type of
impactions (3%). Pericoronitis has been implicated with multiple
facultative anaerobic bacteria. Microbes responsible are
Peptostreptococcus, Fusobacterium and Bacterioides (Porphyromonas) .
Clinical Features
*It includes pain, tenderness, redness, swelling of retromolar tissue,
difficulty in mastication, trismus, pain may radiate to the ear, throat,
floor of the mouth, halitosis.
*Extraoral swelling may be present at the angle of the jaw,
lymphadenopathy and raised body temperature may be also present.
86. (A) Diagrammatic representation of pericoronitis
(B) Clinical picture of recurrent pericoronitis
(C) Radiologic picture of an impacted third molar with recurrent pericoronitis
87. Complications:-
*Pericoronitis may lead to spread of pericoronal abscess
*Cellulitis
*Ludwig’s angina, etc
Treatment:-
* Antibiotics, anti-inflammatory drugs, debridement of the area
with irrigation, chlorhexidine/hydrogen peroxide mouthwash
(frequent gargles).
* Extraction of opposite impinging maxillary third molar or
operculectomy if only soft-tissue impaction or if recurrent
episodes of acute pericoronitis, then surgical extraction of
impacted lower third molar should be carried out.
88. It is the alternative surgical option, suggested for
impacted mandibular third molars, which are in
significantly close proximity to IAN. This method avoids
injury to IAN .
Basis for Coronectomy:-
*It is a common practice for broken root fragments,
which are difficult to remove, to be left behind in situ
and most of them heal uneventfully.
* It involves removal of a crown of mandibular healthy
impacted third molar from the roots, in healthy patients
(40 years and above). It is also termed as intentional
partial odontectomy.
89. Procedure:-
* The tooth is decoronated, with the help of a bur, at an angle of 45°, below CEJ and
the roots are reduced 2–4 mm below the crest of buccal and lingual cortical plates.
* The crown of the tooth is removed, leaving behind the vital roots in situ, untouched.
This procedure was first proposed by Ecuyer and Debien in 1984. But it was not very
popular, as there was a concern that the roots are left behind, will eventually
become a source of infection.
* But since 2005, the renewed interest was generated in this procedure and then many
oral surgery departments in UK and USA started using it routinely in selected cases.
* Through some studies, it was claimed that in 14–81% of cases, there was subsequent
migration of the remaining roots. Otherwise, roots encased in the bone, can
remburied for years together and rarely cause problem.
* In 3% of cases, the root migration, away from IAN is seen within first 24 months.
Pogrel and Renton has also stated that within 2–5 years, roots may erupt away from
IAN.
* Therefore, additional possibility of surgical procedure should be intimated to the
patient
Special Consent
* It should be taken from the patient that this procedure is relatively new preventive
method to decrease the prevalence of IAN injury and there may be risk of early or
late infection following coronectomy. Also, there can be chances of “root walkout”
during coronectomy, in that case the root has to be removed and chances of nerve
injury may be there.
90. COMPLICATIONS
Intraoperative Complications:-
* During IncisionFor molars, facial vessel or buccal vessel may be cut. Injury to lingual nerve, if not careful. For lower
canines, mental nerve vessels and for upper canines—incisive canal or greater palatine vessels may be damaged.
* During Bone Removal
* Damage to the second molar
During Elevation:-
* Luxation of neighboring/overlying tooth
* Fracture of the adjoining bone
* Fracture of the tuberosity
* Slipping of the tooth into pterygomandibular/temporal spaces, sublingual pouch and/maxillary sinus
* Damage to nasal wall/overlying teeth/lingual, inferior alveolar or mental nerve
* Fracture of mandible
* Soft-tissue injury
* Breakage of elevator tip
* Temporomandibular joint (TMJ) dislocation.
During Debridement:-
* Damage to IAN/lingual nerve
* Damage to maxillary sinus.
Postoperative Complications:-
* Pain, swelling, trismus, hypoesthesia, sensitivity, loss of vitality of neighboring teeth
* Hemorrhage, edema, infection, etc.
* Pocket formation
* Sinus tract formation, oroantral fistula, oronasal fistula.
91. *Surgical endodontics is defined as “removal of pathologic
tissues, other than the contents of root canal to retain a
tooth, with pulpal/periapical involvement”.
* Apicoectomy, apical surgery, endodontic surgery, root
resection, root amputation, periradicular surgery are the
terms which are used for surgery involving the root apex to
treat the apical infection. It is the cutting off of the apical
portion of the root and curettage of periapical necrotic,
granulomatous, inflammatory or cystic lesions. In spite of
good endodontic treatment, if periapical lesions are not
resolved, then apical surgery is undertaken.
Objectives of surgical endodontics are to ensure the
placement of a proper seal between the periodontium and the
root canal foramina
92. INDICATIONS
Failed nonsurgical endodontic treatment:
* ■ Irretrievable root canal filling material
* ■ Irretrievable intraradicular post
* ■ Anatomic variations: Apical anomaly of root tip—dilacerations, intracanal
calcification/calcific metamorphosis of the pulp space, open apex, internal/external root
resorption
* ■ Procedural errors:Instrument fragmentation, non-negotiable ledging, root perforation
* Presence of lateral/accessory canal/apical region perforations, symptomatic overfilling
* Extension of root canal sealant cement/filling beyond the apexFracture of apical third of the
root.
Biopsy:
* ■ Formation of periapical granuloma/cyst
* ■ Draining sinus tract/nonresponsive to root canal treatment (RCT)
* ■ When patient with chronic periapical infection, will not be available for follow-up.
Corrective surgery:
* ■ Root resorptive defects/root caries
* ■ Root resection
* ■ Hemisection/bicuspidization
* ■ Teeth with ceramic crowns
93. CONTRAINDICATIONS
* Presence of systemic diseases—leukemia, uncontrolled
diabetes, anemia, thyrotoxicosis, etc.
*Teeth damaged beyond restoration.
* Teeth with deep periodontal pockets and grade III mobility
(preexisting bone loss).
* When traumatic occlusion cannot be corrected
*Short root length.
*Acute infection which is nonresponsive to the treatment.
*Root tips close to the nerves, e.g. mental nerve, inferior
alveolar nerve or in maxilla close to the maxillary sinus.
94. PROCEDURE
Three accepted procedures can be used :-
*1. Root canal filling and immediate apicoectomy and curettag.
*2. Root canal filling is done several days/weeks/months earlier
followed by apicoectomy and curettage
*3. Increase in the periapical lesion even after root canal filling
and draining sinus. May be due to faulty filling which is redone
and then followed by root amputation and curettage.
95. STEPS
* Asepsis and isolation
* Local anesthesia with infiltration technique
* Incision design
* Mucoperiosteal flap—either semilunar or submarginalenvelope flap with extension of at least
one tooth on either side.
* Submarginal envelope flap is known as OchsenbeinLuebke flap design. It is indicated when
the esthetics of the gingival margin cannot be compromised (maxillary teeth with crowns). A
scalloped incision is made below the attached gingiva with one or two releasing incisions.
* Contraindication for this flap—periodontal breakdown, large periapical lesion, a short root
* Raise the mucoperiosteal flap with periosteal elevator
* Retract the flap away with Langenbeck retractor
* Identify the apex in the intact buccal plate—create a bony window with surgical bur over the
root apex area.
* Care is taken not to damage the adjoining roots (make bur holes with round bur and then
join them with tapered fissure bur). Locate the apex
* Section the root tip at an angle of 30–45° from the line perpendicular to the long-axis of the
tooth facing towards the buccal aspect of the root. This is done to provide enhanced
visibility to the root end preparation.
* Current concepts: Bevel-horizontal or maximum of 10°. After this beveling root procedure,
root end preparation is done to create a cavity with small round or inverted cone bur to
receive a root end filling
* Remove all periapical granulation tissue with angulated curettes
* Use hot burnisher to seal the root tip
* Close flap and suture it.
96. RETROPREPARATION
*The ultrasonic tip is used for retropreparation.
*The tip is placed at the apical opening of the canal and guided
gently deeper into the canal as it cuts.
* Once the retropreparation is completed the prepared cavity is
inspected.
*The gutta-percha at the base is recondensed with small 0.5 mm
microplugger .
*The aim of placing root end filling material is to establish an apical
seal that inhibits the leakage of residual irritants from the root
canal into the surrounding tissues.
*A wide variety of retrograde filling materials have been used—gutta-
percha, amalgam, gold foil, titanium screws, glass ionomer, zinc
oxide-eugenol, cavit, composite resin, polycarboxylate cement,
silver points, mineral trioxide aggregation (MTA), etc.
* In the defect in the periapical region, hydroxylapatite can be
packed to enhance the bony healing
97. COMPLICATIONS
Intraoperative
* Bleeding—control with local application of adrenaline pack 1:
1,000, pressure pack/gelfoam
*Damage to the neighboring root
*Entry into sinus/inferior alveolar canal.
Postoperative
*Abscess formation
* Fenestration, sinus tract formation
*Increased mobility of the tooth.
