atlas of minor oral surgery

An Atlas ofMinor Oral SurgeryPrinciples and Practice

Second Edition

David A McGowanMDS, PhD, FDSRCS, FFDRCSI, FDSRCPSG

Professor of Oral SurgeryUniversity of Glasgow, UK

MARTIN DUNITZ

© Martin Dunitz Ltd 1 989, 1999

First published in the United Kingdom in 1989

by Martin Dunitz Ltd, The Livery House, 7-9 Pratt Street, London NW I OAE

Second edition 1999

All rights reserved. No part of this publication may be reproduced, stored in aretrieval system, or transmitted, in any form or by any means, electronic,mechanical, photocopying, recording, or otherwise, without the prior permissionof the publisher or in accordance with the provisions of the Copyright Act 1988or under the terms of any licence permitting limited copying issued by theCopyright Licensing Agency, 90 Tottenham Court Road, London W I P OLP.

A CIP record for this book is available from the British Library.

ISBN 185317 766 0

Distributed in the United States and Canada by:Thieme New York333 Seventh AvenueNew York, NY 10001USATel: 212 760 0888

Composition by Scribe Design, Gillingham, KentPrinted and bound in Singapore

Preface

Despite the success of prevention, and thei mprovement in dental health in many parts of theworld, the ability to extract teeth is still a neces-sary skill for most dentists. Patients do not relishthe experience, but control of anxiety, avoidanceof pain and reduction of discomfort will earn theirgratitude. As in any form of surgery, complica-tions must arise from time to time, and thedentist who undertakes to extract teeth has tobe prepared to meet them. The skills, equipmentand practice organization required for thesepurposes can be usefully employed in preplanneddento-alveolar surgery, and this continuing activ-i ty in turn ensures efficiency of response whenthe need arises.

The purpose of this book is to promote asystematic and organized approach to minor oralsurgery, while still allowing for variation intechnique to suit personal preference, local

circumstances and, most important of all, theneeds of the individual patient. General principlesare emphasized and illustrated by examples of thecommoner procedures. 'Minor oral surgery'comprises those surgical operations that cancomfortably be completed by a practised nonspe-cialist dentist in not more than 30 minutes underl ocal anaesthesia. This defines the scope of thebook. It is intended as a guide book to all thosewho wish to learn, or improve their knowledgeof this branch of the surgeon's art, but cannotreplace the one-to-one instruction and guidancewhich the beginner requires. I hope to pass onsome of the lessons learnt as a teacher ofstudents and practitioners over a number of yearsand, in doing so, I dedicate this book to thepatients in our dental schools and hospitals inrecognition of their contribution to the advanceof our profession.

Preface to thesecond edition

The fundamental principles and techniques ofminor oral surgery have not changed in the tenyears since the first edition was published.However, the importance of strict cross-infectioncontrol has been underlined by the fear of trans-mission of blood-borne viruses, and the necessityof full communication with patients has beenemphasized by the growing culture of publicexpectation and the ready recourse to litigation

when expectation is frustrated. While the proce-dures advocated in the first edition would meetthe first challenge, the text has been expanded tomeet the second. Some cases have been replacedi n the interest of clarity but the others have beenretained as they still represent the expression inpractice of the principles of the prepared andmethodical approach which is the basis of thisbook.

Acknowledgments

I am indebted to many people for help with thisbook; to John Davies and the staff of theDepartment of Dental Illustration of GlasgowDental Hospital and School, whose superb skillsmade the project possible; to my secretary, SaraGlen-Esk, who deciphered my scrawls and cameto terms with the word-processor; to my consul-tant and junior colleagues, not only for helping mefind and follow up suitable patients, but for theback-up which allowed me to find some time forwriting; to the nursing staff who cared for the

patients; to Harub AI-Kharusi and AhmedZahrani, who assisted with most of the cases; toHelen Shanks for duplicating the radiographs; toGordon MacDonald and Jim Rennie for thepathology reports; and to my wife and family fortheir forbearance.

I t has been a pleasure to work with the MartinDunitz organization-and especially with MaryBanks.

I am also grateful to Bernard Smith, who firstsuggested that I might undertake this task.

Acknowledgmentsfor second edition

I continue to be grateful to those who havesupported me in this project and, as well as thoseabove, I particularly thank Kay Shepherd forphotographing the new cases to the same high

standard, Grace Dobson, my present secretary,and Robert Peden of Martin Dunitz for his toler-ance of my delays.

Diagnosis andtreatment planning

All surgery produces tissue damage and patientmorbidity, so every operation must be justified byweighing benefit against detriment. There is nosuch thing as a `routine' operation. The purposemust be one of the following:

elimination of diseaseprevention of future disease or disadvantageremoval of damaged or redundant tissuei mprovement of function or aesthetics.

the safe side. Overestimation of difficulty leads torelief and gratitude, while underestimation leads toembarrassment at least, and distress and litigationat worst. The general dentist who refers a difficultcase to a specialist will earn the respect of bothpatient and colleague. With experience, theaccuracy of assessment will increase and can betailored to the increasing surgical competence ofthe operator.

To take a common example, the removal of acompletely buried asymptomatic unerupted toothor retained root fragment inflicts certain surgicaldamage and is not justified by the hypothetical riskof future infection. However, when there is a defecti n the overlying mucosa, the balance of probabilityi s completely altered and removal is advised.

Effective clinical decision-making depends on thegathering and objective analysis of relevant infor-mation, and then on judgment based on experi-ence, instinct and, it must be admitted, evenprejudice. The clinician can never allow him- orherself the certainty which patients demand.

A minor oral surgical operation is only one itemi n a patient's continuing dental care. The extrac-tion of an impacted third molar, followed later bythe extraction of the carious second molar whichproduced the symptoms in the first place, is notonly foolish but damaging to the interests of bothpatient and dentist.

While diagnosis is a theoretical exercise, treat-ment planning must be responsive to the practicalday-to-day realities of economic and social factors,and successful patient management depends onachieving the right balance.

Apart from the few purely soft tissue proce-dures, minor oral surgery diagnosis depends heavilyon radiographs which are too often of poor qualityand examined hastily. Acceptance of a low standardof radiographic diagnosis is frankly negligent.

Pre-operative assessment of difficulty cannot beexact, and the margin of error must always lie on

Fitness for minor oral surgery

The dangers of minor oral surgery have beengrossly exaggerated. Unnecessary apprehensionhas been aroused by a combination of dominantphysicians ignorant of dentistry, and timid dentistsignorant of medicine. In fact, most of the fearsexperienced have little foundation. Excludinggeneral anaesthesia, minor oral surgery underl ocal anaesthesia, with or without sedation, is aremarkably safe undertaking.

I t was formerly considered sufficient to believethat if patients were fit enough to come to thesurgery, they were fit to receive treatment - andthe cautious sited their premises at the top of aflight of stairs! However, the success of modernmedicine in keeping alive and active manypatients who would have been at least bed-ridden in the past, has negated such a simpleapproach. From student days onwards, consider-able efforts are made to educate dentists to ahigh level of knowledge and understanding ofmedicine, and it is now considered negligent tofail to obtain a current medical history and toappreciate its significance.

I n case of concern, it is prudent to discusspotential problems with the patient's physician. Itmust, however, be remembered that advice oncesought must be taken, and will always tend to erron the side of caution. Minor oral surgery, asdefined in the preface to this book, does not

I

include the treatment of patients who areobviously acutely ill, or the chronically sick, unlessthey are ambulant and able to live a relativelynormal life. Chronic disease, which is well-controlled and stable, is unlikely to raise problems,but the often complex medication itself can raisethe possibility of unfavourable drug interactions.However, 2 to 4 ml of one of the commonly-usedl ocal anaesthetic solutions containing 2 per centlidocaine with 1/80 000 epinephrine will not beharmful.

An atlas of minor oral surgery

I t is far more important to treat the patientwith kindness and consideration, and to avoid thestress which triggers the release of endogenouscatecholamines, than to complicate the issue byusing allegedly safer preparations of less certainefficacy.

For a detailed discussion of the subject, thereader is referred to one of the many textbooksavailable which discuss the myriad possibilities atgreat length. Some recommended texts are listedi n the Recommended Reading section.

4


if stored dry in a closed pack. Autoclaves must beregularly maintained and serviced, and the use ofsterilization indicators is good practice.

Two fundamental requirements, which cannot beoveremphasized, are effective lighting and suction -good surgery is impossible without both and, whendifficulty is encountered, the automatic responseshould be to check vision and exposure before takingany other action. While lighting is equally importantfor other dental procedures, suction for surgicalpurposes should be of the high vacuum/low volumetype to ensure the efficient removal of blood, as wellas the saline irrigation. A large bore, high-volumeapparatus produces drying of the wound and alsocarries the risk of the loss of small fragments of toothor soft tissue, which should be retained for exami-nation. Cutting equipment should be tested beforethe patient is brought in, and any dressings ormedicaments required be made ready in advance.

The assistant

Minor oral surgery is a 'four-handed' proce-dure, and skilled assistance is vital. Most dental

assistants enjoy the variety and the challenge ofthis kind of work, but need special training tobe able to cope with the extra demands of theoften apprehensive patient and the necessityfor rigorous sterility. It is obviously vital toexplain the operation plan to the assistant inadvance.

The operator

The operator needs to be clear as to how he orshe intends to proceed. Most, though not all,problems can be anticipated. The informationobtained from the original history and examina-tion, supplemented by radiography, is the basis ofthe operation plan required for a preliminaryexplanation to the patient and assistant. As theoperation proceeds - particularly as the tissuesare dissected and retracted - the optionsbecome clearer and a change of plan may beneeded.

The patient should be positioned so as to givethe operator a clear view and a comfortableworking position.

6

The operation

All minor oral surgery operations follow a similarsequence of stages, which is the basis of a system-atic approach (see table below). Adherence to al ogical overall plan is a great help when difficul-ties arise. Like any other surgery, the sequencefollows the anatomical tissue planes - firsti nwards until the objective is achieved, and thenoutward until the wound is repaired.

Stages of the operation sequence

RetractionI ncisionReflectionBone removal - access

- point of elevation- removal of obstruction

Tooth sectionDeliveryClean-upSew-upCheck-upFollow-upWrite-up

Retraction

The first procedure is the placement of a suitableretractor so as to display the operation site andhold the lips, cheeks and tongue out of the way.The Kilner cheek retractor will control both lipsand cheek, provided it is held at the correct angleso as to pouch out the cheek. The tongue is bestcontrolled by ignoring it - conscious efforts bythe patient are seldom helpful. When the retrac-tor is in place, a final check should be made onthe relative positions of the patient, the operator,the assistant, and the light.

I ncision

The shape of the incision has to be planned withthe needs of both exposure and closure in mind.

A long incision heals as easily as a short one, andso exposure should be generous. While themental nerve is the only significant structure atrisk, thoughtful placement of incisions can reducehaemorrhage by avoiding unnecessary section ofmuscles or small constant vessels. Most incisionscan be made on to the underlying bone, and thisensures separation of both mucosal andperiosteal layers in the one cut. The scalpelshould be held in a pen grip and the hand shouldbe steadied, if possible, by using a suitable rest forthe fingers. Incisions may sometimes be conve-niently extended with tissue scissors.

Reflection

Bone removal

Removal of bone is usually required and, in theinterest of vision and to reduce trauma fromexcessive elevating force, should be generous. Thisi s most conveniently achieved by using a bur in aslow- to moderate-speed handpiece. Handheldchisels are useful in `peeling off thin layers ofbone, and rongeurs are ideal when the blades canbe placed either side of the piece of bone to beremoved. Bone files are seldom required sincesharp edges can be `nibbled off. Excessive smooth-i ng is unnecessarily traumatic and timewasting.

Although generous in extent, bone removalmust be calculated to achieve an end, and never

3

The mucoperiosteal flap is reflected with a peri-osteal elevator, such as a Howarth's. Two eleva-tors can be used to advantage at this stage - oneworking and the other aiding retraction in thesubperiosteal plane. Adequate undermining of thewound margins is required in order to mobilizethe flap. Generous reflection is the key toadequate vision, and wide exposure reducestraction trauma to the wound edges.


be blindly destructive. The main objectives shouldbe the achievement of access, the establishmentof a point of application for an elevator (orforceps), and the removal of the obstruction tomovement of the tooth or root. It may be that allthese objectives may be reached simultaneously,but in any event they should be considered in thatorder. Slots or gutters around teeth or rootsshould be deep and narrow so as to preserve afulcrum for leverage. Additionally the shape of thetooth must be borne in mind, both when clearingthe cardinal points of the crown and in allowingfor curvature and angulation of the roots.

Tooth section

Division of a tooth into a number of simpler, ormore favourably shaped, segments may resolve theconflicts of the paths of withdrawal, or relievei mpaction. This is best achieved by piercing thesurface with a round bur, which is then sunk to theestimated width of the tooth, and the round `shaft'converted into a slot with a fissure bur. Tungstencarbide tipped burs are essential for efficientcutting. The depth of all cuts should be judged soas to remain within tooth substance, and to avoiddamage to the neighbouring structures. Finalseparation is achieved by levering within the slotwith a flat elevator until the tooth cracks apart. Inorder to avoid propagating the crack through thebone, it is safer to gain even limited movement ofthe tooth within the socket before section.

Delivery

When all necessary bone removal and toothsection is complete, the tooth or root is deliv-ered, usually by leverage with an elevator. Whenthe root form is complicated, and there is markedcurvature in more than one plane, withdrawalwith forceps may be easier, provided that theycan be applied. The successful delivery of thetooth is a cause of some satisfaction, and isusually greeted with relief by the patient, but thisdoes not represent the end of the operation! Thestages which follow are calculated to ensuretrouble-free healing, and are just as important asthose already completed.

Pathological specimens are welcomed by theoral pathology departments of most dentalschools. They will provide suitable containers,advise on postal service rules on packing anddespatch and report on specimens - usuallywithout charge.

Clean-up

The socket, or other bony defect, should beexamined for the presence of debris - pieces ofenamel, amalgam, calculus or loose chips of boneall seem to delay healing until exfoliated. Softtissue tags can be removed with discretion,although there is no evidence that they cause anyharm. Excessive irrigation is unnecessary andwashes away adherent clotted blood, which is thebest dressing material available. Bleeding pointsmay need to be clipped but, fortunately, signifi-cant haemorrhage is very rare and ligation, whichi s often extremely difficult, is seldom required.Persistent oozing will respond to packing with aswab, and to patience.

When bleeding is controlled, and the wound isclean, it is ready for closure.

Sew-up

Most minor oral surgical wounds are sutured soas to replace the flap in the optimum position forhealing. The object is not to pull the edgestogether to form a tight seal, but rather tosupport them in position and prevent displace-ment in the early phase of healing. Reducing thegape of the defect also serves to decrease thechance of ingress of food debris, and gentletraction on the tissues will hold them firmly tothe bone surface and stop them bleeding. Thefewer the number of sutures used to produce thedesired result, the better. Insertion of too manysutures tears the tissue unnecessarily, and theresulting tangle of suture thread tends to accumu-late plaque and promote inflammation. Sutureends should not be cut too short, but rather lefttied in an accessible position for later removal.Resorbable suture materials are preferred bymany, and materials such as softgut andpolyglactin 910 are suitable for the purpose.

8

The operation

Check-up

On completion of suturing, the tension of retrac-tion should be released and the wound re-examined for any gaping. A short period ofpressure, applied by biting gently on a damp swab,will ensure the final cessation of haemorrhage.During this time, the patient's postoperativei nstructions may be discussed. It is prudent to usea set of brief, printed instructions, since memorycan be fallible under such circumstances, and asuggested format for an advice leaflet is listed inAppendix D. Patients must understand how tokeep the wound clean, with frequent saline mouthbaths, and know how to get help if they sufferhaemorrhage, severe pain or excessive swelling.Proscription of mouth-cleaning or rinsing, or oftaking fluids by mouth, or taking alcohol inmoderation, or indeed of smoking is unkind andunnecessary as there is no evidence that any ofthese practices have the slightest effect on initialwound healing. Nevertheless, excess should (asalways) be avoided. Suitable analgesics should begiven, or prescribed, and sensible restriction ofactivity and rest at home overnight advised.

Follow-up

A return appointment must be offered beforethe patient is discharged. Seven days is usually

the most convenient interval, but postponementfor a few extra days is of no consequence.Earlier review, except in response to problems,should be avoided as healing to the point ofreasonable comfort usually needs this 7-dayi nterval. The requirement for postoperativereview in every case has been questioned, but aproper standard of care demands that thematter is at least discussed with the patient. Theuse of resorbable suture materials, while itavoids the discomfort of removal, does not ini tself relieve the surgeon of the duty of adequatepostoperative review. Decisions should be madein patient's best interest and not simply as acost-cutting exercise.

Write-up

Brief, but accurate, operation notes must bemade to record the procedure used, and to noteany variation from the usual technique.I nvolvement of significant vessels or nerves, anaccount of broken apices and the number ofsutures inserted, are all particularly important. Adramatic description is unnecessary and it is bestrather to concentrate on those factors mostl i kely to be significant in the long-term follow-up.All such notes must, of course, be dated andclearly signed, since they constitute the legal aswell as the clinical record of the operation.

9

Postoperative care

A wise oral surgeon once remarked, 'The opera-tion is finished when the patient stops complain-i ng.' For most patients, the follow-up is short anduntroubled, but for a few the consequences canbe lifelong.

At the time of suture removal, patients need,above all, to be assured that their progress isnormal and that the residual discomfort, swellingor trismus are as expected. They should beencouraged to look forward to early improvement.

When black silk is used the appearance of thesutures is in itself a valuable indicator of thesuccess of the patient's wound care.Accumulation of plaque and debris, with resultanti nflammation, tells its own tale. By no means doall minor oral surgical wounds heal by first inten-tion and, in most cases, there will be granulatingareas and often small defects where foodfragments can lodge. Swabbing with damp cottonwool and flushing with saline or chlorhexidinesolution will clean up the area and leave it feelingmuch fresher for the patient.

Premature removal of sutures is difficult due toswelling, and perhaps trismus, although it can bea relief to the patient if there is gross oedemaand the sutures have been tied tightly.Convenient, and therefore comfortable, sutureremoval requires the same conditions as theoriginal surgery - retraction, light, suitable instru-ments and skilled assistance. Many patients fearthe procedure and they can really be reassuredonly by painless removal of the first suture.Scissors must be sharp right up to the points, andnon-toothed tissue forceps are best for holdingand withdrawing the cut threads. Even if sutureshave not been inserted, it is essential that theprogress of healing is reviewed at about one weekpost-operation, and the wound may benefit fromi rrigation or dressing. Large defects may bepacked with iodoform ribbon gauze, which willstay fresh in the oral wound for some weeks.Smaller defects may benefit from regular flushingwith a suitable syringe, and the patient mayrequire instruction in this technique.

Most postoperative pain and swelling is duesimply to surgical trauma and not infection,although bacterial contamination is inevitable atoperation and thereafter. It is not logical to relyon antibiotics to compensate for surgical clumsi-ness, and they should only be prescribed in thefollowing cases:

• where infection was present pre-operatively• where healing capacity is impaired•

where protection from bacteraemia is essential• when surgical trauma is particularly severe.

Patients having teeth removed by surgical methodswill not be immune from the occasional occurrenceof a `dry socket', but prescription of antibioticsshould not be relied upon either to prevent or curethis distressing condition. Effective treatmentrequires irrigation, gentle packing with iodoformribbon gauze and, most importantly, a generousprescription of potent analgesics. Nonsteroidal anti-i nflammatory agents such as ibuprofen may have aspecially effective role in such cases. If the painpersists, then packing with zinc-oxide/eugenol pastei s justified as it does appear to relieve pain, albeitat the cost of prolonged wound healing and somel ocal tissue necrosis.

Postoperative haemorrhage i s unusual,especially if care is taken to ensure completehaemostasis before discharging the patient afterthe operation. In the unlikely event of a postop-erative haemorrhage occurring, the surgeon mustbe available to give advice and help. In most cases,gentle pressure on the wound - achieved bybiting on a damp cloth pack for 10-15 minutes -will compress the soft tissues on to the underly-ing bone and cope with the problem; sittingquietly and bed rest will also help. In more persis-tent or severe cases, the patient must return tothe surgery for re-examination of the wound. Itis important to reassure the patient, and thefamily, that the bleeding, while a nuisance, is notdangerous to life or health.

When in the surgery, the requirements foreffective treatment are the same as for the

4

Postoperative care

planned case, but they are more difficult to meeti n the emergency situation, particularly outsidenormal working hours. The administration of localanaesthetic solution into the bleeding area is oftendramatically effective in arresting the bleeding byvasoconstriction. It allows proper examination ofthe wound and further suturing, or packing, toproceed without pain. The theoretical danger ofrecurrence of bleeding after the vasoconstrictionpasses off is met by the local measures, which willcontinue to exert their effect. Sutures should beplaced to compress tissue at sites where graspingwith tissue forceps reduces bleeding. A modesti ncrease in suture tension is justified when thepurpose is haemostasis.

Persistent oozing may respond to packing withoxidized cellulose gauze. This material forms amatrix for promotion of blood clotting and hasno mechanical effect. Very rarely, a vascularbleeding point may be identified and clipped witha haemostat. Direct ligation of small vessels isvery difficult to achieve, and a light binding suturearound the tissue containing the vessel will usuallybe more feasible, and hence more effective.

Restricted mouth-opening for one or twoweeks after third molar removal is so commonthat all patients should be warned to expect it.Persistence of the problem is usually associatedwith slow healing and prolonged inflammation,and will resolve when the underlying inflamma-tory stimulus is removed. In some cases, trismuspersists for months, although it is never perma-nent. Some of these cases are examples of therare problems that arise after inferior dentalblock injections, due either to haemorrhage ori nfection of the needle track. There is no effec-tive treatment, and much patience is therefore

required of the sufferer, supported by thesurgeon. Relief, when it comes, tends to be rapid,and this lends weight to the suggestion that themechanism is reflex inhibition of movementprovoked by a painful stimulus.

Alteration of sensation in the area supplied bythe mental or lingual nerve can follow surgery inthe mandible especially in the third molar region.I n the case of the inferior dental nerve pre-opera-tive radiography may give a prior warning of thisdanger, and the operation may be modifiedaccordingly, or even avoided, if the indication forsurgery is weak. Flaps raised close to the mentalforamen should be reflected far enough toi dentify the position of the nerve, rather than riskdamaging it while working blind. If, despite theseprecautions, damage does occur, then carefulassessment of the postoperative symptoms isessential. The extent and degree of alteration insensation must be carefully recorded so thatrecovery can be monitored accurately. Generallyspeaking, those cases where some recovery isapparent in a few days will probably return tonormal in a few months, but when there is moredelayed recovery - or indeed no improvement bythe end of 9-12 months - then no furtherprogress can be expected. It follows, therefore,that patients must consent to the operationknowing the possibility of altered sensation, whichoccurs in 5-10 per cent of cases of third molarremoval. Fortunately, only one in ten of thesecases suffer from permanently altered sensation.

Sympathetic and thoughtful postoperative carenot only benefits the patient, but also enables thesurgeon to appraise critically the results of thework. This personal audit is the duty of everyethical clinician.

I I

I ntroduction

The cases illustrated in the following chaptershave been deliberately chosen, not as perfectexamples, but rather to demonstrate one presen-tation of each type of problem and the applica-tion of the basic principles given in Part I to somereal-life situations.

The problems chosen for illustration are thosemost likely to arise in a general dental practice,and that fall within the scope of the skills andl i mitations on time defined earlier. The generalindications for each type of operation are not

discussed specifically, as they are either patentlyobvious or sufficiently exemplified in the caseschosen. A more extensive theoretical discussioni s to be found in the texts listed in theRecommended Reading section.

Each patient is introduced by a case history and,where appropriate, a radiographic assessment. Theoperation photograph sequences have been chosento tell the story with the minimum of accompany-i ng text. The outcome of each procedure is alsodescribed and illustrated, where possible.

Retained roots

Retained upper lateral incisor root

RW, a 24-year-old computer programmer, wasconcerned about the appearance of his upperanterior teeth. He sought advice on the partiallyerupted upper right canine and the retained upperleft lateral incisor root. The panoramic radiograph,while imperfect, was sufficient to exclude any other

pressing surgical problems, although an uneruptedupper right third molar was present. In consulta-tion with an orthodontist and a prosthodontist, itwas agreed that this patient should be advised tohave the lateral incisor root removed, the caninebrought into full eruption by traction with a fixedorthodontic appliance, and bridges provided toreplace the lateral incisors.

Radiographic assessment

The left upper lateral incisor root is small andconical, with substantial caries in the root face.The tooth has previously been root-filled and isl ikely to be brittle. There is some evidence ofperiapical disease. As removal looked to beotherwise easy, no further view was taken.

5


Operation

Operation site

There is a broad band of healthy attached gingivae withno defect.

Incision

The papilla between the canine and the first premolari s released, and the incision carried round the gingivalmargin of the canine to the crest of the edentulousridge mesially. It then runs along the crest to the distalside of the central incisor. The relieving incision ismade at a slightly obtuse angle and need only just crossthe broad attached gingivae.

Reflection

The undermining of the flap commences at the relievinglimb, using the curette end of a Mitchell's trimmer. Thismakes it easier to insert the broader, blunter Howarth'speriosteal elevator, which is advanced along the boneand peels off the mucoperiosteal flap.

Elevation and delivery

The root can be clearly seen, and no overlying boneremoval is necessary. A medium Coupland's chisel isused to loosen the root from its attachment mesiallyand distally, and to define the buccal and palatal marginsprior to the application of forceps.

16

Retained roots

The root is easily removed, with care taken not tocrush the hollow carious area between the blades.

The socket

The socket is clean and the margins smooth.

Closure

The first suture draws the flap into the mesial cornerof the defect, and the second closes the gaping anteriorrelieving limb of the incision.

Follow-up

A week later, the sutures are removed and the area hashealed well. There is some local plaque accumulation,and the patient needs to be encouraged to brush thearea vigorously and not hold back for fear of damagingthe healing wound.

1 7

1 8


Retained lower roots and unerupted

debris. The sockets were irrigated withthird molar

chlorhexidine solution, hot saline mouthbathsadvised, and a prescription for penicillin V given.

YI, a 26-year-old female taxi driver, complained

One week later she was more comfortable, butof infection of the sockets of the lower right

considerable inflammation remained. Threemolars which had been extracted some days

months later she finally kept an appointment forbefore. There was marked inflammation in the

the removal of the roots and the uneruptedarea and gross aggregations of plaque and

third molar.

Retained roots

1 9


The retained fractured mesial roots of the lowerright first and second molars can be clearly seen.Both are large, easy to find and simple in shape,and so easy to elevate. The third molar is in ahorizontal position, with a tapering root shape,and its apex lies close to the inferior dental canal.Once the crown is uncovered, the tooth can bereadily brought forward away from the canal anddelivered into the space left by the extractedsecond molar roots, where bone removal willalso release the mesial first molar root.

The panoramic radiograph shows recurrentcaries and destruction of other molars, and alsoa disto-angular lower left third molar. In view ofthe patient's poor cooperation, she was merelyadvised to have other treatment - more in hopethan in expectation!


Operation

Operation site

Some minimal inflammation surrounds the jagged edgesof the fractured first and second molar roots, but thethird molar is completely covered. There is nokeratinized buccal gingival tissue at the first molar root,and the flap will be friable in this area.

Incision

The incision runs forward from the thick fibrous tissueoverlying the third molar, through the mucosal defectsproduced by the roots, to the distal gingival margin ofthe second premolar, and then down for a short waytowards the sulcus to form an anterior corner.

Reflection

The buccal and lingual tissues are reflected to give aclear view, and to enable the placement of a secondHowarth's periosteal elevator as a lingual retractor.The roots are obscured by bleeding granulations whichare curetted away.

Elevation and delivery of roots

The second molar root can now be clearly seen, andi s easily elevated by mesial application of a Cryer'selevator, while the first molar root can be elevatedbackwards using a Coupland's chisel inserted mesially.

Retained roots

Bone removal

The roots and granulation tissue have been removedand the relationship of the third molar crown to thebone is now clearly visible. Some bone around thecrown has been removed, using a small round bur in a` guttering' technique.

Elevation and delivery of third molar

The tooth is loosened and elevated out, using aCoupland's chisel.

Socket

A clean socket is left.

ClosureThe flap is replaced using five sutures. The first sutureis placed to reposition the mesial corner, and thesecond is halfway along the incision. The other suturesapproximate the gaping areas. As predicted, the flapcannot be completely closed in the first molar rootregion, and any further suturing here would merelytear the delicate buccal tissues.

Follow-upThe incision line healed satisfactorily and the patientwas discharged following suture removal at one week.

21


Retained lower molar root

JJ, a 54-year-old housewife, edentulous for over 30years, was referred for removal of a retained rootand suspected associated cyst in the left lowermolar region. She had suffered an intermittent dullache for over five years which she attributed to

the poor fit of the lower denture. She had beenunder the care of her general medical practitionerfor angina for which she used a glyceryl trinitratespray occasionally. Removal of the root and anyassociated cyst under local anaesthesia wasadvised. She would then be referred back to hergeneral dental practitioner for new dentures.


The panoramic film shows the patient to beedentulous apart from the presence of a root inthe lower left molar region. A breach in continu-ity of the upper border is clearly seen distal tothe root which is tilted mesially. The defectsuggests cystic change and chronic infection. Theimage is clear enough to proceed to surgerywithout any supplementary films.

22

Retained roots

2 3

Operation

Operation site

The anterior surface of the root can be seen through a defect in themucosa which is free of inflammation at the time of surgery. A Mitchell'strimmer is used to probe around it.

I ncision

The incision commences at the retromolar pad and runs anteriorlythrough the defect along the buccal side of the crest of the ridge, to endi n a deliberately angled short relieving branch.

Reflection

The soft tissues are raised off the bone around the socket commencing atthe anterior end of the incision, and the flap retracted using two Howarth'selevators.

Elevation

The root is elevated easily by mesial application of a Coupland's chisel.

The root is lifted out by grasping the attached soft tissue with fine curvedartery forceps.

The root and associated soft tissue remnants are despatched forhistopathological examination.

An atlas of minor oral surgery24

Retained roots

The socket is examined but requires no curettage.

Closure

The first suture positions the anterior angle of the flap and two furthersutures close the distal limb.

Follow-up

Sutures were removed at seven days when healing was acceptable. Thesutures have accumulated debris and there is some mild inflammation.Perfect wound hygiene had not been maintained partly because the patienthad been wearing the lower denture in the healing period. The patholo-gist reported the soft tissue to be a chronic periapical granuloma. At afurther review two weeks later healing was complete.

2 5

Third molar removal

2. Angulation

Angle of mean long axis of the third molar tothe `occlusal plane'. (This can only be anestimate, since accurate geometricalconstruction would be tedious andunnecessary, and the `occlusal plane' is not astraight line.)

• Described as mesio-angular (acute angle),vertical (right angle), disto-angular (obtuseangle), or horizontal (parallel).

3. Depth

Conveniently defined by referring the standardmesial point of elevation of the third molar tothe root of the second molar. The mesialpoint of application is seen on the radiographas the enamel-cementum junction, and thiscan be related by eye to the upper, middle orlower third of the distal root of the secondmolar.

4. Second molar

Crown

• Size• Shape• Caries status and restorations

Radiographic assessment of the inferior dental canal.

lining of the bony tube that contains the softtissue. When one or other margin of the tube isabsent, then the linear image is interrupted as itcrosses the root. In the rare case of true perfo-ration, both lines are interrupted and there is adark band of reduced radiopacity across the root,produced by relative absence of root dentine inthis plane. There is also an apparent narrowing orconstriction of the white linear outline as it meetsa grooved or perforated root. Deviation of thenormally smoothly curved outline of the canal isalso common when there is a true relationship tothe root.

Root

• Size• Shape• Number

5. Inferior dental canal

The relationship of the inferior dental canal to thethird molar roots must be established by adequateradiography so that any potential injury to theneurovascular bundle can be anticipated anddiscussed fully with the patient. The radiographicimage of the canal is produced by the cortical

6. Distal bone level

The exact relationship of the distal bone to thecrown of the impacted tooth is importantbecause clearance in this area is required toupright or deliver the tooth. Because of thesuperimposition of the radiodense inner andouter cortical plates, even a large distal defectmay be difficult to detect, especially whenpericoronal infection has destroyed its corticalsurface. However, a healthy or even a cystic folli-cle will produce a clear outline. The relationshipof the distal bone should be confirmed byprobing prior to elevation of a partially-eruptedtooth.

27


Partially-erupted mesio-angularlower third molar

PMcD, a 17-year-old student, had an episode ofpericoronitis related to his l ower left thirdmolar, which was treated successfully withpenicillin and with warm saline mouthwashes.

The treatment plan involved extraction of thistooth, and prophylactic removal of the otherthird molars. He agreed to have the teethremoved, one side at a time, under local anaes-thesia. The symptomatic side, the left, wastreated first, but the operation on the right sidei s illustrated.


The lower right third molar has a moderatelyl arge, sound crown, and the roots are straightwith a large interradicular space. There is markedmesio-angular inclination, and the mesial point ofapplication is level with the upper third of thesecond molar root. The second molar roots aretapered and its crown is intact, apart from a smallbuccal amalgam filling. The inferior dental canal isclose to the mesial root apex and the distal bonei s level with the neck of the third molar. Sincethe tooth will be delivered upwards andbackwards, pressure from the mesial root on thecanal contents is unlikely.

28

Third molar removal

Operation

Operation site

The partially-erupted third molar is surrounded by agingival cuff of variable thickness, free of inflammation.The mesial part of the crown is directly in contact withthe distal surface of the second molar crown.

Incision

The first incision is made to bisect the gingival margindistally, and the second started with the blade againstthe distal surface of the second molar, cutting acrossthe attached gingivae and turning forward for a shortdistance into the sulcus, to end level with the mesialsurface of the second molar. No attempt is made toi ncise around the crown of the third molar since thetissues will strip off easily.

Reflection

The flap is reflected with a Howarth's periosteal elevator,starting in the mesial incision. A second Howarth's can beused to hold the flap open while the distal tissues arereflected cleanly off the bone. It is essential that thesubperiosteal plane is identified, especially over the inter-nal oblique ridge distally to the third molar crown, so thata guard instrument can be inserted to protect the lingualtissues during distal bone cutting. The lingual tissues musteither be opened gently but widely or else left completelyundisturbed. Compromise risks lingual nerve damage.

Bone removal

The tooth is in clear view and a natural mesial pointof application already exists. It is therefore necessaryonly to relieve the impaction by removal of a gutter ofbone distally so that the tooth may be uprighted.

2 9

3 0


A Warwick-James' elevator is inserted mesially andturned in order to upright and elevate the tooth. Ifnecessary, it can also be elevated using buccal applica-tion at the bifurcation of the roots. Only moderateforce should be used. If there is resistance, then further

distal bone removal will overcome the problem.

Socket

The socket is free of debris, and the flap lies in position.

Closure

Two sutures are used. The first advancescorner across the socket, and the seconddistal incision.

Follow-up

A week later the wound has closed, though the tissuemargins are still oedematous. Frequent warm salinemouthbaths are advised and, if necessary, a disposablesyringe may be given to the patient to be used fori rrigation.


the mesialcloses the

Third molar removal

Unerupted mesio-angular impaction

DK, a 21-year-old apprentice joiner, com-plained of numbness in the right lower jaw. Noexplanation could be found, but he was advisedto have the unerupted right lower third molar

removed, in case the impacted tooth might beproducing pressure on the inferior dental nervein an attempt to erupt. Grossly carious lowerfirst molars had been removed four yearsbefore, but this had not avoided third molari mpaction.


The large lower right third molar has taperedroots with a tendency to distal curvature, whichi s more pronounced in the mesial root. There ismarked mesio-angular inclination, and the mesialpoint of elevation is level with the middle thirdof the distal root of the second molar. Thesecond is the only erupted molar in this quadrant,its roots are of normal size and shape, and itscrown is caries-free. The inferior dental canal isnot clearly demarcated, but it seems to run a safedistance beneath the root apices. The distal bonelevel is at the neck of the tooth, but there is afaint radiopacity which suggests a broad, bonydish around the crown. This impression isstrengthened when the other side is examined, asit shows a similar feature more clearly.

31


Operation

Operation site

The impacted tooth is covered by a bulky, fibrous masswhich will be easy to incise cleanly and will form arobust flap. A faint distal groove can be seen.

I ncision

The incision runs from the distal groove, across thefibrous pad, to the disto-buccal corner of the secondmolar. The second incision is made at a right angle tothe first, and then carried across the attached gingivaeto finish in a short, shallow forward curve.

Reflection

The flap is reflected buccally with a Howarth'speriosteal elevator. The clean, white bony surface caneasily be seen as the sucker mops up the bleeding froma soft tissue tag.

Further reflection distally and lingually exposes thecrown of the tooth which is surrounded by a bulky,soft tissue follicle.

3 2

Third molar removal

The follicular tissue has been removed and the extentof the bony crypt can be seen. The large lingual shelfi s a bizarre and unusual feature of this case.


A straight Warwick-James' elevator is inserted mesiallyand the tooth is easily displaced upwards.

It is pushed up further by inserting the same instru-ment into the bifurcation and applying leverage againstthe buccal bone.

The tooth is lifted out by grasping the attached softtissue with artery forceps - a convenient way of re-moving both at once.

3 3

34


Socket

The lingual bony excrescence is nibbled smooth withrongeurs and the socket aspirated clean of debris.

Closure

The corner of the flap is drawn across to the lingual side.

A single suture holds the flap in good position.

Follow-up

Healing was uneventful. The original complaint ofnumbness had disappeared by the time the patientcame to surgery.

Third molar removal

Horizontal impaction

AD, a 29-year-old electrician, presented withpainful inflammation of the operculum overlyingan impacted lower right third molar. The upperright third molar, which was biting on the swollenoperculum, was extracted. The pocket beneaththe operculum was flushed with aqueous

chlorhexidine (0.2 per cent). Aqueous iodine wasapplied and a 5-day course of metronidazoleprescribed (200 mg, three times daily). Whenreviewed at seven days, the acute condition hadsettled and an appointment was arranged forremoval of the lower third molar. The patientwas warned of the possibility of nerve damage,and the warning recorded in the case notes.


The lower right third molar is of normal size andshape, and is in horizontal impaction with themesial cusps almost in contact with the tooth infront. The mesial point of application is level withthe midpoint of the distal root of the secondmolar. The outline of the inferior dental canalcrosses the tip of the mesial root of the thirdmolar, but there is nothing to indicate groovingor perforation. The periapical view, as is often thecase with horizontal impactions, does not extendfar enough distally to show the whole of the rootand this important relationship. If no othertechnique is available, it may be possible to gainthe patient's cooperation in repeating the viewwith a film placed more distally than before. Thiscooperation is vital, since the more posteriorplacement is uncomfortable. An alternative is touse a film holder or an artery clip.

35


Operation

Operation site

The tooth is partially erupted, with the disto-buccalcusp visible. The distal gingival margin can easily bebisected by an incision from the distal groove, and thebuccal gingival roll is thick and will form a good corner

for advancing across the socket. The distal surface ofthe second molar is apparently intact and unweakenedby caries or restoration.

I ncision

The incision was made as planned. Note the angle atwhich the incision crosses the attached gingivae.

Minor bleeding is often encountered from small vesselscut at the end of the relieving incision. This can be

minimized by keeping the angle of the relieving incisionas flat as possible. In any case the bleeding is usuallytransient and stops when the flap is retracted.

Reflection

A generous exposure has been achieved and, when theremnants of follicle are removed, a more preciseappraisal can be made of the angulation of the toothand its relationship to the bone and the second molar.

36

Third molar removal

Point of application

The point of a curved Warwick-James' elevator isi nserted to confirm that a point of application can bereached. Even a minor degree of movement at thisstage will be helpful, but the force should be appliedj udiciously.

Bone removal

A gutter has been created on the buccal and distal sideby cutting to a depth of about half the root length,using the root itself as a cutting guide. Elevation is triedand is partially successful, but the crown is held by thedisto-lingual bone.

The crucial disto-lingual corner is now cut through,taking care to cut out through to the lingually placedHowarth's periosteal elevator, which acts as a guardand prevents damage to the lingual tissues, includingespecially the lingual nerve.

Elevation

The tooth can now be uprighted and is free for delivery.Caries and calculus deposits can be seen on the occlusalsurface.

3 7


Delivery

The follicular soft tissue tag is grasped with a haemo-stat and used to lift out the tooth. A loosened toothwill always come away with the follicle, but the reversei s not reliably true.

The socket is clean but must be checked for calculusor other debris lying in the blind spot distal to thesecond molar.

Closure

The soft tissues fall back naturally into position.

Closure is simply achieved with a single suture.

Follow-up

The wound healed satisfactorily, and the postoperativecourse was trouble-free.

38

Third molar removal

Disto-angular impaction

MH, a 43-year-old housewife, had sufferedrepeated episodes of painful pericoronitis associ-ated with her lower right third molar. She hadbeen treated previously with antiseptic irrigationand antimicrobials, and advised to have the tooth

removed. When examined, the soft tissue overly-i ng the tooth was thickened and scarred, and theupper right third molar was biting on it. Removalof both teeth was advised, and a warning of possi-ble nerve damage was given and recorded. Thepatient was willing to have the extraction underl ocal anaesthesia


The lower right third molar is large and the fusedroots have an apical extension with a markeddistal hook. The inclination is disto-angular andthe mesial point of application is level with themidpoint of the distal root of the second molar.This tooth has tapered roots and its crown isi ntact distally. The distal bone is level with the tipof the distal cusp, but there is a generous follic-ular space. The outline of the inferior dentalnerve canal crosses the apex and the apical hook.The relationship is best seen on the panoramicradiograph, since the periapical film was notplaced distally enough to show the full extent ofthe root. This radiograph shows how easy it is tomiss a narrow apical extension, even on a well-positioned film.

39

Operation

Operation site

The distal groove is clearly seen in this case. The tooth is completelyunerupted and the distal surface of the second molar is sound.

I ncision

The incision is placed in the groove, with the relieving branch runningacross the attached gingivae and the external oblique ridge, then forwardto end level with the first and second molar interspace.

Reflection

The occlusal surface of the third molar is revealed and a Howarth'speriosteal elevator is pushed subperiosteally over the internal oblique ridgeat the disto-lingual corner.

An atlas of minor oral surgery4 0

Third molar removal

Point of application

A straight Warwick-James' elevator is inserted mesially, and some upwarddisplacement achieved.

The crown is impinging on the distal bone. Elevation moves the crownbackwards, as well as upwards, because of the root curvature.

Bone removal

Bone has been removed to deepen the buccal gutter and relieve thei mpaction distally.

41


The tooth can now be elevated upwards and backwards out of the socket,using a Cryer's elevator. This has been preferred to a Warwick-James', asthe space between the displaced tooth and the second molar is now quitel arge.

The point of the Cryer's is inserted into the root bifurcation to achievethe final upward displacement and delivery. The loose tooth can be graspedand lifted out with any suitable instrument.


The extracted lower right third molar, viewed from the lingual side, showsthe distal hook of the apex and a horizontal groove which may have beenrelated to the inferior dental canal.

4 2

Third molar removal

Socket

A clean socket is left, without any debris. None should be expected asthe tooth was removed intact, and no bone splintering occurred. Thesocket surface is already becoming covered with blood coagulum, and thisneed not be disturbed by flushing.

Closure

The incision closes easily with a single suture.

Follow-up

Healing was uneventful, and there was no alteration in nerve function.

4 3


Removal of retained uneruptedlower third molar

AF, a 31-year-old prisoner, was referred by hisprison dentist with a helpful letter which read:

i nferior dental canal, I would be most grateful ifyou could look at this man and arrange theextraction of the lower left third molar. He is adrug addict and veins in both arms are consid-erably sclerosed.

I saw this man a month ago at his insistence and,because he caused a riot, I arranged for him tobe brought to my practice where I removed hisremaining standing teeth under general anaes-thetic. Unfortunately, I was unable to removethe unerupted lower left third molar. I told MrF that the tooth was still present and mostunlikely to cause trouble. However, yesterday,he came to see me again complaining that thetooth was causing trouble and wanting it cut out.As there is considerable bony covering with justthe cusps showing above bone level, and theroots appear radiographically to be close to the

The patient complained of a shooting pain onthe left side when eating, leading to earache. Thissymptom is more likely to originate from thetemporomandibular joint, but since the provisionof dentures would be delayed until the thirdmolar was removed, it was probably the indirectcause of pain. There were no significant findingson examination. In view of his background of drugabuse, a blood sample was taken to excludehepatitis B infection. This proved to be negativefor virus, and positive for antibody. The patientagreed to have the tooth removed under localanaesthesia.

44

Third molar removal


The panoramic radiograph shows that there areno other retained teeth or roots. The lower leftthird molar is normal in size and shape, and liesi n mesio-angular inclination with only the distalcusps above the bone level. The follicular space isnot obliterated and the distal bone level is justabove the distal crown-root junction. The inferior

dental canal seems to be in close relationship tothe mesial root apex, but the upper white line canjust be seen on the original radiograph, and therei s no dark banding at the apex. Nevertheless, thepatient was warned of the possibility of postop-erative lip numbness. The removal of bone in agutter around the crown should, in any case, allowi ts elevation away from the apex without tippingthe tooth so as to crush the nerve.

4 5

Operation

Site

The extraction sockets have completely healed and there is a broad bandof attached gingiva overlying the completely unerupted tooth.

Incision

The main incision is placed just to the buccal side of the crest of theedentulous ridge, from the retromolar area forward to about the firstmolar area. The relieving incision is made from the first line obliquelyforward towards the sulcus. It was intended to run the relieving incisionfrom the anterior limit of the ridge incision, but it has in fact been placeda little distally.

Reflection

The flap is reflected with a Howarth's periosteal elevator and the exter-nal oblique ridge can be seen clearly.

An atlas of minor oral surgery4 6

Third molar removal

47

The flap must be reflected cleanly over the internal oblique ridge, distallyand lingually, since blind cutting in this area can endanger the lingual nerve.

Bone removal

Using a small rosehead bur, bone is removed to form a deep, narrowgutter around the buccal and mesial sides of the crown.

The entire circumference of the crown has been cleared.


The crucial distal bony gutter is made, with a Howarth's inserted to guardthe lingual soft tissues.

Elevation

The tooth is now easily elevated, using a large Coupland's chisel inserted,buccally and mesially, into the gutter, and rotated to impinge on the toothsurface and drive it upwards.

Socket

I n cases like these, the socket is in direct line with the operator's vision,so any small apices which may fracture off are easily seen and, with delicatemanipulation, it is therefore possible to remove them.

48

Third molar removal

Closure

The first suture is placed across the corner of the flap that was deliber-ately created at the time of incision to aid relocation.

Two further sutures close the distal limb.

Follow-up

Sutures are removed at one week, and the wound has healed very satisfac-torily. The patient was referred back to the prison dentist for provision ofdentures.

4 9


Removal of unerupted upper thirdmolar

AH, a 19-year-old dental surgery assistant, hadsuffered an episode of pericoronitis related tothe lower right third molar, and had in the pastundergone orthodontic treatment to align the

upper canines following surgical exposure. Thethird molars were all completely uneruptedand their removal was indicated. Despitehaving one congenitally-absent kidney, she wasi n good health and agreed to have the teethremoved, one side at a time, under local anaes-thesia.


The upper right third molar is of normal size andshape and has an incompletely formed root. It issurrounded by follicle and lies in a spacious bonycrypt. It has a slight disto-angular inclination, andi s deeply placed with the mesial elevation point atthe level of the apices of the upper second molar.The maxillary sinus is large and adjoins theunerupted tooth.

The upper left third molar is in a similarposition, but even higher, and there are twomesio-angular lowers present.

5 0

Third molar removal

Operation

The first three and penultimate photographs have been taken using amirror and are printed inverted, so as to relate more easily to the otherphotographs in the sequence.

Operation site

The second molar has an intact distal surface and there is no sign oferuption of the third molar.

Incision

The incision runs in a straight line from the palatal side of the tuberosity,obliquely forward at a tangent to the disto-buccal corner of the secondmolar, and up across the buccal attached gingivae towards the sulcus.

Reflection

The flap is raised with a Howarth's periosteal elevator, starting anteriorly

and working around the maxillary tuberosity beneath the mucoperiosteum.

5 1

Bone removal

The thin buccal plate of bone overlying the tooth follicle is easily flakedoff by inserting a Coupland's chisel and levering it outwards.



A Cryer's elevator is used to free a point of application mesially and thento lever the tooth downwards, backwards and outwards so as to displaceit from its crypt. The direction of elevation must be controlled and calcu-lated to avoid displacement of the tooth either into the maxillary sinusabove or the pterygoid fossa behind.

When loosened, the tooth is lifted out with a convenient instrument - inthis case, a pair of artery forceps.

52

Third molar removal

Closure

The wound is gaping open and requires to be sutured to appose the edges.I n the majority of cases, an upper third molar wound would lie togetherwell enough without suturing.

The first suture reconstitutes the buccal gingival margin.

As the buccal end of the incision is still gaping and bleeding, a secondsuture has been inserted there.

Follow-up

The wound healed perfectly.

5 3

Endodontic surgery


The panoramic radiograph shows that both theupper central incisors have been root-filled andpost-crowned, and that there are no otherproblems requiring surgery. The apparent periapi-cal radiolucency, related to the over-filled upperl eft lateral incisor, was not confirmed in a periapi-cal view, which showed no evidence of activedisease about the apices of either left incisor. Theperiapical view of the upper right incisors showsthe root filling in the central incisor to be wellshort of the apex. There is a loss of lamina duradistally from the apical third of the root, and anill-defined radiolucent area extending to the rootof the lateral incisor. The root canal of the laterali ncisor has sharp distal curvature and the laminadura at its apex seems intact.

5 5


Operation

Operation site

The gingival condition about the crowned upper centrali ncisors is poor and the labial fraenal attachment isclose to the papilla between these teeth. No sinus canbe seen.

I ncision

The incision commences in the sulcus on the left sideof the fraenum, and the cut is made towards the mesialsurface of the left central incisor, so as to include thei nterdental papilla in the flap. The tip of the scalpelblade is run round the gingival margins of the upperright incisors and canine.

Reflection

The flap is reflected using two Howarth's periostealelevators. The defective labial bony support of thecentral incisor can be clearly seen. There is a smallbony notch which probably marks the former exit of adischarging sinus.

Bone removal

A Mitchell's trimmer is used to chip away the thin,undermined bony plate overlying the periapicalgranuloma.

56

Endodontic surgery

The granulation tissue has been curetted away and theapex is in clear view.

Apical section

A fine flat fissure bur is used to cut across the rootand sever the apex.

The apex is removed with the sucker tip.

The cut surface is angled so that the root canal openingcan be seen.

5 7


Retrograde root-filling

A small rosehead bur is used to cut an undercut cavity.

The prepared cavity.

Amalgam is placed to seal the end of the root canal.

Closure

The flap is repositioned and sutured into position. Thefirst suture replaces the interdental papilla between thecentral incisors, and the second replaces the papillabetween the central and lateral incisors. The thirdsuture is placed in the sulcus across the relieving limb.

Follow-up

The tissues healed well, but the symptoms recurred. Arepeat procedure, performed a few months later,resolved the problem.

5 8

60



A panoramic radiograph (see page 59) taken atthe beginning of orthodontic treatment, a yearbefore referral, showed a high caries rate withactive lesions in at least two molars and aretained root in the upper right molar region.The anterior occlusal film confirms that there wasno evidence of a mid-line supernumerary tooth,and the upper central incisors were of a normalshape and structure.

Orthodontic surgery

Operation

Operation site

The attachment of the fraenum is demonstrated bytraction, with a finger in the sulcus on either side. Thecooperation of an assistant, using the fingers of bothhands to grasp and evert the lip firmly in this way, isessential both to provide retraction and to help reducebleeding by occlusion of the labial vessels.

Excision

The fraenum is grasped in a curved haemostat.

I t is released by an incision on either side of its base.

Excision is completed by running the scalpel edge downthe back of the haemostat.

61


The excised tissue is removed.

A diamond-shaped defect is left.

Closure

The first suture is placed at the base of the defect soas to draw in the wound edges and tether themtogether to the periosteum at the depth of the sulcus.

Further sutures close the labial part of the defect. Thealveolar side of the wound may be dressed with aperiodontal pack if the exposed area is large or if thebleeding is troublesome.

6 2

Orthodontic surgery

Only two further sutures were required in this case.

Follow-up

Three months later the wound has healed well and themidline diastema has almost closed. The small residualscar is more prominent in the photograph than in reality!

6 3

64


Removal of supernumerary and

of the upper right lateral incisor was impeded by

exposure of upper lateral incisor

the presence of a small supernumerary tooth.Since this supernumerary could neither be seen

FF, a 12-year-old schoolgirl, presented with mild

nor palpated buccally, it was deduced that it mustupper arch crowding and failure of the upper right

lie palatally to the lateral incisor crown. In view ofl ateral incisor to erupt. She had a mild Angle Class

i ts superficial position, removal under local anaes-III malocclusion on a Skeletal Class III base, with

thesia was offered and accepted. The patient wasslightly higher than average Frankfort-mandibular

perfectly fit, although she suffered occasionalplane angle. Radiographs showed that the eruption

attacks of asthma, eczema and hay fever.


The radiographs show a crowded mixed dentitionwith noneruption of an otherwise normal-lookingupper right lateral incisor. The supernumerarycan be seen in the panoramic radiograph to lieabove the cingulum of the lateral incisor. Theocclusal film shows it clearly, lying obliquelyacross the crown of the lateral incisor, with thetip of its crown placed distally.

Orthodontic surgery

6 5

66


Operation

Site

The incisal edge of the lateral incisor can be clearlyseen through the thin, tense overlying mucosa.

I ncision

The incision simply outlines the incisal edge of thel ateral incisor.

Exposure merely consists of pushing the edge of the thinmucosa apically with a straight Warwick-James' elevator.

Elevation

The elevator is inserted against the palatal surface ofthe crown.

Orthodontic surgery

The Warwick-James' pushes the supernumerary mesially

and upwards out of its crypt.

The small conical tooth.

Follow-up

The upper second primary molars and first premolarswere extracted and, three months later, an upperremoval orthodontic appliance was used to retract theerupting right upper canine and to make space for the

l ateral incisor to come into position.

6 7


Exposure of upper canine

MD, a 13-year-old schoolgirl, presented with anunerupted misplaced upper left canine. She had acrowded upper arch and a shift of the midline tothe right with an Angle Class I incisor relationship

on a Skeletal Class I base. Removal of the retainedbut mobile upper left deciduous canine and thefour second premolars was advised. The first stagewas to be the removal of the deciduous canine andexposure of the permanent successor. The patientagreed to have this done under local anaesthesia.

68

Orthodontic surgery

69


l eft permanent canine is tilted, with the crownoverlapping the lateral incisor. The periapical film

The patient had a full adult dentition and one

shows the tooth to be of normal shape and size,retained deciduous canine, of which hardly any

and confirms the advanced resorption of theroot remains. She is almost caries-free, but there

deciduous tooth. The vertex occlusal film clearlyappears to be a recurrent lesion beneath the

shows that the tip of the crown is placed palatallyamalgam in the upper right first molar. The upper

to the lateral incisor.


Operation

Operation site

The fractured upper left lateral incisor and the retaineddeciduous canine can be clearly seen, and there is a` bump' palatally overlying the unerupted tooth. Theexposure can be achieved within the attached gingivaltissue.

Extraction

The deciduous canine is simply removed with forceps.

Exposure

The first bite of tissue over the crown is removed withrongeurs.

The excision is completed with a scalpel.

70

Orthodontic surgery

The gingival tissues are pushed back from the newly-

exposed crown with a Coupland's chisel. This will alsocreate some space in the bone which is required forthe tooth to erupt.

Dressing

The lips are lubricated with petroleum jelly to preventthe resin from the pack sticking to the lips and the skinof the face.

The I cm ribbon gauze pack has been soaked iniodoform and blotted dry on a swab.

The pack is placed over the exposed crown and tuckedinto position beneath the soft tissues buccally andpalatal ly.

71


The pack has proved unstable without support, so amattress suture is inserted across the defect and loopsdrawn up in the central portion.

The pack is then re-inserted beneath the loops, whichare drawn tight one at a time by traction on the looseends.

The suture is tied and cut (such sutures are moreusually tied on the buccal side).

Follow-up

The pack was removed in seven days and healing wasexcellent. If exposure is wider and more raw surfacei s exposed, then the pack may be left in position for

1 0-14 days. A bracket or attachment can be cementedto the exposed crown surface and, after initial healing,traction can be applied to guide or accelerate eruption.

74



The panoramic radiograph (see page 73) showsthe patient to be truly edentulous apart from aretained unerupted upper left canine, which liesbeneath the margin of the bony ridge and demon-strates no related pathological changes. Thelower anterior region appears to be perfectlysmooth and regular in outline on this film. Themore detailed periapical view contributes littlemore, other than to exclude definitely thepresence of any root fragments.

Prosthodontic surgery

Operation

Operation site

The edentulous lower ridge looks quite normal. Thecentral blanched area is produced by traction on the lipand does not indicate the presence of a bony lump!

Incision

The incision runs just buccally to the crest of the ridgefrom the molar region to just across the midline, whereit is continued in a short-angled relieving limb.

Reflection

The friable tissues are reflected using the curette endof a Mitchell's trimmer initially, followed by the inser-tion of a Howarth's periosteal elevator.

Bone-smoothing

When exposed buccally and lingually, the ridge isi nspected for abnormalities of shape and surface, andi s smoothed with a small bone file.

7 5

The cortical crest of the ridge after smoothing.

Closure

The wound is closed with five sutures, the first beingi nserted at the anterior corner to relocate the flap.

Follow-up

Sutures were removed a week later, and the woundhas healed well. The patient was unavailable for furtherfollow-up.



77

Surgical removal of fibrous

Radiographic assessmenttuberosity

The panoramic radiograph shows the patient toHM, a 45-year-old perfume consultant, required

be completely edentulous. The outline of a large,reduction of a large, flabby left maxillary tuberos-

l eft maxillary tuberosity can be made out, and iti ty, prior to the construction of a new upper

appears to consist entirely of fibrous tissue. Thedenture. She had no symptoms, and agreed to

shape and extent of the underlying bone is quitehave the surgery under local anaesthesia.

symmetrical.

78


Operation

Operation site

The left maxillary tuberosity is

undercut.

I ncision

A Y-shaped incision is made, commencing from about thesecond molar region and diverging buccally and palatally.

A wedge of tissue is demarcated for excision.

The wedge is cut free at its base and excised.

mobile and deeply


The edges of the defect are undermined by cutting intothem with the scalpel so as to mobilize them for closure.

The flaps are brought together with tissue forceps tocheck the extent of reduction obtained.

Closure

Sutures are placed so as to draw the wound edgestogether into the best shape which can be achieved.

The position of the flaps is controlled by careful sutureplacement.

79


Deep bites of tissue are taken, and the sutures are placed under slighttension. Further undermining cuts may be needed if the tension is judgedto be excessive.

Dressing

A dressing of zinc-oxide/eugenol paste is applied to the denture to coverthe wound and support the tissues in the new position.

Follow-up

Sutures were removed seven days later and the initial healing was satis-factory.

80


81

Excision of denture-induced

l eft side approximately three years earlier. A largehyperplasia

l ump of hyperplastic tissue was present, which hada typical bibbed shape with the denture flange in

I L, a 54-year-old housewife, complained of a `piece

the central cleft. She wished to retain use of theof skin' growing out from under her lower denture

l ower denture and so the flange was cut away inon the right side. This had been present for a few

the related area to encourage resolution of themonths and had sometimes become swollen. She

l ocal inflammation. An appointment was arrangedhad required surgery for a similar problem on the

for excision of the lesion under local anaesthesia.


Operation

Operation site

The hyperplastic tissue forms a short thick deeply-clefted lump in the right lower sulcus with a narrowfolded extension buccally and forwards.

The base was generously infiltrated with local anaestheticand the lingual fold grasped with tissue forceps. Thetissue blanches as the traction reduces its blood supply.

I ncision

The soft tissue is held in tension and released by incisionat the base.

The incision is repeated on the other side.


A third sweep of the scalpel separates the lesioncompletely.

The anterior fold is drawn up.

I t is incised at the base.

The final strands of fibrous tissue are released.

The bleeding comes mostly from capillary oozing.

Closure

Bleeding from the raw area is arrested satisfactorilywhen the edges are drawn together with sutures. Veryl arge areas may require grafting and present a difficultsurgical problem.

Follow-up

A week after operation, healing - although incomplete -is satisfactory.

The excised tissue, seen here with a millimetre scale,was sent for histopathological examination.

Pathology report

The pathologist reported that the histology showedfeatures in keeping with the clinical diagnosis ofdenture-induced hyperplasia.



Removal of unerupted maxillarycanine

MG, a 42-year-old housewife, required a replace-ment upper denture and, as part of the examina-tion and assessment, a panoramic radiograph was

taken. An unerupted upper right canine was foundto be lying horizontally beneath the upper ridge.I n view of the close proximity of the crown tothe ridge and its lack of bony cover, removal ofthe unerupted tooth was advised. The patientagreed to an operation under local anaesthesia.

85

86



of any other maxillary tooth. The three periapicalfilms demonstrate its size and shape, and show

The panoramic radiograph (see page 85) demon-

clearly that, in this case, there is no significantstrates the presence of the canine and the absence

apical curvature to complicate extraction.


Operation

Operation site

The mucosa is healthy and intact. The tooth crown liesbeneath a visible and palpable prominence in the rightupper anterior region.

I ncision

The incision extends from the right molar region to arelieving limb, just to the left side of the midline. It isplaced buccally to the crest of the ridge.

Reflection

The flap is raised with some difficulty due to thecomplicated mass of fibrous tissue around the crown,but the first cardinal point of the tooth, the distal bulgeof the crown, can be seen.

Bone removal

Soft tissue, and then covering bone, is removed gradu-ally with rongeurs to uncover the second point, the tipof the crown. Uncovering the mesial bulge is not neces-sary, as forceps will be used for extraction.

87

88


Delivery

The crown is now uncovered sufficiently for the

conventional application of forceps.

The tooth is grasped in the forceps blades. In these cases.forceps can often be applied mesio-distally to advantage.

The tooth is delivered easily.

There is minor apical curvature.


Socket

Soft tissue tags and sharp bony edges are removed withthe rongeurs in preparation for closure.

Closure

The first suture replaces the corner of the flap.

The incision is closed with interrupted sutures but tendsto gape where it is unsupported by bone, so a mattresssuture is used to reinforce the apposition of the edges.

The knot is tied firmly, but not tightly, and the cut endsare left longer than those of the interrupted sutures inorder to make it easier to distinguish them at the timeof removal.

Follow-up

Healing was uneventful, and the new dentureconstruction was commenced a few weeks later.

8 9


The outline of the cyst in the right upper anteriorregion can be seen clearly on the panoramicradiograph, but the extent of this lesion and thepresence of another smaller one in the premolararea are more accurately delineated on theocclusal film. The mandibular lesions are suffi-ciently well demonstrated by the panoramicradiograph. The deepest parts of the bone defectsare close to the inferior dental canal.

Cysts

9 I


Operation

Operation site: upper cysts

The edentulous ridge is fairly smooth and the mucosai s healthy.

Incision

The incision is made slightly buccal to the crest of theridge, commencing distally to the position of the distalcyst (estimated with reference to the radiographs) andending anteriorly, with a short relieving incision just tothe left of the midline.

Reflection

The flap is raised buccally, using two Howarth'speriosteal elevators.

There is a fibrous scar at the site of a previous discharg-i ng sinus, which indicates the position of the cyst beneaththe bone surface. The subperiosteal tissue plane isopened around the tethered area, and the band of fibroustissue is freed from the bone surface with a scalpel.

9 2

Cysts

Exposure

The thin bone overlying the cyst is picked away with aMitchell's trimmer.

Delivery

The curette is scraped around the smooth cortical wallof the bony cavity, easily freeing the cyst capsule whichcan then be scooped out in one piece.

The bony defect can be slightly saucerized by trimmingsharp edges, but gross bone removal is unnecessary.

93

94


The cyst is delivered in the same way as the first.

I t needs to be cut free from the overlying mucosa withscissors.

The bony cavity is left to fill with blood clot.

Closure

The first suture replaces the anterior corner of the flap.

Cysts

The second suture closes the relieving incision and thethird bisects the length of the incision.

Further sutures close the remaining parts.

Follow-up

Healing was successful.

One month later, no trace of the surgery can be seen.

Operation site: lower cysts

The lower ridge is quite bulky, but the extent of attached gingival tissuei s limited.

I ncision

The incision runs from the retromolar pad forward, to a point wellanterior to the estimated position of the anterior cyst.

Reflection

The soft tissues are reflected buccally and, to a limited extent, lingually.The position of the cysts is revealed by defects in the bony cortex.

9 6 An atlas of minor oral surgery

Cysts

The posterior cyst is curetted out.

The anterior cyst is freed.

It is drawn from the wound on the sucker tip. Care is required in removingsmall tissue pieces in this way, since they may disappear into the tubing!

9 7

The clean bony cavities are allowed to fill with blood clot.

The flap is sutured back in its original position.

Follow-up

A week after operation, the incision lines have healed well.

9 8 An atlas of minor oral surgery

Cysts

Long-term healing was satisfactory and new dentures were provided.

Pathology report

The cysts are shown with a millimetre scale. The specimens were placed

i n bottles of formal saline and, together with clinical and radiographicdetails, were sent for histopathological examination.

Maxillary cysts

The cyst from the upper central incisor area was found to be lined bynonkeratinized stratified squamous epithelium, consistent with a residualcyst. The cyst from the premolar area, which had a small root fragmentattached to it, showed the features of a periapical cyst.

Mandibular cysts

The pathologist remarked that both cysts showed essentially the sameappearance, with linings of nonkeratinized stratified squamous epithelium,consistent with residual cysts.

9 9

1 00


Mucocele

palpable - especially when he had a cold. A fewcervical lymph nodes could be palpated but, in view

ED, a 26-year-old lawyer, was referred by his

of his obvious good health, he was simply advisedgeneral medical practitioner, whose advice he had

to consult his physician if the problem persisted.sought about a painless swelling of his right lower

The lip lesion was a typical mucocele and theli p. His medical history was clear, but he mentioned

patient was reassured of its harmless nature. Hethat he had noticed `glands in his neck' which were

agreed to its removal under local anaesthesia

Cysts

Operation

Operation site

The lesion is visible in the right lower lip. The assis-tant's fingers hold the lip firmly and, to reduce theblood supply to the area, firm but gentle pressure isapplied on either side of the working area.

Local anaesthetic infiltration beneath and around thel esion not only anaesthetizes the area, but reducesbleeding by vasoconstriction.

Incision

An elliptical incision is made, through the mucosa only,over the dome of the lesion. This isolates a patch ofmucosa overlying the thin friable cyst lining, which isrobust enough to be grasped with toothed forceps.I ncidentally, the elliptical shape also eases the straightli ne closure of the mucosal defect.

The elliptical patch of mucosa is grasped with toothedforceps and upward traction applied.


Dissection

Sharp-pointed scissors are inserted, with the bladesclosed, into the tissues between the cyst and the mucosa.

The tissues are blunt-dissected away by opening theblades.

A steady upward traction is maintained, and eventuallythe cyst is freed.

There are usually some berry-like minor salivary glandsattached to the base of the lesion, and these are alsosnipped free with scissors.

102

Cysts

Closure

The underlying connective tissue and muscle can beseen in the base of the wound. Control of bleeding isstill being aided by the assistant's finger pressure.

A sheet of connective tissue is grasped in the forcepsand sutured to a similar layer, on the other side of thewound, using a 3/0 catgut suture.

The needle passes from beneath the edge of the sheetof tissue on the first side, and then from above thesheet of tissue on the second side. In this way, whenthe knot is tied, it retracts deep to the connectivetissue layer and is buried in the wound. The ends arecut very short.

1 0 3


Generous `bites' of tissue can be taken, as this willassist approximation and eversion, and also preventpostoperative bleeding.

The wound has closed easily with only three sutures.

Follow-up

At suture removal, five days later, healing is alreadyalmost complete.

The intact lesion is despatched for histological exami-nation. The lobulated cystic shape is apparent, as arethe minor glands attached to the deep pole. When amucocele bursts during removal - as they often do -there is no choice but to remove approximately theright amount of tissue and a few neighbouring minorglands for good measure. Accurate dissection is reallyonly possible if the mucocele remains intact.

1 04

1 06


The lesion is drawn up and severed at the base with ascalpel.

The lesion is removed and bleeding from the base isminimal.

The specimen is despatched for histopathologicalexamination, without removing the suture.

The elliptical defect before suturing.

Soft tissue biopsy

Closure

The first of two sutures is passed across the ellipseone-third of the way along. A generous bite of softtissue is taken.

The second suture completes the closure.

The sutures are tied with moderate tension and bleed-i ng is arrested. Persistent bleeding is dealt with by firmfinger pressure for two minutes (by the clock!).

Follow-up

One week later the sutures have been shed sponta-neously and the wound has healed well. The smallherpetic vesicles are a common consequence of surgi-cal trauma in a patient susceptible to recurrent herpesl abialis. The pathologist reported the lesion to be anarea of fibrous overgrowth covered by hyperkeratoticepithelium. The patient was cautioned to avoid chewinghis lip in case he provoked any recurrence.

1 07


Excision of large fibro-epithelial

i n size over a 2-year period and was a nuisance

polyp from the cheek

to him when eating. He was told that it washarmless and accepted the offer of removal under

AC, a 37-year-old fit man, had a large painless

l ocal anaesthesia.l ump in his left cheek which had slowly increased

108

Soft tissue biopsy

Operation

Operation site

The large pendulous polyp is attached to the cheek bya narrow stalk.

Excision

The lesion is transfixed with a suture.

The polyp is easily manipulated by traction on thesuture. Blanching of the cheek shows where the localanaesthetic solution has been infiltrated generously toreduce haemorrhage by vasoconstriction. Small vesselscan be clipped temporarily or coagulated withdiathermy if available.

The polyp is held with firm traction and the base cutacross with a scalpel. Scissors could be used ifpreferred and are particularly convenient for excisionof small lesions.

1 0 9


The final attachment is severed with a scalpel.

An irregular-shaped defect is created. The edges aremobile and require no undercutting for closure.

The lesion is despatched for histopathological exami-nation with the suture still in place. This helps thepathologist with orientation of the specimen and identi-fication of the transfixing needle track.

Closure

The first suture is placed across the wound, taking agenerous bite of tissue so as to achieve good appositionand to control bleeding from subsurface vessels.

110

Soft tissue biopsy

The first suture is tied and used to pull the defect intoline for subsequent suturing.

The next suture is placed to reduce the length of theresidual defect. An advantage of the Gillies'-typeneedle-holder is the ability to hold the curved needlein line with the blades, using the eye on the upper bladeto accommodate its end.

Three sutures were used for closure, the edges areclosed neatly and bleeding has been arrested.

Follow-up

One week later the sutures have been removed andthe area is healing well, although still slightly oedema-tous. Complete healing can be anticipated with only

minimal scarring.

I I I


Excision of a fibro-epithelial polypfrom the palate

JM, a 65-year-old housewife, had been awaresince childhood of a small lump in her palate,but had resisted surgery for it. However, she

was advised that its presence would complicatethe provision of a new denture and she there-fore agreed to excision under local anaesthesia.The clinical diagnosis was fibro-epithelial polyp,with pleomorphic salivary adenoma as a possi-bility.

1 1 2

Soft tissue biopsy

Operation

Operation site

The base of the lesion is infiltrated with local anaes-thetic solution.

Excision

The lesion is transfixed with a suture, which is used topull it to each side in turn.

The stalk can be cut free with the scalpel.

The residual defect is roughly elliptical in shape.

1 1 3

Closure

The edges of the wound are undermined to ease closure.

The needle is held end-on in the Gillies' needleholderand a generous bite of tissue taken.

Two sutures suffice to close the wound.

Follow-up

When examined, one week later, the sutures have beenshed spontaneously and, despite the inflamed appearance,there were no complaints and healing was satisfactory.

Pathology report

Histological examination showed an area of simple fibrousovergrowth covered by a mildly keratotic epithelium. Thefeatures were in keeping with the clinical diagnosis of afibro-epithelial polyp.

An atlas of minor oral surgery1 1 4

1 1 6



be no doubt that displacement is minimal andthe root should be readily accessible through the

The periapical film shows the displaced double

socket. The occipito-mental film does not showroot apparently lying just above the socket,

the displaced root but demonstrates awithin the sinus cavity. The occlusal film

radiopaque area in the lower part of the leftconfirms this information and shows the two

maxillary sinus, which otherwise appears to beroot canals particularly clearly. As the films have

healthy and of similar radiolucency to the rightbeen taken at slightly different angles, there can

side.

Oro-antral fistula

Operation

Operation site

The socket of the upper right second molar is filled with blood clot andthe buccal gingival margin is intact.

Incision

Two short relieving incisions are made across the gingival margin towardsthe sulcus.

Delivery

A few loose fragments of bone are removed from the socket. Thanks toefficient suction and the precise direction of the operating light, the rootcan just be seen lying in the sinus, not far removed from its original position.

1 1 7

The root can be grasped with fine straight forceps.

The root is withdrawn.

Closure

The periosteal lining of the flap is incised antero-posteriorly to allow it tobe drawn across the socket without tension.

118 An atlas of minor oral surgery

Oro-antral fistula

The first two sutures appose the corners of the flap to the palatal socketmargin.

Further sutures repair the buccal relieving incisions and close the centralportion of the wound.

The root with its attached bone fragment is retained and photographedfor medico-legal reasons.

Follow-up

Amoxicillin, ephedrine nasal drops and menthol and eucalyptus inhalationswere prescribed for five days. The wound healed without difficulty, and therewas no residual fistula. The patient accepted that the problem arose throughmisfortune rather than negligence.

1 1 9

1 20


Chronic oro-antral fistula

was generally fit, although occasionally takingl orazepam for anxiety. She agreed to have the

SM, a 51-year-old school secretary, had a dental

fistula closed under local anaesthesia.clearance, followed by generally satisfactoryhealing. However, a socket persisted in the upper

Note: The wisdom of undertaking the closurel eft molar region, through which she noticed the

of a longstanding fistula in general practice haspassage of air when blowing her nose. There was

been questioned. This case is presented mainly tosome pain in this region after the extractions, but

demonstrate the important surgical technique ofi t gradually settled. When examined in the clinic

buccal flap advancement, but closure of a smallsix months later, a fistula could be probed. There

defect in an asymptomatic patient does notwas little local inflammation and no discharge. She

require the intervention of a specialist.

Oro-antral fistula


A periapical film shows the persistent outline ofa molar socket with an impression of discontinu-i ty of the outline of the sinus floor. In cases suchas this, periapical films serve mainly to excludethe presence of a retained root.

The occipito-mental view shows partial opacity ofthe left maxillary sinus. This is probably due toswelling of the sinus lining where contaminationthrough the fistula is most frequent. The rightsinus is quite clear.

1 2 1

Operation

Operation site

The alveolar mucosa is pale and healthy, and the ridge still demonstratesthe outlines of the sockets of the teeth extracted six months previously.

A probe (in this case, the spike end of a Mitchell's trimmer) is used todemonstrate the site of the fistula - at the base of a small depression ofthe ridge.

Incision

The epithelialized edge of the fistula is first excised, using a no. I I blade.


Oro-antral fistula

An incision incorporating this defect is made for about 1.5 cm along thecrest of the alveolar ridge. From each end a relieving incision is made,starting at a right angle and then diverging into the buccal sulcus, so as togive a broad base for the flap.

Reflection

A Howarth's periosteal elevator is inserted subperiosteally and used toseparate the flap from the bone, starting buccally and working up beneaththe attached gingival edge.

The underlying bony defect can now be seen, partially occluded by inflamedsinus lining.

1 23


The periosteum is deeply undermined to free the flap.

The flap can be replaced across the defect, but broad surface contact canonly be obtained at the cost of tension across the wound.

Periosteal incision

The tough inelastic fibrous periosteal layer is incised to relieve the tension.

1 2 4

Oro-antral fistula

The buccal mucosal layer is extremely elastic and easily extensible. The cutedge of the periosteum can clearly be seen, as can the degree of releasealready achieved. The anterior edge is finally severed with the scalpel.

Traction on the flap with the tissue forceps gives a feel for the degree ofmovement and, when the periosteal incision is completed, the flap can beadvanced, without creating tension, across the defect and beyond. Evenl arge defects can be closed readily in this way.

Closure

The first two sutures are placed obliquely across the angles of the incisionto anchor the corners of the flap.

1 2 5


The next three sutures close the anterior and posterior relieving incisions.

Final broad approximation of the edges is achieved by the insertion of ahorizontal mattress suture.

The ends of this suture are cut longer than the others so that they canbe identified at the time of removal. The precise number and placementof sutures varies from case to case, but this general order will suit formost.

Follow-up

Amoxycillin, ephedrine nasal drops and menthol and eucalyptus inhalationswere prescribed for five days. Sutures were removed 10 days later, andsatisfactory healing was achieved.

1 26


Top row, l eft to right

- 2 towel clips- metal aspirating cartridge syringe- disposable needle-

cartridges of 2% lidocaine with 1/80 000 epi-nephrine

- mirror- probe- tweezers-

5 gauze swabs, 10 cm X 10 cm

Third row, left to right

Warwick-James' elevators - right, left andstraight (US: Miller no. 73 and no. 74 or Pottselevators)2 Coupland's chisels - medium and small (US:no. 301 and no. 34S elevators)2 Cryer's elevators - right and leftupper universal extraction forcepsrongeursdisposable plastic irrigating syringe

Second row, l eft to right Bottom row, left to right

aspirator tip and matching stiletteKilner cheek retractor (US: Minnesota retrac-to r)scalpel handle with disposable blade (no. 15)2 Howarth's periosteal elevators (Howarth'snasal raspatory; US: Molt no. 9 periostealelevator)Mitchell's trimmer (Cumine scaler is similar)straight handpieceno. 6 rose-head bur (steel or tungstencarbide; US: no. 6 round bur)no. 6 tapered fissure bur (tungsten carbide;US: no. 701 tapered fissure bur)cloth sleeve2 plastic gallipots

small mosquito artery forcepslarge straight artery forcepsGillies' needleholderMayo needleholderGillies' tissue forcepsdisposable suture, 3/0 silk on 3/8 cutting needlesmall sharp-pointed scissors

1 28

Appendix A Instruments 1 29

Appendix BMedicaments andmaterials

Only a few simple, inexpensive medicaments and materials arerequired. All are available from a pharmacist if not already in thesurgery stock.

sterile surgeon's glovessterile normal saline - for irrigation of wound0.2% chlorhexidine - for preparation of skin and mucosa orpostoperative irrigationbuffered formal saline (in suitable containers) - for pathologicalspecimensgauze swabs, 10 x 1 0 cmperiodontal packing materialcotton wool rollssutures - silk, gutI cm ribbon gauzei odoform paintsterile resorbable oxidized cellulose

Appendix CSamplepre-operativeadvice leaflet

Important information for patientswho need wisdom teeth removed

This leaflet is to help you understand and remem-ber what you have already been told in our clinic.Please read it carefully.

they can be removed. Problems with wisdomteeth tend to get worse as you get older.Removing them is easier when you are young.Healing will also be quicker.

The troublesome wisdom tooth

What should you expect afterremoval of impacted wisdom teeth?

Your wisdom teeth are the last teeth to emergefrom your gums. This usually happens during yourl ate teens, or `the age of wisdom', which givesthem their name. Often there is not enoughroom for them in the jaw. They may becometrapped, or impacted, in the jaw bone and gums,and remain partly or fully buried.

Why do we remove impacted wisdomteeth?

The gum around an impacted tooth may becomei nfected. This may cause severe pain, swelling, jawstiffness or even general illness.

An impacted tooth may decay even though iti s not visible in the mouth. This can cause pain.I t may also damage adjacent healthy teeth or pushthem out of position.

You may have had trouble already and beenadvised to have your wisdom teeth removed. Ifyou wait until they do cause trouble, you mayhave to be treated for pain and infection, before

The removal of an impacted wisdom tooth is nota simple extraction. It is a small operation. Somebone may need to be removed to allow removalof the tooth. Stitches are often needed too.

As with any other operation you must expectsome pain afterwards. Your face will probablybe swollen for a few days. You may also havesome stiffness in your jaw joints. This is just thebody's way of protecting the healing gumagainst too much movement. It may makeeating and swallowing difficult for a while.Sometimes there will be some bleeding after-wards. We try to be sure this has stoppedbefore you go home. You may also have somebruising on your face. This is nothing to beconcerned about. It will disappear in a week orten days.

The amount of discomfort and how long it lastsvaries. If your teeth are removed with an injec-tion in the mouth you should expect to beuncomfortable for at least a day or two.

I f you have your teeth removed in hospital,there will be the added effect of the generalanaesthetic. You may need a few days to rest andrecover.


Sometimes healing takes a little longer.Someone is always available to help ifneeded.

Are there any risks?

There are always some risks involved in surgery.Removal of wisdom teeth is no exception. Theremoval of a wisdom tooth leaves a socket in thebone to heal. Sometimes healing may be delayedi f the blood clot in the socket is dislodged orwashed away. This may prolong your pain. It canbe treated to make it more comfortable for youi f you contact us, or your dentist, for help. Thereare two nerves very close to your lower wisdomteeth. They supply feeling to your teeth, lower lipand side of your tongue. The greatest care is takento protect these nerves while your teeth are

removed, but sometimes they may be unavoidablyi njured, causing temporary tingling or numbness.I t is rare for this to last more than a few weeksat most. It does not alter your appearance. In anextremely small number of patients, some, or all,of the numbness may remain permanently.

You must balance these small risksagainst the benefits of removing yourwisdom teeth.

The decision to have your wisdom teethremoved is always yours.

If your teeth pose any special risks thesewill be discussed with you. Any questionsyou may have will be answered as fully aspossible.

Once wisdom teeth have been removedthey do not grow again. The benefits willbe life long.

1 32

Appendix DSamplepostoperativeadvice leaflet

Recommendedreading

Medical background

Davidson Sir Stanley, The Principles and Practice of Medicine, 17thedn (Churchill Livingstone: Edinburgh 1995).

Scully C, Cawson R A, Medical Problems in Dentistry, 4th edn(Wright: Oxford 1998).

Dental Practitioners' Formulary with British National Formulary,Number 32, 1996-8 (BDA, BMA and RPSGB, London) (ThePharmaceutical Press: Oxford 1996).

Surgical texts

Barnes I E, Surgical Endodontics corrected reprint (MTP Press:Lancaster 1991).

Howe G L, Minor Oral Surgery, 3rd edn (Wright: Bristol 1985).MacGregor A J, The Impacted Lower Wisdom Tooth (Oxford

University Press: Oxford 1985).McGowan D A, Baxter P W and James J, The Maxillary Sinus

(Wright: Oxford 1993).Seward GR, Harris M, McGowan D A, Killey H C and Kay L W,

An Outline of Oral Surgery (Wright: Oxford 1998).

nonsteroidal anti-inflammatory agents(NSAIDs), 10

notes, clinical, 9

oozing, control of, I Ioro-antral fistula, 115-26orthodontic surgery, 59-72

exposure of upper canines, 68-72removal of supernumerary teeth,

64-7upper labial fraenectomy, 59-63

oxidized cellulose gauze, I I

packing material, 130pain, postoperative, 10painkillers, 9, 10, 133palate, fibro-epithelial polyps, 112-14paracetamol, 133pathological specimens, 8patients

consent, 5, I Ipostoperative care, 9, 10-11, 133preparation, 5

periapiczl cysts, 99periosteal elevators, 7, 128pleomorphic salivary adenoma, 112polyps, palatal fibro-epithelial, 112-14postoperative care, 9, 10-11, 133preparation, 5-6probes, 128prosthodontic surgery, 73-89

excision of denture-inducedhyperplasia, 81-4

removal of fibrous tuberosity,77-80

smoothing of edentulous ridge,73-6

unerupted maxillary canine, 85-9

radiographs, 3, 5, 11, 26-7reflection, 7residual cysts, 99resorbable oxidized cellulose, 130retained roots, 15-25retractors, cheek, 7, 128ribbon gauze, 130ridges, edentulous, 73-6rongeurs, 7, 128root-filling, incisors, 58roots, retained, 15-25rose-head burs, 128

saline, 130salivary glands

adenoma, 112mucocele, 102

scalpels, 128scissors, 128sedation, 5soft tissue biopsy

hyperkeratotic epithelium, 107fibro-epithelial polyp from cheek,

1 08-IIfibro-epithelial polyp from palate,

1 1 2-14sterilization, instruments, 5stiffness, postoperative, 131stress, 4suction, 5-6supernumerary teeth, removal of,

64-7

sutures, 8, 128catgut, 103, 130mattress, 72, 89postoperative haemorrhage, I Iremoval, 10silk, 130

swabs, gauze, 128, 130swelling, postoperative, 10, 131syringes

aspirating, 128i rrigating, 128

third molarsremoval of, 26-53unerupted, 18-21, 44-53

tissue forceps, 128tongue

retraction, 7towel clips, 128trismus, I Ituberosities, fibrous, 77-80tweezers, 128

universal extraction forceps, 128upper labial fraenectomy, 59-63

Warwick James' elevators, 128wounds

closure, 8incision, 7infection, 10postoperative care, 133suture removal, 10

X-rays, 3, 5, 11, 26-7

zinc-oxide/eugenol paste, 10

1 36 Index

atlas of minor oral surgery

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