11 - Third molars 4

Question 1

What are the basic principles of of surgical removal?

Answer 1

• risk assessment
• aseptic technique
• minimal trauma to hard and soft tissues

Question 2

What are the steps of surgical removal?

Answer 2

• anaesthesia
• access
• bone removal
• tooth division
• debridement
• suture
• haemostasis
• POI

Question 3

Describe access for surgical removal.

Answer 3

• raise a buccal mucoperiosteal flap
  +/- raise a lingual flap (high risk)
• open a larger slap than you may think, as minimal trauma required
• use scalpel with one firm continuous stroke
• minimise trauma to dental papilla

Question 4

How do you reflect a flap?

Answer 4

• begin raising flap at base of relieving incision
• undermine and free papilla before proceeding distally
• reflect with elevator firmly on bone

Question 5

What instruments can be used to reflect a flap?

Answer 5

• Mitchell’s trimmer
• Howarth’s periosteal elevator
• Ash periosteal elevator
• Curved Warwick James elevator

Question 6

Why do you retract a flap?

Answer 6

• access to operative field
• protection of soft tissues

Question 7

Describe how to retract a flap.

Answer 7

• the flap design facilitates retraction
• atraumatic and passive retraction is done by resting the instrument firmly on bone
• be aware of adjacent structures

Question 8

What instruments can be used to retract a flap?

Answer 8

• Howarth’s periosteal elevator
• rake retractor
• Minnesota retractor

Question 9

Describe a rake retractor.

Answer 9

Has small “teeth” at the end to grip the tissue

Question 10

Describe a Minnesota retractor.

Answer 10

• wide application point
• reflects light into surgical field

Question 11

What is used to remove bone?

Answer 11

Electrical straight handpiece with saline cooled bur

Question 12

Why can you not use air driven handpieces in oral surgery?

Answer 12

• can cause surgical emphysema
• air is driven into soft tissues and can cause severe infection

Question 13

Which burs are used for bone removal?

Answer 13

• round or fissure
• stainless steel
• tungsten carbide

Question 14

Describe bone removal for third molar extraction.

Answer 14

• buccal aspect drilled and onto distal aspect of impaction
• deep but narrow gutter
• bone removed to allow application of elevators on mesial and buccal aspect

Question 15

Describe tooth division.

Answer 15

• most common to section the crown from the roots
• occasionally roots require sectioning

Question 16

How do you section a tooth horizontally for removal?

Answer 16

• placed bur horizontally and begin to cut above the CEJ
• once initial cut is made, insert elevator and rotate to crack tooth
• warn patient about noise

Question 17

How do you section a tooth horizontally for a coronectomy?

Answer 17

• placed bur horizontally and begin to cut below the CEJ
• once initial cut is made, insert elevator and rotate to crack tooth
• warn patient about noise

Question 18

How do you section a tooth vertically?

Answer 18

• cut along crown
• feel for a drop into the furcation
• elevate roots and crown, distal first then mesial

Question 19

Describe the debridement of the extraction socket.

Answer 19

• physical debridement can be carried out using a bone file or handpiece
• irrigate the socket with saline and under flap
• aspirate under flap to remove any debris

Question 20

What instruments are used to physically debride the socket?

Answer 20

• Mitchells trimmer
• Victoria curette

Question 21

What is the purpose of suturing?

Answer 21

• approximate tissues
• compress blood vessels
• cover bone
• prevent wound breakdown
• achieve haemostasis

Question 22

What POI should be given to the patient after a surgical extraction?

Answer 22

• avoid disturbing socket
• no smoking for as long as possible
• no alcohol for >24 hours
• no vigorous exercise for >24 hours
• optimal pain relief advice

Question 23

What is a coronectomy?

Answer 23

• alternative to removal of entire tooth when the roots are in close proximity to the ID canal
• crown is removed with deliberate retention of roots

Question 24

Describe the coronectomy procedure.

Answer 24

• flap design as necessary for access
• transaction of tooth 3-4mm below enamel of crown into dentine
• elevate/lever crown without mobilising roots
• pulp left in place and untreated
• socket irrigated
• flap repositioned

Question 25

Describe the follow up for a coronectomy.

Answer 25

• review 1-2 weeks
• further review 6-12 months then discharge to GDP

Question 26

What are the risks you must inform the patient of regarding coronectomy?

Answer 26

• if roots mobilised the entire tooth must be removed
• leaving roots behind can result in infection although rare
• can heal slowly and painfully
• roots may migrate after surgery and begin to erupt, these would require extraction although would now be safer

Question 27

How are upper third molars extracted?

Answer 27

• generally easier
• can be removed by elevation only or with forceps

Question 28

What instruments are used to remove upper third molars?

Answer 28

• straight or curved Warwick James elevator
• couplands
• Bayonet forceps