It was noted that factors affecting the removal of third molars vary from country to country depending on the stakeholders (Esposito, 2005).
In this section, we discussed the origins of third molars, as well as the different types of impaction that can occur. The effects of the type of impaction were found to be a factor in the ease if removal and the complications that may occur. Understanding types of impactions and the affect that they can have on the potential for complications is an important step in preventing complications before and after surgery. The following section will discuss the surgical procedures for removal of mandibular impactions.
Surgical Extraction of Impacted Mandibular Third Molars
Surgical extraction of third molars is performed for a number of reasons. They are sometimes performed to prevent surgery in older patients, although this reasoning is questionable (Valiati, Ibrahim, & Poli, et al., 2009). It can be performed to prevent root reabsorption, odontogenic cysts, tumors, and mandibular fractures (Valiati, Ibrahim, & Poli, et al., 2009). There are many conditions that could result in the need to remove a third mandibular molar. The exact surgical procedure used depends on the type of impaction, the depth of the impaction, depth, whether it is bony or in soft tissue, and many other factors. Removal of third molars is one of the most common procedures performed in the field of dentistry. The following will discuss the information available regarding how to perform the procedure.
Under normal conditions, the procedure is performed under local anaesthesia (Obiechina, Oji, & Fasola, 2001). However, if the impact is or unusual in any way, general anaesthesia is used (Obiechina, Oji, & Fasola, 2001). General anaesthesia is also used when the extraction lingual bone split technique is used (Obiechina, Oji, & Fasola, 2001). A majority of the procedures are performed under local anesthesia, with use of general anaesthesia representing the minority (Obiechina, Oji, & Fasola, 2001).
The procedure for removal of third molars is outlined in general dentistry textbooks (Sailor & Pajorola, 1999). The first step of the surgery is an examination and medical history. This examination will help to determine the type and extent of impaction, as well as uncover any medical conditions that could create extra risk during the procedure.
One of the key difficulties of oral surgery is that it is impossible to maintain aseptic conditions in the oral cavity. Therefore, the focus of surgical fields for oral surgery to prevent entry of foreign contaminants into the mouth (Sailor & Pajorola, 1999). One fields have been established, anaesthesia is administered. This will be either local or general, as indicated by the perceived difficulty of the extraction. Local anaesthesia is administered by injecting it into the interior alveolar nerve and the long buccal nerve (Sailor & Pajorola, 1999).
The process for all extractions follows the same general procedure. An incision is made in the gum where the tooth to be extracted is located. Positioning of the tooth determines the type of incision that will be used. For teeth that are positioned bucally, a vestibular tissue flap is used (Sailor & Pajorola, 1999). However, if the tooth is positioned lingually, an incision is made along the lingual gingival margin (Sailor & Pajorola, 1999). This allows the surgeon to access the tooth. An extraction pathway is established.
Once a pathway has been established, tooth removal begins. Retractors are used to protect soft tissues surrounding the tooth (Sailor & Pajorola, 1999). A metal spatula is inserted between the tooth to be extracted and any surrounding teeth to keep them from being damaged. The spatula is also used to separate the tooth from surrounding tissues and to "lift" it from the surrounding tissues (Sailor & Pajorola, 1999).
After the tooth is loosened from its position, the removal proves begins. This can be accomplished using the appropriate method depending on the type of impaction that has occurred. Soft Tissue extraction differs from bony extraction. Soft tissue extraction often involves using forceps to pull out the tooth. Bony extraction can be more complicated and may involve some fracturing of the bone (Sailor & Pajorola, 1999).
The tooth may need to be severed from surrounding tissues, or untangled from the second molar or the alveolar nerve. Care must be taken not to sever the alveolar nerve. One cannot determine the exact procedure that will be needed for tooth extraction until they are ready to perform it. It is likely that the impaction has changed the structure of the bones and tissues surrounding it.
Once the tooth is extracted, the skin flap is sutured and the wound it closed. Minimizing soft tissue damage during the procedure is the key to minimizing swelling and bleeding after the surgery. During the procedure, certain complications may occur that can affect the ability to minimize tissue and bone damage during the procedure, such as fracture of the mandible or exposure of the roots of adjacent teeth. Although the goal is to avoid these complications, sometimes they do occur despite one's best efforts. The procedure can become quite lengthy, as these new complications must be dealt with during the procedure.
This section presents the basics of the procedure. There are many variations to these practices. There are many situations that can arise during the procedure that can cause the surgeon to need to vary the procedures. Tooth extraction can be simple or complex, depending on the conditions that are present surrounding the tooth. The procedure for soft impactions is always easier then when the procedure involves bony impaction. Soft impactions often take shorter times to heal than bony impactions. The procedure for bony impactions can lead to mandibular fractures, at which point the heal time includes time for the mandible to repair itself.
Gauze pads should be placed at the site and the patient asked to bite down with firm, even pressure to control the bleeding (Sailor & Pajorola, 1999). However, this should not be overdone, as there is a potential to dislodge clots that have formed, thus prolonging bleeding rather than stopping it (Sailor & Pajorola, 1999). The bleeding should decrease over the course of the day and should completely subside on the day of the surgery, if the patient continues to follow instructions regarding changing and use of gauze pads (Sailor & Pajorola, 1999).
Post operatively the patient can expect to experience bleeding at the wound site. This can last for as long as three days and is of no concern, unless it is heavy or associated with pus (Sailor & Pajorola, 1999). Post operative instructions are an important part of the procedure and the patient must not disregard them. Following the instructions is essential for the prevention of serious side effects.
For the first 24 hours post-op it is not advised to rinse out the mouth with anything. Rinsing the mouth during this time can impede the formation of clots. The wound should be allowed to form clots naturally in order to control the bleeding as soon as possible (Sailor & Pajorola, 1999). Avoidance of prolonged bleeding is advisable at this time, if possible.
After the first 24 hours have passed the wound should be rinsed with lukewarm salt water. This practice promotes healing and reduces the likelihood of infection. This should be done twice a day until the swelling goes down (Sailor & Pajorola, 1999). This practice should continue for about a week after the surgery, rinsing every 6-12 hours (Sailor & Pajorola, 1999).
It is not unusual for the patient to experience a rancid tasting fluid for the first day or two after surgery. This is typically no cause for concern, although it is caused by bacteria in the mouth (Sailor & Pajorola, 1999). This different from the development of an actual infection. There are many naturally occurring flora in the human mouth and they tend to increase after surgery. The presence of an actual infection should be a point that is checked in a post operative examination 7-10 days after the surgery (Sailor & Pajorola, 1999).
One of the most important aspects of the surgery is aftercare. This aspect of the treatment is essential for the detection and elimination of any post-operative complications that may occur. At the time of the surgery, the patient should be advised as to what is normal and what may signal a complication. They should stay in contact with the dentist's office and report any unusual symptoms that may occur, particularly in the first week after the operation.
Post Operative Complication of Impacted Wisdom Tooth Extraction Surgery
Most wisdom tooth extractions occur without incident They are performed on such a regular basis that the new dentist quickly becomes experienced and has the opportunity to see many different situations and scenarios early on in their practice. Although most procedures occur without incident, occasionally problems arise that could be considered complications. Some of these complications are common and pose…