Subject: management of 3rd molar postoperative care

Date:9/11/2008

Doctor: Ma’amon Rawashdeh Done

by:Sanaa Al-ademi

References: contemporary and minor oral surgery for Geoffery _L

howe.

Last lecture we talked about how we assess the 3rd molar for
extraction , then we talked about general factors like age ,
medical condition , local factors including clinical examination ,
radiographic assessment and about white line and Pell and
Gregory classification, and these two classifications will give us
an idea about the dense of impaction and the position of the 3rd
molar , also about the axial inclination(mesioangular ,
distoangular ,horizontal or vertical).

Now about position of the 3rd M we said that it could be partially

covered by bone , completely covered or fully erupted (not
covered by bone).

For example:

When we talked about Pell and Gregory classification we said

that :

Pell and Gregory class A: occlusal surface of the 3rd M is at the

same level of the occlusal surface of the 2nd M.

Class B: occlusal surface of the 3rd M is between the occlusal

surface and cervical line of the 2nd M .

Class C:occlusal surface of the 3rd M is below the cervical line of

the 2nd M (and this indicate how deep is it ).

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White line : is a line over the occlusal surfaces of the 1st ,2nd and
3rd molars and it gives you an indication of the inclination of the 3rd
M , whether its mesioangular ,distoangular, vertical or horizontal.

Amber line: it’s an imaginary line from the retromolar area and
goes toward the interproximal between the 1st and 2nd molars . by
this line any part of the tooth in this area will appear in the mouth
or in the soft tissue and any part of the tooth below this line is
covered by bone.

Now let’s talk about Pell and Gregory classification :

Class 1: the whole occlusal surface of the 3rd M is anterior to the

ascending ramus , which means it’s not covered by bone and it
might be completely erupted .

Class 2: up to half of the crown is in front of the anterior border of

the of the ascending ramus and this is more difficult to remove
than class 1 .

Class 3: the whole tooth is posterior to the anterior border of the

ascending ramus and this is the most difficult to remove.

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 Class 2

Class 1

Class 3

Now the Red line :its perpendicular dropped from the amber line
to a point of application for elevator .with exception of disto-
angular impactions, the amelocemental junction .

The longer the red line the more difficult the extraction to perform , coz of
more bone is covering the tooth so more bone is required to be removed.

Class 1
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Root morphology of impacted 3rd molar :

 A tooth with not completely formed root will be easier for

extraction than completely formed root.

 But in case of unformed root (just crown, like ball and

socket), it will be more difficult to be removed .

 Conical roots are easier than curved bulbous roots .

 Large periodontal space will make our extraction more

easier.

Lack of root development. If extraction is

Roots that are two thirds formed, which
attempted, crown will roll around in crypt, which
are less difficult to remove.
makes it difficult to remove.

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 Wide periodontal ligament space.
Fused roots with conic shape. Such space makes extraction process
less difficult.

Shape of the crown of the 3M:

If you have a small crown its removal will be easier than large
square crown with prominent cusps.

Note: when we have bulbous blunt end we suggested that tooth has more
than one root and that’s more difficult.

Size of the dental follicle:

Dental follicle is a space around the crown ,, the larger the
follicular space the easier the extraction as less bone need to be
removed.

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 Large follicular sac. When space of sac is large,
amount of required bone removal is decreased.

Density of the surrounding bone:

Q: which determine the bone is dense or not?

A: this varies between individuals and with age, younger people

have more elastic bone because they have wide narrow spaces ,
this means the percentage of cancellous bone is higher.

More cancellous bone more elastic and this is in younger people ,

also the density affects by the site of bone.

Q: whats the difference between the maxillary and mandibular

bone?

A: maxillary bone is less dense , coz its contain more cancellous

bone.

Position and root pattern of the 2nd molar:

 if the M2 distally tilted toward the M3 it will lead to tooth
impaction and prevent the eruption of the M3.

 If the crown of the M2 heavily restored we might fracture it

during surgical procedure.

 If the M2 has a simple conical root it will dislodged very

easily during removal of M3 using an elevator, especially if
the 1st molar missing.

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 Relationship to the inferior dental bundle:
Q:How can we describe the different positions of the inferior
dental canal to the M3? On X-ray (OPG or PA)

 Superimposition: on x-ray you might see that inferior

dental canal is coming through the root.

 Grooving: inferior dental canal (IDC) might grooving the

root of M3

 Perforation: inferior dental canal perforating the roots of

M3

Q:how can we differentiate between superimposition, grooving

and perforation?

A:in IDC we have upper line presenting the roof and lower line
presenting the floor and if we look to the radiograph and see the
two lines are clear and uninterrupted that mean its
superimposition. While in grooving we see the upper line is
interrupted. In perforation the upper radio opaque line and the
lower radio opaque line are both interrupted and the outline will
appear narrow.

So this is how we describe the position of the IDC to the M3 and to

do this we need good quality radiograph .
NOTE:The surgical procedure becomes more difficult as the M3 is
close to the IDC.

Nature of the overlying tissues:

 Soft tissues impaction :superficial portion of tooth is covered
by soft tissues only.

 Could be partially covered by tissues and bone: superficial

portion of tooth is covered by soft tissues, but the height of

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 the tooth’s contour is below the level of the surrounding
bone.

 Completely covered by bone (most difficult ,coz its complete

bone impaction and in order to remove it we need to remove
bone first)

Soft tissue impaction in which crown of tooth is covered by

soft tissue only and can be removed without bone removal.

Partial bony impaction in which part of tooth, usually posterior

aspect, is covered with bone and requires either bone removal
or tooth sectioning for extraction.

Complete bony impaction in which tooth is completely covered

with bone and requires extensive removal of bone for
extraction.

Factors that Make Impaction Surgery Less Difficult:

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Factors that Make Impaction Surgery More Difficult:

Surgical procedure:
The principles and steps for removing impacted teeth are the
same for other surgical extraction:

1. Local anesthesia (1st step to perform surgery)

Q:Which nerves we need to anesthetize in order to extract wisdom

tooth ?

A: inferior dental nerve, lingual and long buccal nerves.

2. Reflecting adequate mucoperiosteal flap: to be able to

see the surgical area .

Q: what are the types of flaps?

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A/ envelope, circular and classical three sided flaps.

3. Bone removal: bone removal is acquired to:

 Expose the crown.

 Create a gutter around tooth neck.

 Create a point of application for an elevator.

We can remove bone by :

• Chisel.

• Surgical bur (drilling), the speed of the high speed hand

piece is (150000-250000), when we use high speed hand
piece air will pull into the tissues and cause (emphysema ),
so we use special surgical drill.

4. Sectioning the tooth: why we section the tooth ?

to avoid removal of bone , saving the hard tissue and if the

tooth has unfavorable roots or different lines of withdrawal so
it’s better to section the tooth than remove bone .

5. Delivery of the tooth: we take the crown first then the

roots
First remove bone .

A/divide the crown

B/remove the 1st root

C/ remove the 2nd root

This arrow indicates the line of

withdrawal.

Line of withdrawal is a line along

which u can deliver the tooth or
the roots

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Wound debridement and wound closure:
If we used surgical bur you may have follicular remnants so we
need to remove it, irrigation with normal saline and use a
curette ,also we can have sharp bony edges (smooth it with bone
file )

Now what are the types of sutures?

 Resorbable

 Nonresorbable

Postoperative squelae and care:

 You should tell the patient how can he care of himself .

 Give the patient the proper instrumentation .

 They should predict what they are going to experience after

the surgery and explain why this happen for them and if
these complications happen how to they can manage them
too.

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  We need to give these instructions in a language they
understand

 You should mention to the patient :

• Ecchymosis

• Swelling

• Trismus

• Diet

• Oral hygiene

• Infection

• Parasethesia of lip or side of tongue.

Postoperative care following oral surgical procedures:

1.control of postoperative bleeding:

We should tell the patient after extraction it’s reasonable to
expect that there will be certain amount of blood during the 1st 24
hours following the surgery. What happens is that the heme part
of the blood is a stain ,so it can stain the saliva , so blood
consume saliva production and after extraction there will be more
saliva production and this large amountof saliva is stained by
blood(heme) so it will appear red and this give the patient the
impression of that he is bleeding which is in fact a stained saliva
,so usually we ask the patient to:

 Bite firmly on gauze for at least 30 minutes.

 If bleeding starts again , bite again on gauze for 30 minutes.

 No strenuous exercise, because increase circulation may

result in bleeding .

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  Not to smoke for at least 12 hours , because this will promote
bleeding and interfere with healing( negative pressure)

 Not to spit during the first 12 hours after surgery (negative

pressure)

 Not to suck on a straw when drinking (negative pressure)

2.Ecchymosis:
Is a collection of blood in submucosally and subcutaneously
appears as :

 Bruise in the oral cavity.

 Bruise in the face .

You must reassure the patient that its harmless .

3.Swelling/edema:
We said in surgical procedure we make flap ,removing bone,
dividing the tooth after that we smooth the bone and all of this
will lead to tissue edema and swelling . in most cases swelling
usually reaches it’s maximum 48 to 72 hours after surgical
procedure, so we will explain this to the patient and this swelling
differs in different individuals ,some people will have big swelling
and others will have large swelling.

We can’t standardized the patients but in a certain degree

To minimize the swelling:
we can standardize the procedure.
• 1st day: Ice pack for 20 mints, stop for 20 mints for 1st 24
hours.

• 2nd day: neither ice or heat.

• 3rd day: application of heat.

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4.Trismus: Is limitation in opening the mouth which is due to
inflammation involving the muss of mastication , it could be slight,
small or he cant open his mouth totally .

Possible causes of trismus:

 Multiple injections , like when we do ID block the needle goes

through the muscles and this cause bleeding to the muscle.

 Surgical extraction of impacted mandibular third molars,

because the inflammatory response to surgical procedure is
sufficiently widespread to involve several muscles of
mastication.

To prevent alarm, patients should be warned that this

phenomenon may occur.

5.Diet:
Patients who have had extractions may avoid eating because of
local pain or fear of pain when eating. Therefore they should be
given very specific instructions regarding their postoperative diet.

We recommended soft diet or sometimes it’s simple extraction

and he can eats as usual, but in wisdom tooth extraction patient
may has trismus , swelling …. ,so the only things that patient can
tolerate are soaps.

6.Oral hygiene :Patient should be advised that keeping the

teeth and mouth reasonably clean results in a more rapid healing.

 On the day of surgery

• Brush the teeth away from the area of surgery in the

usual fashion .

• Avoid brushing teeth immediately adjacent to the

extraction site to prevent bleeding and pain.

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  On the following days(2 to 4 days post extraction):

• Gentle rinse with warm salty water:

a. As warm (not to burn tissues )as possible.

b. As frequent as possible.

c. As long as possible.

7.Control of postoperative pain and discomfort:

We can give him revanin.

8.control of infection:
We can give antibiotic as a prophylaxis or for already established
infection.

9.Postoperative follow-up visit:

To check the patient’s progress and for suture removal.

The End
Plz refer to the books and handout.

Your colleague:

Sanaa Al ademi

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