Dental students

1. Minor Oral
Surgery
Thilanka Umesh Sugathadasa

2. Thilanka Umesh Sugathadasa Page 1
Minor Oral Surgery
Definition
A surgical procedure that can be comfortably done by competent non specialized dental surgeon
within 30 minutes under LA with or without sedation.
MOS
Trans alveolar extractions
Impaction
Definition – A tooth has not erupted to the functional position with in expected time period due to
Malpositioning/ Lack of space in the dental arch/ Obstruction (Soft tissues or hard tissues)
Etiology
Hereditary
 Due to cleft palate
 Cleidocranial dysostosis
 Jaw size
 Supernumerary tooth
Indications for surgical removal of impacted tooth (NICE)
1. Unrestorable caries
2. Untreatable pulpal pathology/ periapical pathology
3. Fracture of tooth
4. Tooth associated with fracture lines
5. Internal or External resorption of tooth or adjacent tooth
6. Tooth impeding a surgery
7. Orthodontic purposes
8. Recurrent infection of that region/ Cellulitis/ Abscess or osteomyelitis
Soft tissues
 Frenectomy
 Removal of
fibrous epulis
Hard tissues
 Removal of
impacted tooth
 Canine
transplantation
Acquired
 Early loss of deciduous
 Retention of deciduous more
than expected time
 Damage to the tooth bud

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9. Cyst or tumor
10. Prophylactic removal or in combine surgeries.
Contraindications
1. Extremes of Ages(Higher ages the bone become highly calcified though less flexible & less likely
to be bend also post-operative problems more in the elderly persons)
2. Compromised medical status
3. Excessive damage to the adjacent structures.
Classifications(Extraction difficulty indices)
1. Pell & Gregory classification.
2. Winter’s line
3. Penderson scale
4. Parents scale
5. WHARFE scale
6. Classify according to angulation of the tooth.
- Mesio angular
- Disto angular
- Horizontal
- Vertical
- Transverse
- Inverted
Pell & Gregory
Pell and Gregory class 1 impaction. Mandibular third molar has sufficient anteroposterior room (i.e., anterior-to-anterior border of ramus) to
erupt.

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.
Pell and Gregory class 2 impaction. Approximately half is
covered by anterior portion of ramus of mandible
Pell and Gregory class 3 impaction. Impacted third molar is
completely embedded in bone of ramus of mandible.
Pell and Gregory class A impaction. Occlusal plane of
impacted tooth is at same level as occlusal plane of second
molar.
Pell and Gregory class B impaction. Occlusal plane of impacted
tooth is between occlusal plane and cervical line of second molar.
Pell and Gregory class C impaction. Impacted tooth is below
cervical line of second molar.
Impaction with distoangular, class 3 ramus relationship and class
C depth makes it extremely difficult to remove.

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Winter’s line
White line Amber line Red line
 White line – Indicate the depth of impaction
 Amber line – Indicate the bone cover to the
third molar
 Red line – Indicate degree of difficulty in
elevation
Perents scale
1. Easy 1 – Extraction require forceps only
2. Easy 2 – forceps + osteotomy
3. Difficult 1 – Osteotomy + coronal
section
4. Difficult 2 – Root sectioning
Radiographic analysis
Mostly – IOPA
OPG
Lateral oblique
In IOPA radiograph there should be ½ 0f the 1st
molar, second molar & third molar, ID canal,
Roots , Distal bone
Third molar analysis
 Angulation
 Crown – size, shape, caries, restorations
 Roots- Number, shape, curvatures
 Relationship with IDN
Roots
Darkning of the roots
Dark & bifid roots
Narrowing of the roots
Deflected roots
Canals
Interuption of white line
Narrowing of the canal
Diverted canals
 Depth of tooth in alveolar bone.
2nd
molar analysis
 Crown - Restorations, Caries,
Resorption
 Roots- Number , Shape , Periodontal
statu of tooth, Apical tissues
Surrounding bone
 Density
 Infections
CLINICAL ASSESSMENT
 eruption status of third molar
 presence of local infection
 caries in or resorption of the third
molar or adjacent tooth
 periodontal status
 orientation and relationship of the
tooth to the inferior dental canal
 occlusal relationship
 temporomandibular joint function
 regional lymph nodes
 Any associated pathology should be
noted.

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SERIOUS COMPLICATIONS
 Fracture of the mandible or maxilla:
Treat at time of surgery or arrange
immediate referral.
 Oro-antral communication: Repair at
time of surgery, usually with a buccal
advancement flap. Antibiotic therapy is
advisable and the patient should avoid
nose blowing.
 Broken instrument: Remove at time of
surgery. If not retrievable, inform the
patient and record in notes
.
 Nerve damage: For complete
transection of lingual or inferior dental
nerves, arrange immediate nerve repair
by experienced surgeon. For partial
damage, debride gently
and maintain good apposition of the
ends
COMMON COMPLICATIONS
 Haemorrhage:
Control at time of surgery. Soft tissue bleeding
may require haemostatic agents, bipolar
diathermy and/or sutures.
 Bruising:
Patients should be informed that bruising is
common and will usually resolve within two
weeks
 Displacement:
Appropriate instruments should be in place
prior to elevation to help prevent displacement.
Recover any displaced tooth at time of surgery
if possible, or arrange referral to a specialist
centre
 Wound dehiscence:
If no pain or infection, advise patients to
continue wound toilet (e.g. hot salty
mouthwashes, socket syringing).
 Damage to adjacent teeth:
Inform patient at time of surgery (or when fully
conscious). Record in notes and arrange repair
if required.
Factors that Make Impaction Surgery Less
Difficult
Factors that Make Impaction Surgery More
Difficult

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Prophylaxis doses
 Amoxicillin(Oral)
Adults - 2g
Childs - 50mg/kg
 Amphicillin(IV)
Adults – 2g
Childs – 50mg/kg
 Clindamycin
Adults – 600mg
Childs – 20mg/kg
 Clarythromycin
Adults – 500mg
Childs – 15mg/kg
Indications
1. Heart transplantation
2. Prosthetic heart valves
3. Previous Hx of IE
4. Cyanotic heart diseases.
Flap
Definition ; A unit of skin & Subcutaneous
tissues that transferred from donor site to the
recipient site, while surviving it’s own
intravascular circulation.
Graft
Does not carry it’s own blood supply survive by
the blood supply of the recipient site.
Mucoperiosteal flap
Definition : A unit of mucosa & periosteal
elevated by surgical incision for exposure of an
underlying pathology of bone (jaws)
Main principles
1. Preserve blood supply
2. Good accessibility
3. Easy to repositioning
4. Margins should be lying on the intact
bone
5. Prevent damage to the vital structures
 In 3rd
molar removal surgery when
suturing the suture distal to the 2nd
molar should be very tight. Otherwise it
causes post-operative sensitivity.
 Also most of the time when raising flap
in the edentulous mandible we have to
take extra precautions to not to
damage the periosteum, Because due
to no teeth ID artery blood supply
reduced though most of the time
edentulous arch depend on the
periosteal blood supply. So we have to
raise supraperiosteal flap.
Effect of root morphology in impaction surgery
 Root morphology plays a major role in
deter-mining the degree of difficulty of
the impacted tooth's removal
 The first consideration is the length of
the root when the root is one third to
two thirds formed, the ends of the
roots are blunt and almost never
fracture
 If the tooth is not removed during the
formative stage and the entire length of
the root develops, the possibility
increases for abnormal root
morphology and for fracture of the root
tips during extraction.
 If the root development is insufficient
(i.e., less than one third complete), the
tooth is more difficult to remove,
because it tends to roll in its crypt like a
ball in a socket, which prevents easy
elevation.
 The curvature of the tooth roots also
plays a role in the difficulty of the
extraction

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Lack of root development. If extraction is attempted,
crown will roll around in crypt, which makes it
difficult to remove.
 Finally, the surgeon should assess the
periodontal ligament space. older
patients, especially those over age 40,
tend to have a much narrower
periodontal ligament space, which
thereby increases the difficulty of the
extraction.
 Size of Follicular Sac
The size of the follicle around the
impacted tooth can help determine the
difficulty of the extraction. If the
follicular sac is wide (almost cystic in
size), much less bone must be removed,
which makes the tooth easier to extract
Large follicular sac. When space of sac is large, amount of
required bone removal is decreased