Oral Surgery 2 Prelims 1

FERNANDEZ PAMELA SY 2020-2021
ORAL SURGERY 2 by: Dr. Gary Brillo
IMPACTED TEETH INDICATIONS FOR REMOVAL OF IMPACTED

TEETH:
 Any tooth that remains trapped inside
the bone preventing it from erupting 1. prevention of periodontal disease.
properly inside the oral cavity. 2. Prevention of dental caries.
3. Prevention of pericoronitis
Most common Impacted tooth (inflammation of tissues surrounding
1. Lower third molars the crown of a tooth)
 Lack of space in dental arch - Operculum- tissue surrounds
 Abnormal positioning of tooth bud the tooth
- OPERCULECTOMY - removal
 Supernumerary tooth
 Ankyloses of the deciduous or 4. Prevention of root resorption.
permanent tooth 5. Impacted tooth under prosthesis.
 Non resorbing bone due to local or 6. Prevention of odontogenic cyst and
tumors
systemic causes
2. Upper third molars 7. Prevention of pain of unexplained
3. Canine origin.
4. Premolars. 8. Prevention of fracture of the jaw.
9. Facilitation of orthodontic treatment
10. Damage to adjacent structures
THIRD MOLAR SURGERY

CONTRAINDICATIONS FOR REMOVAL OF
 The extraction of 3rd molar (m3) is one of IMPACTED TEETH
the most common surgical procedures
performed worldwide. (Andres Savi et al.) 1. Damage to adjacent structures
 Removal of impacted or erupted third molar 2. Compromised physical status
is one of the most frequently performed - Immunocompromised patient
dento alveolar surgical procedures. (Gry 3. juvenile full mouth extraction
Karina Kjelle et al.)
 Trigeminal nerve injury is the most - 3rd molar can be an abutment for RPD
problematic consequence of dental surgical
4. extremes of age
procedure with major medico legal
implications. (Waseem jerjes et al.) 5. teeth to be moved orthodontic ally
- surgical exposure/ forced eruption.
As a General rule:
 All impacted teeth should be CLASSIFICATION OF IMPACTED TEETH

romoved unless removal is
1. Partially impacted teeth
contraindicated.
2. Fully impacted
PAGE | 1 ODR ODP FRATERNITY SORORITY

Indications for TMS present results, the author suggested

that 1.) MESIALLY INCLINED third
 Prevention of molars (mesioangular and horizontal)
periodontal diseases have a greater potential of being
 Prevention of dental associated with ERR in second molars
and 2. CLASS A AND B third molars
caries patients older than 24 years are more
 Prevention of root associated with the presence of
resorption External Root Resorption (ERR). In the
 Furthermore, considering the adjacent teeth. These conditions
propensity of these teeth to cause ERR indicate a high risk for ERR and removal
in second molars, third molar of these third molars should be
prophylactic extraction could be considered. (Oenning et al.)
suggested. (Oenning et al)  In subjects with mild pericoronitis
 The prophylactic removal of a partially symptoms, experiencing problems with

erupted mesioangular third molar will oral function and lifestyle, factors not
prevent distal cervical caries forming in often considered by clinicians, were
the second molar tooth. (L.W McArdle et significantly associated with subjects
al.) decision for early 3M removal. (Tang et
al.)
 The results indicate that the presence
of partially erupted mandibular 3rd
molar with an angulation of 31 degrees
or more, is risk factor for caries on distal
surface of the mandibular 2nd molars.
(S.G.M field et al)
 Prevention of fracture
 The presence of impacted M3s

increased the risk of angle fracture
and simultaneously decreased the risk
of condylar fracture. However, no
relation appeared to exist between M3
 The continued interest of surgeons and
position and fracture pattern.
researchers on evidences to support the
(S.Naghipur, et al.)
management of third molars is
completely justifiable. Based on the

 This present respectively study  Upon extraction on both sides, the

concluded that the presence of number of displacements of the midline
impacted third molar predisposes the is reduced, thus giving more space.
angle to fracture and reduces the risk of (berit lindqvist et.a;.)
a concomitant condylar fracture. (R.  Significant disagreements exists among
Gaddipati, et.al) practitioners, including orthodontists
 Both the presence and the position of and underlying the role of the third
the M3 influence the fracture pattern of molars in dental crowding (lindaur
the mandibular angler and condylar et.al.)
regions. This influence is recorded in
both analysed trauma situations,
namely, in the case of frontal blow and
in the case of lateral blow. ( S. Antic, et
al.)
INCIDENCE OF COMPLICATION
 Neurosensory impairment-
common complication of
extraction of impacted
mandibular third molars, and
the incidence ranges from 0.5%
to 8%
 The average complication rate
for permanent nerve injury was
0.7%.
 120 patients with nerve injury
following M3M surgery were
assessed.
 44.2% inferior alveolar
nerve (IAN)
 55.8% lingual nerve
 Facilitation of injury (LNI)
orthodontic treatment
 This finding suggest that the
recommendation for mandibular third NEUROVASCULAR INJURIES
molar removal with the objective of
alleviating or preventing mandibular Dysfunction of the alveolar nerve after
extraction of mandibular third molars, although
incisor irregularity may not be
uncommon, is one of the most undesirable
justified. (ades, et al.)
complications, and is acknowledged to be very
distressing for most patients affected.

 To determine whether treatment

modifications are required to enable
The subsequent distorted sensory sensation
the patient better tolerate the stresses
can result in significant impairment in speech
of dental surgery.
and chewing, and taste loss from the ipsilateral
 To determine whether
anterior segment of the tongue, which was a
contraindications exist to any of the
negative impact on socializing and the patient’s
medications to be employed.
psychological well-being.
 To determine which technique of
anesthesia is appropriate for the
patient.
 NERVE INJURY
PATIENT EVALUATION AND SELECTION
In this study, early removal of the third lower
molar was effective in avoiding some  Systemic disease
postoperative complications, especially nerve - Psychologic or physical
injury. Early extraction of lower third molar in condition that might lead to
youngsters is recommended following a team alteration of physiologic rate.
consultation.  Health
questionnaire/case
history
 Physical examination
 Request for medical
clearance
 Request for laboratory
1. medical condition/ systemic diseases patient
tests
evaluation
Physical examination
2. conditioning of patient “ the bottom line is that most people
with peripheral edema do not have
Patient dialogue/ clinical examination
heart disease, but it could be an
3. local complication radiographic examination important signs and symptoms of heart
failure.”
4. intra-operative and post-operative
management A type of Xanthoma called
XANTHELASMA PALPEBRA appears on
the eyelids. These yellow, fat deposits
GOALS OF PATIENT EVALUATION can potentially be sign of heart disease
because they may indicate high levels of
 To determine patient’s ability to fats in the blood.
physically and psychologically tolerate
the stresses involved in oral surgery

 Creatinine
SEQUENCE OF IMPACTED TEETH
1. mandibular 3rd molars

2. maxillary 3rd molars
3. maxillary canine
4. mandibular premolar
5. maxillary premolar
6. mandibular canine
Check if the lesion could be an oral
7. maxillary central incisors
manifestation of systemic diseases
8. maxillary lateral incisors
(immunocompromised patient)
CLASSIFICATION AND LOCALIZATION OF

IMPACTED TEETH
A. PELL AND GREGORY’S CLASSIFICATION
IMPACTED MANDIBULAR 3RD MOLAR

Request for medical clearance
CLASSIFICATION
 Biographic data
 Purpose of referral
 Medical condition concern
 Current medications
 Contemplated treatment plan
 Referring doctors contact
numbers
Request for laboratory test
 Clotting time/bleeding time

 Prothrombin time/ partial
thromboplastin time
 INR
 FBS Based on space available distal to second
 BUN molar

 CLASS I - The crown is fully covered by

- Sufficient space available the anterior border
between the anterior border of
the ascending ramus and the
distal side of the second molar Based on depth
for the eruption of the
3rd molar.  POSITION A
- The highest position of the
- Anterior to the anterior border tooth is on a level with or above
the occlusal line
 POSITION B
- Highest position is below the
 CLASS II occlusal plane, but above the
- The space available between cervical level of the second
the anterior ramus and the molar.
distal side of the second molar
less than the mesiodistal width
of the of the crown of the 3rd
molar.
- Half of the crown is covered by
the anterior border
 POSITION C
- Highest position of the tooth is
below the cervical level of the
second molar.
 CLASS III
- The 3rd molar is totally
embedded in the bone from the
ascending ramus because of
absolute lack of space.

 CLASS B
- The occlusal plane of the
impacted tooth is between the
occlusal plane and the cervical
line of the adjacent tooth.
IMPACTED MAXILLARY 3RD MOLAR

CLASSIFICATION
 CLASS C
- The occlusal plane of the
impacted tooth is apical to the
cervical line of the adjacent
tooth.
Based on occlusal plane

 CLASS A
-the occlusal plane of the impacted
tooth is at the same level as the
adjacent tooth.

c. Archers classification
B. Winters classification
mandibular 3rd molars
CLASSIFICATION OF MAXILLARY IMPACTED

CANINE
 Class I- located in the palate
 Class II- located in the labial or buccal
surface of the maxilla.
 Class III- located in both of the palatine
and maxillary bones. Crown on the
palate/ root on buccal surface

 Class IV- located in the alveolar process

usually vertically between incisor and
first bicuspid.
 Class V- located in an edentulous ridge
The
following factors are considered when
interpreting the radiograph:
F- FOLLICULAR SAC
- surgical advantage
displacement space
R- ROOT MORPHOLOGY
- distinction of root
- to prevent root fracture
RADIOGRAPHIC EVALUATION - curvature root
I- IAN CANAL
E- EXTENT OF CARIES or PATHOLOGY
- Must concerned to other
structures.
- Tingnan maigi kung saan talaga
nagmumula yung pain baka
mamaya yung adjacent tooth
pala yung may problem
Surgical technique
N- NATURE OF OVERLYING TISSUES
D- DENSITY OF OVERLYING BONE
- Dense bone more difficult to
remove
- Form of abnormality
S- SHAPE OF CROWN AND UNDERCUT

WAR lines
 The first line or White line is drawn along the
occlusal surface of the erupted mandibular
molars and extended posteriorly over the
third molar region.
 The second imaginary line or amber line is
drawn from the surface of the bone lying
distal to the third molar to the crest of the
interdental septum between the first and
second molar.
 The third line or red line is used to measure
the depth at which the impacted tooth lies
within the mandible. It is a perpendicular
dropped from the ‘amber’ line to an imaginary
point application of an

1.HORIZONTAL SHIFT/ VERTICAL

SHIFT
LOCALIZATION USING PERIAPICAL

RADIOGRAPHS
1. Horizontal shift/ vertical shift
2. Right angle technique
3. Definition evaluation

Step 2
STEP 1

3.DEFINITION EVALUATION
 Radiographic analysis
- Structure that lie closer to the
x-ray film have better
radiographic definition than
those that are farther from the
film
2.RIGHT ANGLE TECHNIQUE

SURGICAL STEPS IN REMOVING

IMPACTED TEETH
Guidelines/rules
Step 1
ANESTHETIC SOLUTION
 Type of anesthetic solution

 Epinephrine content
 Duration of action
 Technique
Reason for failure
 Local anesthetic solution or

vasoconstrictor
 PKa-Ph discrepancy in tissues
 Needle jaw size discrepancy
 Inadequate volume solution
 Anatomical variance
ANESTHETIC SOLUTION AVAILABLE IN THE

PHILIPPINES
1. Short acting (30 mins)
Mepivacane 3%

2. Intermediate acting  Intra-arterial injection

Articaine 4% with 1:100k epi - Anesthetic overdose (always
Lidocaine 2% with 1:80k epi aspirate before you deposit)
Lidocaine 2% with 1:100k epi  Needle breakage
3. Long acting ( >90 mins) - Re-sterilization of needles
Bupivacane 0.5% with 1:200k - Wrong needle size length
epi - Inadequate anatomical
knowledge
Possible complications
- Improper technique
- Lack of patient orientation
 Allergic reactions  Nerve damage
- Anaphylactic reaction - Technique related injury
 Overdose - Anesthetic solution related
- Excessive amounts of injury
anesthetics or epinephrine
 Pain
- Intraoperative/ post
operative
STEP 2 SURGICAL ACCESS
MAXILLARY INCISION
TECHNIQUE FOR MAXILLA
 Triangular flap
Nerves involved:  Trapezoidal flap
 Sulcular incision
 PSAN, MSAN, ASAN
 Greater palatine nerve/ anterior MANDIBULAR INCISION
palatine nerve  Triangular flap
 Nasopalatine nerve  Trapezoidal flap
 Sulcular incision
TECHNIQUE FOR MANDIBLE

Possible complications:
 Inferior alveolar nerve
 Mental nerve/incisive nerve  Nerve damage
 Lingual nerve
-extended distal extension can result to
 Long buccal nerve
damage of long buccal nerve
POSSIBLE COMPLICATIONS

- straight line distal incision can result to -the bone on the occlusal aspect and the buccal
damage of lingual nerve and blood and distal aspects down to the cervical line of
vessel. impacted tooth should be removed initially.
- releasing or vertical incision on
premolar or lingual area can lead to
damage of mental nerve and lingual -bur 701-704 use for ditching
vessel respectively.
- faulty lingual flap reflection could lead
to lingual nerve paresthesia Possible complications
 Bleeding
- Anatomical variation of
mandibular canal blood vessels
can lead to bleeding duriwng
removal of overlying bone.
 Maxillary sinus exposure
- Excessive removal of bone
around the maxillary impacted
tooth can result to perforation
of maxillary sinus.
 Injury to adjacent teeth
- Injury to adjacent teeth can
 Lingual nerve injury occur due to inaccurate bone
- “the incidence of LN injury removal.
varies and depends on a  Tooth mobility
number of factors: the - Excessive bone removal can
experience of the surgeon, lead to mobility of adjacent
difficulty of the case, depth of teeth
impaction, presence of  Distal ditching
overhanging ramus bone,
lingual flap elevation, operating
time, surgical approach.”
 Exposure of distal bone
STEP 4 SECTIONING OF TOOTH
SECTIONING
- Surgical bur or chisel can be

STEP 3 REMOVAL OF OVERLYING used
BONE - The tooth is sectioned ¾ of the
way towards the lingual aspect.
DITCHING MANAUEVER

- A few millimeters of crown is - With the use of exolever(

left on the inferior portion to elevator or luxators), the crown
avoid damage of IAN. is separated and removed from
- Angulation of surgical bur the socket.
should be parallel or divergent
in relation to long axis of distal
of second molar Genu&vasconcelos
“influence of the tooth section technique in

alveolar nerve damage after surgery of
impacted lower third molars” .int. J. oral
maxillofac surg.2008
ROOT SECTIONING
- Dividing the mesial and distal

POSSIBLE COMPLICATIONS
root facilitates easy removal of
 Damage to adjacent tooth roots and prevent damage of
- Wrong angulation of surgical vital structures.
bur can result to difficulty in
removing sectioned crown can
lead to damage of adjacent
tooth.
 Nerve damage and bleeding
- Accidental sectioning of
mandibular canal will result to
damage of IAN and blood
vessels.
 Nerve damage
- Full thickness sectioning of
crown from buccal to lingual
can lead to injury of lingual
Possible complications:
nerve.
 Nerve damage and bleeding
- Wrong direction of force can
result to damage of IAN and
blood vessels.
STEP 5 DELIVERY OF TOOTH - Relationship of nerve to roots
of impacted tooth can result to
REMOVAL OF CROWN

damage of nerve  Co-manage if needed

 Recall
 Hemorrhage/ bleeding
- Clot promoting materials
- Ct scan for better isolation of
a. Collagen- place in the
mandibular canal.
socket and it expands
 Fracture of bone
b. Bone wax- absorbing
- Uncontrolled force, improper
the bleeding coming
placement of instruments, can
from the bone
lead to fracturing of bone.
c. Gel foam- form a clot to
 Displacement of tooth stop bleefing
- Wrong instrument handling can - Vasoconstrictive substances
lead to displacement of tooth. - Suture ligation
 Fractured root fragment - Thermal coagulation
- Unfavorable root morphology
and wrong application of force
can lead to fracturing of roots.
HEMATOMA
- Pressure dressing
STEP 6 DEBRIDEMENT AND - Bleeding control
- Compression
CLOSURE
DEBRIDEMENT AND CLOSURE

- Removal of follicle, particulate
bone chips and debris
- Smoothen rough edges of bone
- Final irrigation
- Closure of wound using sutures
“open healing of the surgical wound after PARESTHESIA

removal of impacted third molars produces less - Tincture of time
post-operative swelling and pain than occurs - Vit B. comples
with closed healing” - Microvascular surgery
“ data from the present study
lead to same conclusion: a wait-
MANAGEMENT and-see policy for at least 4
months is justified.” S. Hillerup
 Identification of cause
 Classification of severity of condition

DRY SOCKET  It has been suggested that ice

- Remove unhealthy clot and
compression controls inflammation
debris and hemorrhage.
- Surgical pack
- Don’t curette
 Failure of repair  “ICE THERAPHY”- no statistically
 If blood clot doesn’t form properly or significant difference was found
becomes dislodged from your gums it between the two treatment groups
can create a dry socket. with respect to pain, facial swelling
and trismus.
Oro-antral communication  Constantly recall patients until all

-surgical closure defect complications are resolved and
normal conditions restored.
 an unnatural communication
between the oral cavity and the
maxillary sinus. These complications ODONTECTOMY GUIDELINES
occur most commonly during  Pre-operative concerns
extraction of upper molar and  Patient preparation
premolar teeth. -informed consent
-clearance
-pre-medications
SOFT AND HARD TISSUE INJURY.  Surgical plan
- Stabilize fractures  Operative concerns
- Close soft tissue injury  Procedure/technique
-armamentarium
- surgical approach
INFECTION
 Immediate post-op
- Occurs 4-5 days post op procedure
- Prophylactic antibiotics -post-op medications
- I&D (localization) (algesia)
-post-op instruction (written)

A. Wound care 2. Take your pain pills with a

1. Bite firmly on gauze pack whole glass of water and
that has been placed, until with a small amount of food
you arrive home, then if the pills cause nausea.
remove it gently. 3. Do not drive or drink alcohol
2. Do not smoke for at least 12 if you take prescription pain
hrs, because this will pills.
promote bleeding and D. Diet
interfere with healing. 1. It is important to drink large
3. Do not sleep on the volume of liquids. Do not
operative site. drink thick fluids through a
B. Bleeding straw because this may
1. Some blood will ooze from promote bleeding.
the area of surgery and is 2. Eat normal regular meal as
normal. You may find blood soon as possible after
stain on your pillow in the surgery. Cold, soft food such
morning, so it is advisable to as ice cream or yogurt may
use an old pillow case the be the most comfortable for
first night. the first day.
2. Do not spit or suck thick E. Oral hygiene
fluids through a straw, 1. Do not rinse your mouth or
because this promotes brush you teeth for the first 8
bleeding. hrs after surgery.
3. If bleeding begins again, a 2. On the next day, rinse gently
small damp gauze pack with warm salt water (1/2)
directly over the tooth socket teaspoon of salt in 8 oz. of
and bite firmly for 30 mins. warm water) every after
4. Keep your head elevated meals.
with several pillows or sit in a 3. Brush your teeth gently but
lounge chair. avoid the area of surgery.
C. Discomfort F. Swelling
1. Some discomfort is normal 1. Swelling after surgery is
after surgery. It can be normal body reaction. It
controlled but not eliminated reaches maximum about 48
by taking the pain pills your hrs after surgery and usually
dentist has prescribed. last 4 to 6 days.

2. Applying ice packs over the 3. you have increased swelling after
area of surgery for the first the 3rd day following your surgery.
12 hrs helps control swelling 4.you feel that you have fever.
and may help the area to be 5. you have any questions.
more comfortable.
3. Apply warm compress on the
third day over the area of
surgery for 20-30 mins of
every hour. NEUROVASCULAR INJURIES
G. Rest
1. Avoid strenuous activity for RELATED TO 3RD MOLAR
12 hrs after your surgery. SURGERIES
H. Bruising
1. you may experience some
mild bruising in the area of your OBJECTIVES:
surgery. This is a normal responses  Identify and locate the different
in some persons and should not be a neurovascular structures near third
cause for alarm. It will disappear in 7 molar area.
to 14 days.  Discuss the common causes of
I. Stiffness complications related to damage to vital
1. after surgery you may structures.
experience jaw muscle stiffness and  Analyze different methods on how to
limited opening of your mouth. This prevent neurovascular damage/nerve
injury in third molar surgery.
is a normal and will improve in 5 to
 Review ways to management nerve
10 days.
injuries.
J. Stitches
1. if stitches have been placed in
the area of surgery, you will need to THIRD MOLAR SURGERY
have them removed in about 1
week.  The extraction of 3rd molar (m3) is one of
K. Call the office if: the most common surgical procedures
performed worldwide. (Andres Savi et al.)
1. you experience excessive
 Removal of impacted or erupted third molar
discomfort that you cannot control
is one of the most frequently performed
with your pain pills. dento alveolar surgical procedures. (Gry
2. you have bleeding that you Karina Kjelle et al.)
cannot control by biting gauze.  Trigeminal nerve injury is the most
problematic consequence of dental surgical

procedure with major medico legal block (focal conduction block).

implications. (Waseem jerjes et al.) Recovery 3 to 6 weeks.
 Axonotmesis
- Is more severe injury, with
disruption of axons &
TRIGEMINAL NERVE surrounding endoneural
sheaths. Recovery (months)
 Motor root
 Neurotmesis
- supplies the muscles of
- Most severe nerve injury where
mastication.
there is complete disruption of
- Other muscles in the region.
axons, endoneurium,
 Sensory root
perineurium and epineurium.
- Skin of the entire face
- Mucous membrane of the
cranial viscera and oral cavity
MAXILLARY ARTERY
EFFECTS OF NERVE INJURY  The maxillary artery, the larger of the
two terminal branches of the external
 Paresthesia
carotid artery.
- Unusual, abnormal, but painful,
spontaneous or evoked Types of bleeding
sensations ( tingling or pricking
 Bleeding
sensation)
- Improper manipulation of
 Hyperaesthesia
tissues
- Increased sensitivity to all forms
- Systemic disease
of stimulation
- Injury to local blood vessels
 Hypoaesthesia
- diminished sensitivity to all Capillary
forms of stimulation
- Steady oozing of bright red
 dysaesthesia
blood
- any unpleasant abnormal
sensation, either spontaneous Venous
or evoked, used to describe
painful paraesthesia and - Dark red color exhibiting a
burning neurogenic discomfort steady flow.
and pain. Arterial
 Neuropraxia
- Least severe injury, is - Bright red flow numning
characterized by a conduction intermittent flow
NERVES

 Posterior superior alveolar nerve disabling anaesthesia of the lip;

 Greater palatine nerve anaesthesia of the lower gingivae and
anterior teeth may also result.
Common cause of complications

MAXILLARY 3RD MOLARS
The most common cause of IAN and LN injury is
 HEMATOMA after PSAN block traumatic 3rd molar surgery. Shown to account
- This is commonly produced by for 52% of injuries, and risk factors included the
inserting the needle too far patient’s age (more than 30 years), horizontally
posteriorly into the pterygoid impacted teeth, close radiographic proximity to
plexus of veins. In addition, the the inferior alveolar canal (IAC) and treatment
maxillary artery may be by experienced graduate or post graduate
perforated. Use of a short students.
needle minimizes the risk of
pterygoid plexus puncture.
- A visible intraoral hematoma
Major factors associated with IAN and LN
develops within a several
injury
minutes, usually noted in the
buccal tissues of the  Advanced patient age
mandibular region. - Investigation shows that nerve
- Bleeding continues until the damage is frequent and often
pressure of extravascular blood temporary in patients less than
is equal to or greater than of 30 years of age. In older
intravascular blood. patients, nerve damage seems
to be more permanent.
- The removal of impacted teeth
MANDIBULAR 3RD MOLARS from adult patients was found
to be more difficult and led to
 Long buccal nerve sensory loss more often than in
 Inferior alveolar nerve the younger people.
 Lingual nerve - Factors that make removal
difficult:
 Increased bone density
pterygomandibular space  Surgical difficulty
 Complete formation of the root
 Reduced capacity for
INFERIOR ALVEOLAR NERVE INJURY subsequent healing
 Depth of impaction
 The surgical removal of an impacted 3rd - Impacted tooth position
molar may result in damage to the influences the incidence of
inferior alveolar nerve and may cause operative complications.

- Unerupted mandibular 3rd - Knowledge, ability and

molar teeth are closer to the experience
inferior alveolar canal than are - Perform surgical cases only
erupted teeth. those with “comfort zone”
 Tooth angulation  RADIOGRAPHIC PREDICTORS
- Mesioangular mandibular 3rd  The radiological prediction of inferior
molar impactions are most alveolar injury during third molar
closely positioned to the surgery.
inferior alveolar canal, and this  The most significant sign which related
may present an independent to nerve injury was diversion of the
risk factor for postoperative inferior alveolar canal followed by
paresthesia. darkening of the root; then
 Need for tooth sectioning interruption of the white line.
- Accidental sectioning of  The signs found to be unrelated
mandibular canal will result to statistically to nerve injury were
damage of IAN and blood narrowing of the root, dark, and bifid
vessel. root, narrowing of the inferior alveolar
- Full thickness sectioning of canal, and deflected tooth.
crown from buccal to lingual  Panoramic film does not reflect the
can lead to injury of lingual relations between the impacted teeth
nerve. and the mandibular canal as accurately
 Bone removal as CT, which should be used as the gold
-bone should be removed only where it standard for judging these relations.
can be seen and that the bur should be  Elimination of permanent injuries to the
advanced toward the surgeon; bone inferior alveolar nerve following surgical
should not be removed blindly from the intervention of the “high risk” third
distal surface of the tooth. molar.
 Surgeon experience  Panoramic findings were not consistent
- one of the most influential with the CT findings (275 teeth; 62.5%).
factors Therefore, panoramic radiography
- Clinicians should know when alone does not provide sufficiently
specialist referral is reliable images required for predicting
appropriate, with regard to the nerve lesions.
possible need for microsurgical
OTHER FACTORS
exploration and repair of the
damaged nerve.  Technique of anesthesia/ anesthetic
- Surgical risk, which depends on solution
the operator and the technique, - paresthesia occurs more
should be also consider. commonly after use of 4
percent local anesthetic

formulations. These findings are - Face of the nerve to the

consistent with those reported lingual plate of mandible was
in a number of studies from 2.53+0.67mm( range, 0.00 to
other countries. 4.35). in the 3rd molar region,
there morphology of the
lingual nerve, which
LINGUAL NERVE DAMAGE highlights the high/low
 because of the different anatomic classification system.
position of LN, the surgeon is often not
able to identify its location pre-
operatively.
 Permanent alterations of LN were more
discernible for the patients. Some
studies have reported a lower recovery
proportion for the LN compared with
the IAN, in agreement with our
observations, where little improvement
was seen in tongue sensation from first
to the twelfth month and up to 5 years,
though other studies have failed to
support this.
 Lingual nerve protection
- By retracting a lingual flap
should be preserved for
selected cases, when possible
nerve damage might be
anticipated because of
unfavorable circumstances.
 Factors that predicted lingual nerve

injury were lingual flap retraction,
tooth sectioning, and buccal
- Face of the lingual nerve to guttering. The incidence of lingual
the lingual crest was 2.75 nerve injury was greater when
+0.97mm ( range , 052 + combinations of these operative
4.61mm). the mean variables were used.
horizontal measurement  Lingual retraction per se was the
strongest predictor of developing

temporary postoperative lingual plate fracture may result in

hypoesthesia, presumably due to a lingual nerve paresthesia.
stretch-type injury from the
Management and treatment for nerve
retractor.
injury
 Anatomical factors such as lingual
angulation of the 3rd molar, surgical  Vitamin B complex
maneuvers such as retraction of the  Vitamin B+ analgesics
lingual flap or vertical tooth  Gabapentin
sectioning, and the surgeon  Steroids
inexperience all increase the risk of
Nutritional therapy can include B
lingual nerve damage.
complex vitamin supplementation,
 The incidence of LN injury and
particularly vitamin B12
depends a number of factors:
 The experience of the  Outcome following lingual nerve
surgeon repair with vein graft cuff: a
 Difficulty of the case preliminary report.
 Depth of impaction - Microvascular surgery
 Presence of overhanging
ramus bone
 Lingual flap elevation Nerve lesions after injury
 Operating time
 Surgical approach  Exploration and decompression of
 Clinicians cannot depend on the the left inferior alveolar nerve. The
lingual plate to act as a protective small arrows indicate the site of the
barrier during 3rd molar surgery. cortical cuts made before a segment
 The inconsistent position of the of the buccal plate was removed.
lingual nerve in the region of the The large arrow indicates a neuroma
retromolar area means that it may that extended laterally and towards
be subjected to damage throughtout the alveolar crest from the
the procedure- during incision, neurovascular bundle, and the
buccal flap elevation, flap retraction, bundle narrows distal to this point.
tooth sectioning and removal and  Endoscope-assisted removal of
suturing. intraosseous schwannoma with
 Some studies have shown that the preservation of inferior alveolar
raising of a lingual mucoperiosteal nerve.
flap, clumsy instrumentation, and

Healing and recovery

 The recovery rate was highest
during the 6t months. Recovery was
not influenced by gender, and only
slightly by age.
 Patients should be monitored
repeatedly for at least 3 months,
and not operated until neurosensory
function no longer improves, and is
less than what might be rendered by
microsurgical repair.
 Sensory loss lasting longer than 6
months is mostly permanent.
 The overall risk of lingual nerve
injury associated with third molar
removal ranges from 0.2%
(permanent disturbance) to 22% (
sensory disturbances in the early
postoperative period)

Oral Surgery 2 Prelims 1

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Oral Surgery 2 Prelims 1

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FERNANDEZ PAMELA SY 2020-2021

ORAL SURGERY 2 by: Dr. Gary Brillo

IMPACTED TEETH INDICATIONS FOR REMOVAL OF IMPACTED

THIRD MOLAR SURGERY

- surgical exposure/ forced eruption.

 All impacted teeth should be CLASSIFICATION OF IMPACTED TEETH

PAGE | 1 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

Indications for TMS present results, the author suggested

 The prophylactic removal of a partially symptoms, experiencing problems with

 The presence of impacted M3s

PAGE | 2 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

 This present respectively study  Upon extraction on both sides, the

PAGE | 3 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

 To determine whether treatment

PAGE | 4 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

SEQUENCE OF IMPACTED TEETH

1. mandibular 3rd molars

CLASSIFICATION AND LOCALIZATION OF

A. PELL AND GREGORY’S CLASSIFICATION

IMPACTED MANDIBULAR 3RD MOLAR

Request for laboratory test

 Clotting time/bleeding time

PAGE | 5 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

 CLASS I - The crown is fully covered by

PAGE | 6 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

IMPACTED MAXILLARY 3RD MOLAR

Based on occlusal plane

PAGE | 7 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

mandibular 3rd molars

CLASSIFICATION OF MAXILLARY IMPACTED

PAGE | 8 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

 Class IV- located in the alveolar process

S- SHAPE OF CROWN AND UNDERCUT

PAGE | 9 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

PAGE | 10 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

1.HORIZONTAL SHIFT/ VERTICAL

LOCALIZATION USING PERIAPICAL

PAGE | 11 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

PAGE | 12 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

2.RIGHT ANGLE TECHNIQUE

PAGE | 13 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

SURGICAL STEPS IN REMOVING

 Type of anesthetic solution

Reason for failure

 Local anesthetic solution or

ANESTHETIC SOLUTION AVAILABLE IN THE

PAGE | 14 ODR ODP FRATERNITY SORORITY

ORAL SURGERY 2 by: Dr. Gary Brillo

2. Intermediate acting  Intra-arterial injection

TECHNIQUE FOR MANDIBLE