DETAILED TREATMENT PLANNING (MANDIBULAR)

Administration of anesthesia

• Anesthesia: 2% lidocaine with 1:100,000 epinephrine: maximum of 9 carpules

• Computation for maximum allowable dose and maximum number of cartridge can be used: 9 cpl

• Anesthesia Technique
o Inferior nerve block and lingual nerve block
▪ Long needle
▪ Penetration depth: 2/3 to ¾ (deepest part of the pterygomandibular raphe)
▪ Bone contact too soon (too far anteriorly)- bring the syringe barrel more anteriorly
on the contralateral, to position the needle more posteriorly
▪ Bone not contacted (too far poteriorly)- bring the syringe barrel more posteriorly
on the contralateral, to position the needle more anteriorly
▪ Deposit 1.5 mL
▪ Withdraw needle until half of its length remains, place the syringe barrel in between
canine and lateral incisor.
▪ Deposit the remaining anesthesia.
o Left long buccal nerve block
▪ Long needle
▪ Penetration depth: 1-2 mm (buccal and most distal to the last molar)
▪ Deposit 0.3 mL
o Buccal local infiltration
o Lingual local infiltration
▪ Anesthetize through the interdental papilla on both mesial and distal aspect of tooth
treated
o (In case) Mental nerve block
▪ 0.6 mL
▪ Penetration depth (5-6 mm)

PLAN: Closed Extraction of tooth

· Establish finger guard with left hand

· Loosen soft tissue attachment from the cervical portion of the tooth
· Luxation of tooth with an elevator (palm grip and finger guard)- lever principle
· Adaptation of the forceps to the tooth
· Luxation of the tooth with forceps
· Removal of root fragment from the socket
· Check if the root is intact and check the socket for granulation tissue, debris and fragment
· Initial control of hemorrhage
· Suture: Figure of 8 on each socket (tooth #16 and #15).
· Post-operative Instructions and Medications
• Mefenamic acid 500mg Tablet every 6 hrs or as needed for pain.
• Celecoxib 200mg Tablet every 12 hrs or as needed for pain.
 PLAN B:

- Open Extraction
· Flap: Full-thickness mucoperiosteal flaps- includes surface mucosa, submucosa and periosteium.)
· Developing a flap: Use No. 15 blade on No.3 scalpel
· Incise and reflect to provide adequate visualization and access. Make a one firm and continuous
stroke incision.
o Principles of flap design
o Principles of incision
o Reflection of flap using Molt 9 mucoperiosteal elevator
· Removal of tooth
- Option 1: same with the closed extraction after opening
- Option 2
o Remove underlying bone
- Use no. 8 round bur
- Let the assistant irrigate the site with NSS
- Remove labiocortical bone
- How much to remove: mesiodistal width of bone removal should be approximately
the same as the mesiodistal dimension of the tooth root itself
- Rationale: creates a clear path for the removal of the root in the labial direction
- Vertically, bone should be removed approximately one-half up to two-thirds of the
length of the tooth root
o Once labial bone has been removed, apply the straight elevator on the palatal aspect of the
tooth to displace the tooth root in the buccal direction
- Establish finger guard
o A purchase point can be made if the tooth is still difficult to extract after bone removal
- How: Made using a surgical round bur at the most apical portion of the root and should be
about 3mm in diameter, deep enough to allow the insertion of instrument. A crane pick
elevator can be used to elevate the tooth root from its socket.
- Option 3
o Remove small amount of crestal bone
- Use no. 8 round bur
- Let the assistant irrigate the site with NSS
- Remove small amount of labiocortical bone
o Sectioning of the tooth
- Using no. 8 straight burr or no. 557 or 703 fissure bur
o Luxate the roots with a straight elevator
o Delivered each root with Cryer elevator using rotational movement
· Check if the root is intact and check the socket for granulation tissue, debris and fragments
o Use periapical curette performing outward motion.
o Irrigate the area using the asepto syringe with saline water.
· Initial control of hemorrhage
o Use 2x2 wet gauze soaked in NSS placed over the extraction socket and apply force for 30
seconds.
o Let the patient bite the gauze.
· Suture: Continuous locking suture

- Simple Alveolectomy
- Suture: Continuous Locking Suture
· Starting with the fixed soft tissues, go on to the mobile soft tissues. Begin at the release incision's most
posterior-to-anterior location.

- Post-extraction tooth socket care and medication

- Celecoxib 200mg Tablet every 12 hrs or as needed for pain.