Minor oral surgery.

Minor Oral

Surgery

Thilanka Umesh Sugathadasa

Thilanka Umesh Sugathadasa Page 1

Minor Oral Surgery

Definition

A surgical procedure that can be comfortably done by competent non specialized dental surgeon

within 30 minutes under LA with or without sedation.

MOS

Trans alveolar extractions

Impaction

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

Due to cleft palate

Cleidocranial dysostosis

Jaw size

Supernumerary tooth

Indications for surgical removal of impacted tooth (NICE)

1. Unrestorable caries

2. Untreatable pulpal pathology/ periapical pathology

3. Fracture of tooth

4. Tooth associated with fracture lines

5. Internal or External resorption of tooth or adjacent tooth

6. Tooth impeding a surgery

7. Orthodontic purposes

8. Recurrent infection of that region/ Cellulitis/ Abscess or osteomyelitis

Soft tissues

Frenectomy

Removal of

fibrous epulis

Hard tissues

Removal of

impacted tooth

Canine

transplantation

Acquired

Early loss of deciduous

Retention of deciduous more

than expected time

Damage to the tooth bud


9. Cyst or tumor

10. Prophylactic removal or in combine surgeries.

Contraindications

1. Extremes of Ages(Higher ages the bone become highly calcified though less flexible & less likely

to be bend also post-operative problems more in the elderly persons)

2. Compromised medical status

3. Excessive damage to the adjacent structures.

Classifications(Extraction difficulty indices)

1. Pell & Gregory classification.

2. Winter’s line

3. Penderson scale

4. Parents scale

5. WHARFE scale

6. Classify according to angulation of the tooth.

- Mesio angular

- Disto angular

- Horizontal

- Vertical

- Transverse

- Inverted

Pell & Gregory

Pell and Gregory class 1 impaction. Mandibular third molar has sufficient anteroposterior room (i.e., anterior-to-anterior border of ramus) to

erupt.


.

Pell and Gregory class 2 impaction. Approximately half is

covered by anterior portion of ramus of mandible

Pell and Gregory class 3 impaction. Impacted third molar is

completely embedded in bone of ramus of mandible.

Pell and Gregory class A impaction. Occlusal plane of

impacted tooth is at same level as occlusal plane of second

molar.

Pell and Gregory class B impaction. Occlusal plane of impacted

tooth is between occlusal plane and cervical line of second molar.

Pell and Gregory class C impaction. Impacted tooth is below

cervical line of second molar.

Impaction with distoangular, class 3 ramus relationship and class

C depth makes it extremely difficult to remove.


Winter’s line

White line Amber line Red line

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

1. Easy 1 – Extraction require forceps only

2. Easy 2 – forceps + osteotomy

3. Difficult 1 – Osteotomy + coronal

section

4. Difficult 2 – Root sectioning

Radiographic analysis

Mostly – IOPA

OPG

Lateral oblique

In IOPA radiograph there should be ½ 0f the 1st

molar, second molar & third molar, ID canal,

Roots , Distal bone

Third molar analysis

Angulation

Crown – size, shape, caries, restorations

Roots- Number, shape, curvatures

Relationship with IDN

Roots

Darkning of the roots

Dark & bifid roots

Narrowing of the roots

Deflected roots

Canals

Interuption of white line

Narrowing of the canal

Diverted canals

Depth of tooth in alveolar bone.

2nd molar analysis

Crown - Restorations, Caries,

Resorption

Roots- Number , Shape , Periodontal

statu of tooth, Apical tissues

Surrounding bone

Density

Infections

CLINICAL ASSESSMENT

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.


SERIOUS COMPLICATIONS

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

COMMON COMPLICATIONS

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.

Factors that Make Impaction Surgery Less Difficult

Factors that Make Impaction Surgery More

Difficult


Prophylaxis doses

Amoxicillin(Oral) Adults - 2g Childs - 50mg/kg

Amphicillin(IV) Adults – 2g Childs – 50mg/kg

Clindamycin Adults – 600mg Childs – 20mg/kg

Clarythromycin Adults – 500mg Childs – 15mg/kg

Indications 1. Heart transplantation 2. Prosthetic heart valves 3. Previous Hx of IE 4. Cyanotic heart diseases.

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

1. Preserve blood supply 2. Good accessibility 3. Easy to repositioning 4. Margins should be lying on the intact

bone 5. Prevent damage to the vital structures

In 3rd 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.

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


Lack of root development. If extraction is attempted, crown will roll around in crypt, which makes it difficult to remove.

Finally, the surgeon should assess the

periodontal ligament space. older

patients, especially those over age 40,

tend to have a much narrower

periodontal ligament space, which

thereby increases the difficulty of the

extraction.

Size of Follicular Sac

The size of the follicle around the

impacted tooth can help determine the

difficulty of the extraction. If the

follicular sac is wide (almost cystic in

size), much less bone must be removed,

which makes the tooth easier to extract

Large follicular sac. When space of sac is large, amount of

required bone removal is decreased

Minor oral surgery.

Education

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