Impacted Wisdom Tooth: How to Prevent Complications (5/5)
Discover the detailed process of removing mesio-angular, disto-angular, vertically, and horizontally impacted mandibular third molars
Table of Contents
Intoduction
This article discusses different techniques for bone removal in dental procedures. The first technique mentioned is the bur technique, which involves removing bone in layers using a bur. This technique is well-tolerated by patients but has a delayed healing process and a higher risk of postoperative oedema and infection. The second technique mentioned is the chisel and mallet technique, which involves cutting the bone into sections using a chisel and removing it. This technique offers precision and versatility but is not well tolerated by patients under local anaesthesia. It has a good healing process and a lower risk of postoperative oedema and infection.
Bone Removal
- In cases where bone obstructs access to the impacted tooth, a portion of the bone may need to be removed using surgical instruments like drills or burs.
- The main aim of bone removal is to expose the crown of the tooth under the bone or to remove the bone that is obstructing the path for the removal of the impacted tooth.
The bone removal can be done in two ways:
a) By Bur technique
- It is a simple bone removal technique that involves sweeping the bur to remove the bone in layers.
- It is the preferred method in which a handpiece with adequate speed and high torque is used, and the bur should rotate in the correct direction at high speed.
- It is a well-tolerated and accepted way of bone removal by the patient under local anaesthesia.
- The healing of the bone with this method is delayed.
- The chances of post-operative oedema and post-operative infection are higher.
Moore and Gillbe’s Collar technique
- The Moore and Gillbe Collar Technique is a method used in oral surgery, specifically for the extraction of impacted mandibular third molars.
- This technique involves creating a collar of soft tissue around the tooth to aid in its removal.
- The collar is formed by making an incision around the tooth, separating the soft tissue from the tooth, and then reflecting it to expose the impacted tooth for extraction.
- It is a conventional technique of removing bone by using a bur.
- It is a modification of the split bone technique that is designed to be used with burs.
- To expose the underlying bone, a mucoperiosteal flap of standard design is raised.
- After raising the flap, a rosehead bur no. 3 is used to create a gutter along the buccal side and distal aspect of the tooth.
- A mucoperiosteal elevator is used to protect the lingual soft tissues during the removal of the distolingual spur of the bone.
- A mesial point of application is then created with the bur, and a straight elevator is used to deliver the tooth.
- In this technique, the amount of bone sacrificed is less.
- This technique helps in better visualisation and access to the impacted tooth, facilitating its safe removal.
- It is convenient for the patient and can also be used in old patients.
b) By Chisel and Mallet technique
- It is a difficult method in which the bone is cut into sections by chisel and removed.
- Chisel: The chisel used in this technique is a specialised surgical tool with a sharp cutting edge. It is typically made of high-quality stainless steel to ensure durability and precision. The chisel’s design allows it to be driven into the bone using the mallet without causing excessive damage to surrounding tissues.
- Mallet: The mallet used in conjunction with the chisele is specifically designed for surgical purposes. It is often referred to as a bone mallet and features a cylindrical head with flat sides. The mallet’s design allows for controlled striking force when used in combination with the chisel for bone removal procedures.
Technique: The chisel and mallet technique of bone removal requires skill and precision on the part of the surgeon.
- Assessment and Diagnosis: Before proceeding with any dental procedure, a thorough assessment of the patient’s oral health is conducted. This includes examining the affected molar, determining the extent of damage or decay, and deciding whether the chisel and mallet technique is appropriate for the specific case.
- Anesthesia: Local anesthesia is administered to numb the area around the molar to ensure the patient does not experience pain during the procedure. This step is crucial for patient comfort and safety.
- Isolation: The tooth to be treated is isolated using a dental dam or other appropriate methods to keep it dry and free from contamination during the procedure.
- Chiselling: A dental chisel, which is a sharp instrument with a flat edge, is used to carefully cut into the enamel and dentin of the affected molar. The chisel is applied with controlled force to remove decayed or damaged portions of the tooth while preserving healthy tooth structure.
- Malleting: A dental mallet, typically made of metal or rubber, is then used in conjunction with the chisel. The dentist applies controlled force to the chisel, using the mallet to effectively chip away at the targeted areas of the tooth.
- Precision and Control: Throughout the process, precision and control are essential to avoid damaging surrounding teeth or tissues. The dentist must have a steady hand and good tactile sensitivity to ensure accurate removal of damaged tooth material.
- Evaluation: Periodic evaluation during the procedure helps assess progress and make any necessary adjustments to achieve optimal results.
- Completion: Once the desired amount of decayed or damaged tooth structure has been removed, the dentist will clean and shape the remaining tooth structure in preparation for further treatment, such as filling placement or restoration.
- Post-Procedure Care: After completing the chisel and mallet technique, post-procedure care instructions are provided to the patient to promote healing and prevent complications.
- Benefits: The chisel and mallet technique offers several benefits in surgical procedures involving bone removal:
- Precision: The combination of the sharp chisel and controlled striking force from the mallet allows for precise bone removal.
- Versatility: This technique can be used in various orthopedic procedures that require accurate shaping or removal of bone tissue.
- Minimized Trauma: By using controlled tapping motions, surgeons can minimize trauma to surrounding tissues during bone removal.
- It is not tolerated by the patient during local anesthesia and is not accepted.
- The healing of the bone with this method is good.
- The chances of postoperative oedema and infection are lower.
Lingual split bone technique
- The lingual split bone technique is a method used for the removal of impacted mandibular third molars. It involves removing a thin piece of disto-lingual bone and extracting the tooth lingually.
- This technique is designed to address distal and lingually inclined impacted mandibular third molars.
- The procedure aims to reduce tissue trauma, minimise complications, and facilitate the extraction process by accessing the tooth from the lingual aspect.
Steps of Lingual Split Bone Technique:
- Preparation: Gather the necessary armamentarium for the procedure, including local anaesthesia, surgical instruments like chisels and mallets, sutures, and needles.
- Assessment: Take pre-operative radiographs (OPG and IOPA) to assess the impaction level and plan the approach accordingly.
- Anaesthesia: Administer local anesthesia with an inferior alveolar nerve block and long buccal nerve block to ensure patient comfort during the procedure.
- Incision: Depending on the type of impaction, make Ward’s or Modified Ward’s incisions, then raise a full-thickness mucoperiosteal flap to access the impacted tooth.
- Bone Splitting: Create a point of purchase in the buccal side for elevator placement. Use a chisel parallel to the external oblique ridge to make a distolingual split with gentle taps from a mallet, creating a window on the lingual side.
- Tooth Removal: Luxate the tooth by elevating it on the buccal side and delivering it on the lingual side without fracturing the lingual plate, thus avoiding lingual bone loss and nerve damage.
- Closure: Suture the surgical site using appropriate materials to promote proper healing post-operatively.
- Post-Operative Care: Monitor patients for any complications such as nerve injury, paresthesia, infection, or trismus, providing necessary treatment as required.
Advantages of Lingual Split Bone Technique:
- Reduced Trauma: The technique causes less tissue trauma compared to other methods.
- Minimal Complications: It has a low complication rate, making it a safe option for impacted molar removal.
- Quick Procedure: The lingual split bone technique is relatively quick, requiring less time for completion.
- Good Outcomes: Despite initial concerns about potential morbidity, this technique has shown good outcomes in terms of successful extraction and reduced postoperative issues.
- Less risk of inferior alveolar nerve damage.
Complications and Modifications:
- While the lingual split bone technique offers advantages, there are potential complications associated with this method.
- These include the risk of lingual nerve injury, increased bleeding from lingual soft tissues, infection spreading to adjacent spaces, and edema near the airway.
- To address these concerns, modifications have been made to refine the technique and enhance its safety profile.
Odontectomy technique
- Odontectomy is a surgical procedure used to remove impacted teeth, particularly wisdom teeth that have grown improperly due to lack of space in the jaw.
- Impacted teeth can cause various issues, such as infections, damage to other teeth, and cyst formation.
- The procedure involves making an incision, removing surrounding bone tissue, and extracting the impacted tooth.
- The difficulty of performing an odontectomy can vary depending on the position of the impacted tooth, the age of the patient, and the root shape of the tooth.
- It is recommended to undergo odontectomy at a younger age when the bone tissue is softer and surgical trauma is minimal.
Procedure for Odontectomy
- An oral examination and dental x-rays are conducted to assess the position of the impacted tooth.
- Surgical incision and flap creation to access the impacted tooth.
- Removal of surrounding bone tissue.
- Extraction of the impacted tooth.
- Closure of the incision with sutures.
