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Technique PowerPoint Presentation

Technique

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Technique

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  1. Technique Surgical Anatomy Procedure Basics Perioperative management Post operative management

  2. Mandible

  3. Applied AnatomyFlap design • Applied Anatomy • Flap design • Distal incision –Direct it laterally • Buccal incision-Facial artery and vein • Lingual Nerve Close proximity to mandibular third molars

  4. Surgical Anatomy • Surgical Location • Distal end of body of mandible • Embedded between thick buccal alveolar bone and narrow inner cortical plate. • Transverse direction • Applied Anatomy • Flap design

  5. Applied Anatomy • Flap design • Distal incision –Direct it laterally • Buccal incision-Facial artery and vein • Lingual Nerve Close proximity to mandibular third molars

  6. Surgical Anatomy • Inferior alveolar nerve • External Oblique ridge • Lingual Alveolus • Lingual pouch • Loose connective tissue • Tendinous insertion of the temporalis muscle

  7. Upper third molar • Location- Tuberosity region • Close proximity to maxillary sinus • Conical rooted Maxillary molar • Tuberosity fracture • Infratemporal fossa

  8. Technique-Basic Procedure • Adequate exposure for accessibility • Removal of overlying bone • Sectioning of the tooth • Delivery of the sectioned tooth with an elevator • Debridement and wound closure

  9. General differences between bone removal while extracting a root stump vs. impacted tooth

  10. Lower third molar Surgery • Step1 – Adequate flaps for surgery • Incisions • Flap Types • Envelop flap • Relaxing incision

  11. Step1 – Adequate flaps for surgery

  12. Step1 – Adequate flaps for surgery

  13. Step1 – Adequate flaps for surgery

  14. Step1 – Adequate flaps for surgery

  15. Tearing – the most common error Failure to cleanly elevate the flap Too much tension and stretching of the flap because the flap is too small for the access needed

  16. Bone Removal

  17. Bone Removal

  18. Step 2- Bone Removal

  19. Step 2- Bone Removal • Chisel and Mallet • Types • Use • Strokes are a succession of short, sharp taps sustained by wrist movement

  20. Sectioning of the tooth • Assess the need for sectioning • Direction of sectioning depends on the angulation of impaction • Procedure • Section tooth until ¾of the way towards lingual aspect • Split the tooth using a straight elevator

  21. Sectioning of the tooth

  22. Sectioning of the tooth

  23. Elevators Straight elevator #301, #304 Cryer Crane pick Sectioning of the tooth

  24. Sectioning of the tooth • Mesioangular least difficult (Class 1 Position A) • Followed by Horizontal and Vertical impactions • Distoangular is most difficult • Lot of distal bone removal • Crown is sectioned

  25. Example of Sectioning-Distoangular Impacted

  26. Example of Maxillary Third Molar

  27. Releasing Incision

  28. Exposure of Maxillary third molar

  29. Removal of thin Buccal plate

  30. Application of Elevator

  31. Application of Elevator

  32. Follicle removal

  33. Suturing

  34. Extracted Maxillary third molar

  35. Take home points • Use finesse not force • Don’t loose your handle • Watch the adjoining tooth • Deeper Buccal troughing ( Drill at the expense of the tooth instead of bone) • Conserves Bone • Avoid proximity to vital structures

  36. Take home points (contd.) • Use purchase point on root component • Use of small or large root picks depending on the size of the root • Inter-radicular bone removal to gain access to a root • Leaving the root tip • Not infected • Document it

  37. Take home points (contd.) • Use a good light source • No indiscriminate deep drilling in the socket • No surgery without radiographs • Take additional radiographs when in doubt • Lingual plate is thin and tooth fragments can slip in to ‘lingual pouch’

  38. Perioperative patient management • Patient anxiety control • Goals • Achieve a level of patient consciousness that allows the surgeon to work efficiently • Achieved by • Long acting anesthetics • Nitrous oxide • IV sedation

  39. Perioperative patient management • Pain control (Analgesics) • Best achieved before the effect of LA wears off • Doses to be prescribed to last 3-4 days (Beat the pain before it beats you) • Swelling Control • Parental corticosteroids • Ice packs

  40. Perioperative patient management • Infection control (Antibiotics) • Pre existing pericoronitis • Periapical abscess • Systemic disease • Other • Topical Antibiotic (Tetracycline) • Effective in prevention of dry socket

  41. Trismus • Mild to moderate • Resolves in 7 to 10 days • If does not resolve -Investigate

  42. Post operative management • Prevention of complications • Give Proper Instructions • Verbal • Written

  43. Post operative complications • Hemorrhage- Controlled by • Pressure gauze 15 minutes • Placement of gelfoam/sutures • Debridement of site with subsequent placement of gelfoam/sutures • Placement of surgicel (oxidized cellulose) • Topical thrombin with sutures, • Pressure!! • Pressure!!! • Further work-up may be indicated if above measures do not achieve adequate hemostasis.

  44. Factors that Aggravate bleeding(Four S’s) • Negative pressure – Three S’s • No Smoking • No Sucking (on a straw) • No Spitting • No Strenuous exercises

  45. Control of Pain • Pain is expected • Normal PO—3-5 days PO • Cessation of pain by 7 days • Severe pain within first 24 hrs—avg. pain tolerable • Most quit taking meds within 4-7 days • Direct correlation between • Operating time and resultant pain • Pain and trismus Appropriate analgesics • Codeine –Acetamenophen • Oxycodone-Acetaminophen etc.

  46. Dry Socket • Pre op regimen for prevention of dry sockets • Antibiotics • Chlorhexidine rinses • Placement of antibiotics in site of tooth extraction • Copious irrigation (dilution of the pollution) • Occurs 3-5 days PO up to 2-3 weeks • Pt. Presents c/o pain (radiates to my ear) • malodorous breath • foul taste intraorally