Minor Intraoral Surgical Procedures

Dr Tegegne,RI

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 Outlines
• Introduction
• Principle of Minor Surgery
• Minor Intraoral Procedures
• Types of Intra Oral Incisions
• Intraoral Flap Types
• Surgical management of Impacted tooth

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 Introduction
• Minor oral surgery comprises of those surgical
procedures which can be comfortably completed
within 30 minutes.
• Include
Simple exodontia
complicated surgical exodontias
Elimination of small lesions in the oral
cavity.

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 Basic Purpose of surgery

Includes
 Elimination of disease
 Prevention of disease
 Removal of damaged tissue
 Improvement of function& esthetics

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 Principles of oral surgery

o Developing a surgical diagnosis

o Basic necessities for surgery
o Aseptic technique
o Incision planning
o Flap design
o Tissue handling
o Hemostasis

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Dead space management
Decontamination and debridement
Suturing
Edema control
Postoperative infection control
Patient’s general health and nutrition
Follow-up.

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 1.Developing surgical Diagnosis

Before undertaking the surgery, the clinician

should perform these steps:
• First identify the clinical problem
• Carry out thorough logical reasoning and use
the available data
• Establish the relationship between the
individual problems

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• Obtain the pre-surgical evaluation data
• The thorough history of lesion
• Patient’s physical, laboratory& imaging
data
• Possible etiological factors for the lesion
development

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 Minor Intraoral procedures

1. Incision &Flap
• Most commonly on buccal side flap raised are
envelope type
• Features of this flap
• Crevicular Incision around neck of teeth
• Edentulous area incision is continued over edentulus
alveolar ridge

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– Base of flap should be broader than margin
for good blood supply.
– No releasing incision is given in palate

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 Cont.
– Incision is placed in such a way that
complete interdental papilla is included in
the flap for proper interdental suturing.
– All incision lines should be supported by
bone

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 2.Incision & drainage
• When swelling localizes into soft, fluctuant,
palpable mass, it should be incised and
drained to reduce swelling and pain.
• Area is anaesthetized by IAN or infiltration not
in swollen tissues.
• Spray topical anesthetic to swollen area

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 Cont.
• Using scalpel enter swelling through center of
soft fluctuant mass.
• If swelling is hard or indurated bathe the
tissue in saline rinse for 5min. every hr.

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 3.Incisional biopsy
• A part of lesion is removed to confirm
Diagnosis

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 4.Excisionaal biopsy
• In small lesion, whole lesion with normal
tissue is removed.
• Specimen is placed in 10% formalin for
transport to laboratory.
• If lesion is benign and do not interfere with
function it can be removed after child grows.

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 5.Excision of Mucocele
• Elliptical incision around the lesion and is
excised
• First superficial incision is placed over the
lesion. Then lesion is separated on either
sides and is excised.
• In both cases minor salivary gland around the
lesion is excised.
• If lesion is deep, tissues are sutured.

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 6.Marsupilization
• Removal of a part of lining, then lesion shrinks
in size
• In case of large cysts or cyst interfering the
vital structures marsupliazaion should be
done.
• Lining is sutured to edge of mucosa.
• Gauze is placed in the cavity
• Patient should keep cavity clean.

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 7.Enucleation
• Lesion is removed along with lining.
• Envelope flap is raised.
• If bone is covering cyst, it is removed
• Cyst lining is separated from bone and is removed.
• Spoon excavators are used to separate lining from
bone.
• If impacted tooth is there it should be removed

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 8.Frenectomy
• Frenectomy is done in following cases
– Gingival recession
– Diastema formation
– Accumulation of debris by opening of sulcus.
• Technique: complete excision.
• Incision perpendicular to frenum is done in
mucobucal fold

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21
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 Cont.
• It is extended around frenum in both direction
such that bell shaped defect is formed.
• The incision is carried out in bone.
• Tissue is then excised.
• If vestibule is not deep enough, it should be
deepened.
• Sutured & Periodontal pack can be given and
is removed after 2 weeks.

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 Apicoectomy
• Resection of root
• Indications:-
– Apical discharge or perforation
– Unsuccessfully treated apical accessory canal.
• Technique:- Determine level at which the root
to be amputated.
• Should remove unfilled portion of root canal.

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 Cont.
• If periapical cyst or granuloma is there, it
should ensure complete removal.
• Mucoperiosteal flap is elevated.
• Incision is made up to bone.
• Soft tissue should be supported by healthy
bone when replaced.
• Make an opening in labial plate with bur or
chisel.

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 Cont.
• Amputate root with cylindrical bur.
• Cyst, granuloma are enucleated by curettes.
• Control bleeding by pressure or cotton pellets
in epinephrine.
• Suture with silk or catgut
• Maintain firm pressure over area to prevent
hematoma.

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 Trans alveolar Extraction

 Exodontia is painless removal of teeth with

minimal injury to surrounding tissue
 Trans alveolar extraction is the method used for
- Recovering the roots that are fractured
during routine extraction of teeth
-Impacted tooth
- It consists of removal of some amount of the
bone investing the roots
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 Indications for trans alveolar surgical Extraction

• Any tooth which offers a lot of resistance for

elevation technique
• Retained roots which cannot be grasped by
the forceps or delivered with an elevation
technique

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• Hypercementosis/ankylosis of a tooth
• Geminated/Dilacerated tooth
• Radiographic evidence of complicated/difficult root
• Previous history of difficult of extraction
• Any large restoration with root canal therapy
— brittle teeth

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• Pattern or roots with unfavorable or
conflicting lines of withdrawal
• Sclerosis of the bone
• Teeth associated with pathology—periapical
granuloma ,cyst, tumor .
• Impacted teeth, embedded teeth

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 Pre-extraction Clinical assessment

• Presence of Infection
• Access to the tooth
– Oral opening of the patient—adequate
– Restricted—due to trismus, TMJ disorders
muscle fibrosis, etc.
• Hypomobility of the tooth
—hypercementosis, ankylosis

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• Condition of the crown
– Marked attrition—usually with calcified pulp
chamber, brittle tooth
– Presence of extensive caries, large
restorations
– Previous history of endodontic treatment

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• Tooth alignment in the arch
• Age of the patient—old age—sclerosis
• Embedded roots.

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 Indications for preoperative radiographs

• History of difficult or attempted, failed

extraction
• A tooth which is abnormally resistant to
elevation or forceps extraction
-Hypercementosis, ankylosis
-Dilacerated roots
-Extra long roots

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• Any teeth or roots in close relationship to
either the maxillary sinus or inferior dental
canal or mental nerve
• Any teeth with history of trauma
• Any partially erupted, unerupted tooth,
missing tooth, supernumerary tooth, retained
root, lingually placed tooth, impacted tooth

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• Heavily restored tooth or pulpless tooth
• Any condition, which predisposes to dental or
alveolar abnormalities like
-Osteitis deformans
-Hypercementosis of the roots
-Osteoradionecrosis
-Osteopetrosis

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 Pre-extraction radiological evaluation

• Relationship with associated vital structures

-Maxillary sinus
- Inferior alveolar canal
- Mental nerve
-Adjacent teeth roots.
• Configuration of roots
-Number of roots
-Width greater below CE junction than at the
CE junction
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• Size of roots
• Curvature of roots, divergence of roots
• Length—thin, tapered roots
• Resorption of roots
• Shape of the individual root
• Hypercementosis, ankylosis, root caries
• Previous endodontic therapy.

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• Condition of surrounding bone
• Density of bone surrounding the tooth
Dense bone—condensing osteitis,
Sclerosis will increase the difficulty

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 Serial Extractions

• Single sitting procedure for multiple adjacent

teeth
• With slight modification of routine extraction
pattern
• Facilitates a smooth transition from a
dentulous to an edentulous state.

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• Soft tissue reflection is to form a small
envelop flap, exposing a crestal bone prior to
extractions
• After extractions, the ridge is checked for any
sharp bony spicules or undercuts
• Alveolectomy/plasty—suturing

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 Order of Multiple Teeth Extractions

• Maxillary posterior teeth

• Maxillary anterior teeth
• Maxillary first molar
• Maxillary canine
• Mandibular posterior teeth
• Mandibular anterior teeth
• Mandibular first molar
• Mandibular canine.
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 Complicated Extractions
• Unplanned extractions—an event that can
convert an uncomplicated extraction into a
complicated one
• Proper pre extraction assessment of a difficult
case

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• Any suspicion that the tooth/bone will break
—think and plan
• Properly planned surgical extraction is always
less traumatic
• Do not shy away from complicated extraction
• Proceed as predicted with fewer surprises

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 Postage Stamp Technique
for Trans alveolar Extraction

• Helps in controlled removal of bone

• Preventing uncontrolled fracture of the
alveolar process
• Allows judicious use of elevators & forceps
• Allows tooth sectioning in a controlled manner
• Facilitating predictable result .

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 Steps of surgical exodontia
• Local anesthesia and incision
• Reflection of mucoperiosteal flap and bur
holes are made
• Connected bur holes to create a window

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• Exposing the roots
• Sectioning the crown and roots for easy
removal
• Transalveolar extraction of a root piece by
planning small envelop flap

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 Three Basic Principles of surgical exodontia

• Obtain adequate access

• Create an unimpeded path of removal
• Use controlled force

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 2.Basic necessities for surgery

• The main requirements for any surgery are

adequate visibility and assistance.
• Adequate visibility will depend on
-Adequate access
-Adequate light source
-A clean surgical field
-free from excessive bleeding

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 Adequate Access

Adequate access will require:

• Comfortable patient
• Adequate oral opening
• Proper retraction of the tissues by assistant
• High volume suction
-hemostasis of the operating field.

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 Patient

• Comfortable, mentally and physically

• Alleviation of fear, assurance
• Informed consent
• Minimum amount of draping
• Rinsing with antiseptic mouth wash.

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 Equipment

• The instrument kit should be prepared and

sterilized
• Effective light source and suction

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 Assistant

• Four handed surgery with the help of a skilled

assistant.
• The assistant should be familiar with the
procedure
• Should anticipate the surgeon’s needs.

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 Surgeon’s & Assistant’s Preparation

• Wearing of protective eye glasses

• Wearing mask
• Wearing surgical cap
• Wearing gloves

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 3.Planning of an Incision

• Incision is defined as ‘a cut or a wound

deliberately made by an operator in the skin
or mucosa using a sharp surgical blade,
cautery so that the underlying structures can
be exposed adequately for surgical access.
• Thorough anatomical knowledge is essential.
• Incision is placed parallel to vital the
structures

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• Extraoral incisions should be planned along
the ‘Langer’s lines’ of the normal skin tension
or creases, so that minimum scar formation
will be seen.
• Intraoral incision should be planned to
prevent subsequent scar contraction or
fibrosis which will prevent normal functioning
of the oral soft tissues.

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• The sharp blade of a proper size and shape
should be selected.
• Essential for clean, single stroke incision
without much tissue damage

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• Incision should be placed on the sound bone
• Either pen (intraoral incision) or table knife
(extraoral incision) grasp is used with proper
support and pressure
• The skin or the mucosa to be incised, should
be stabilized with finger pressure to guide the
passage of the blade

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• A firm continuous stroke should be used.
• Long continuous strokes are preferable to
short interrupted ones
• No sharp angles, the change in direction is
accomplished by a gradual curve.

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• Sharp angles tend to produce slough due to
poor circulation
• May lead to extensive scarring

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 Incisions in the Oral Cavity

• It is desirable to incise through attached

gingiva and over a healthy bone.
• The suture line should have adequate bone
support underneath for uneventful healing
• Incisions placed near the teeth for extractions
should be made in the gingival sulcus

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• Incisions involving the reflection of the
mucoperiosteal flap are direct, straight line or
curvilinear
• Taking the shortest distance vertically through
the tissues

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• Indirect incisions are used to access the areas
like soft palate, tongue, cheeks, lips, floor of
the mouth
• Integrity of the interdental papillae should be
maintained as far as possible
• Blood supply to the incision should be
adequate

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• Incisions should be at right angles to mucosa
- Prevent shelfing edges that might cause
necrosis of the undermined part

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 Contraindications for Placement of Incision Lines

Avoid placing incisions

• Over the canine prominence—soft tissue
defect will be created due to bony
fenestration
• Vertical incision in the mental nerve region
• On the palate—near the greater palatine
vessels

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• Through incisive papillae
• Over bony lesions—dehiscence
• Over freni
• Vertical incisions on the lingual side of the
mandibular arch.

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 Types of Incisions

1.Horizontal/ envelope incision

• Is used along gingival margin either mesially
or distally.
• Two types of horizontal incisions
-Internal bevel
- Crevicular

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 Internal bevel incision
 starts at distal area from the margin & is
aimed at exposing bony crest& root
 This is also known as first incision.

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Crevicular incision
• starts at the bottom of the pocket & is
directed to the bony margin

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• This is known as second incision.
• used in periodontal flap surgeries

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• Y Shape palatal incision

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2.Vertical/oblique /releasing incisions
• Most desirable on one or both the sides of the
flap.
- Triangular & Trapezoidal flap
• The incisions should extend beyond
mucogingival junction
• Reach the alveolar mucosa to allow the
release of a flap for reflection
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• Vertical incisions should be placed at obtuse
angle to the horizontal incision
• It should leave interdental papillae intact

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3.Semilunar (curved, elliptical)
• Used when we want to maintain the attached
gingiva intact & for endodontic surgery.
• The horizontal component of the flap rests on
the alveolar bone.
• The gap of 5 mm must be present from the
base of the gingival sulcus to the incision.

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 4.Flap Design

• The preparation of adequate mucoperiosteal

flap is of paramount importance.
• Standard surgical protocols should be followed
while designing a flap or reflecting it to
preserve the integrity and function of the soft
tissues.

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• The properly designed flap may bring about
minimum morbidity like pain,
swelling,complications associated with
damage due to inadequate exposure.
• Intraoral incision for flap designing should be
convenient , accessible& avoid injury to the
vital structures and maintain interdental
papilla integrity

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 Complications of Flap Surgery
• Flap tearing
• Flap necrosis
• Flap dehiscence.

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Flap tearing
• The incision should be clean, sharp and should
penetrate the entire mucoperiosteum
• The flap should be reflected as one unit.
• The flap should be large enough to prevent
tearing

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• Adequate size of the flap is a must for proper
instrumentation and visual access.
• The length of the flap should be no more than
twice the width of the base.

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Flap necrosis
• The base of the flap should be wider than the
reflected free margins to allow for the
adequate blood supply to the reflected
tissues.
• Flap should have margins that either run
parallel to each other or preferably converge
from the base to the apex of the flap.

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• Whenever possible, the axial blood supply
should be included in the base of the flap.
• Palatal flap can be based on greater palatine
artery (pedicled flap)

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Flap dehiscence: separation of the flap margins
or gaping of a wound & is seen in the immediate
postoperative phase after suturing
• Poor tissue handling, Too tight suturing,
hematoma formation, Infection, Suturing
under tension cause dehiscence.
• Prevented by designing a flap in a way sutures
will be placed over the solid healthy bone

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 Principles of Flap Designing

• Intraoral surgical flaps are made to gain

surgical access to the area to be operated or
to move tissues from one place to another.
• Used for basic oral surgical procedures to
allow complete visualization of the operative
field and to access osseous tissues when
required

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 Types of Flaps
A.Full thickness—mucoperiosteal flap
- Partial thickness
B.Envelope flap
• Two sided triangular flap
• Three sided rhomboid flap
• Semilunar flap.
C • Labial, buccal flaps
• Palatal, lingual flaps
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 Envelope Flap

• The most common type of 2 Sides flap.

• The incision is made to any length (depending
on the amount of exposure needed)
• Intraorally around the necks of the teeth along
the free gingival margin on the buccal or
lingual aspect including the interdental
papillae

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 Two-sided triangular flap
• In addition to the envelope flap, a vertical
releasing incision is used in order to have
better access to the area.
• This vertical releasing incision is made on one
side of the envelope flap -at the proximal or
distal end
• Divergen towards the buccal vestibule
forming an obtuse angle at the free gingival
margin.
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• The vertical incision should be made in the
interproximal area as the tissues here are
thick.
• To avoid periodontal defect, the incision
should never lie directly on the facial aspect of
the tooth.
• The two sided triangular flap is reflected
towards the base of the flap by using
periosteal elevator
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 Three-sided rhomboid flap
• Is the modification of envelope flap to
improve the visibility and access.
• An additional vertical incision is added in the
opposite direction from envelope flap.
• The base of the flap must be wider than the
apex to ensure good blood supply

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 Semilunar flap
• Used in periapical surgery.
• The base of the flap should be broader than
the apex and the suture line should not lie on
the bony defect.
• The incision is taken at least 5 mm away from
the free gingival margin.

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• This flap is useful to avoid damage to
interdental papilla
• Prevent periodontal post surgical defects.
suturing is not a problem with this flap but its
disadvantage is that the flap often lies on the
bony defect

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• The entire mucoperiosteal flap is raised by
using periosteal elevator to a point to the
apical one-third of the tooth
• This is mainly used for the surgical extraction
of a tooth or roots

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 5.Tissue Handling

• Gentle handling, no excessive pulling or

crushing
• Proper retraction with judicious force,
avoidance of extreme temperature
• Minimum use of electrocautery, avoidance of
the use of chemical agents are the key factors
for satisfactory wound healing.

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• During cutting of the bone by using electrical
engine and hand piece and bur, continuous
saline irrigation should be done to avoid
generation of heat.
• Selection of the proper instruments is also
important to minimize the tissue trauma

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 6.Hemostasis

Hemostasis should be achieved during surgery for

the following reasons:
• To minimize the intraoperative total blood loss
• Increase visibility
• To cut down the total operating time
• To minimize the postsurgical hematoma.
- Hematoma decreases BS
- Increases the wound tension
- Wound infection
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Hemostasis can be Achieved by
• Intermittant pressure:
-With cotton/gauze sponges or with hemostat clamping
-Pressure is usually applied for 20 to 30 seconds
for smaller tiny vessels
-For large vessels require about 5 to 10 minutes
of continuous pressure.
• Use of electrocautery
Judicious thermal coagulation
-Avoid unnecessary burning the tissue.
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• Suture ligation: injured vessel is grasped with a
hemostat&tied by nonabsorbable suture (linen) to
ligate the ends of the vessels.
• Placement of compression dressing over the
wound using cotton pad or folded ribbon gauze is
stabilized and secured with tie over sutures and left
in place for 2 to 3 days.
• Use of vasoconstrictor agents
Epinephrine,commercial thrombin or collagen
Gelfoam
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 7.Dead Space Elimination

• Dead space is the area that remains devoid of

tissue after closure of the wound.
• It is created as a result of
-Removal of tissue in the depths of a wound
-By not suturing in multiple layers .
• Dead space is usually filled with hematoma.

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 Management of Dead Space

1.Multiple layer suturing

-From the depth to the surface
2.Pressure dressing over the wound for
12 to 18 hours
3.Surgical packing of the defect.
- Ribbon gauze impregnated with an
antibacterial medication can be used

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4. Use of drains +_ the pressure dressings
includes Non suction drains or suction drains
 Fine superficial drains
 Large superficial drains
 Deep drains…tube drains
 Vacuum drains

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 8.Decontamination & Debridement

• Irrigation during surgery

• Irrigation at the end of surgery
• Careful debridement of necrotic tissue,
Foreign bodies, severely injured tissues
• Antibiotic prophylaxis

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• In intraoral wounds, patients should be
instructed to use frequent medicated
mouthwashes after every food intake.
• In extensive oral surgical wounds, the patient
should be fed through Ryle’s tube till the
wound heals to avoid oral contamination

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 Surgical Management
of impacted teeth
• Impaction is cessation of eruption of a tooth
caused by a physical barrier or ectopic
positioning of a tooth.
• An impacted tooth is one that is erupted,
partially erupted or unerupted and will not
have normal arch relationship with the other
teeth and tissues

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• An unerupted tooth—is a tooth that is in the
process of eruption and is likely to erupt based
on clinical and radiographic findings.
• Malposed tooth—A tooth unerupted or
erupted which is in an abnormal position in the
maxilla or in the mandible
• An embedded or impacted tooth—is the tooth
that has failed to erupt completely or partially
to its correct position in the dental arch
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Impacted teeth seen in the following order of frequency:
1. Mandibular third molars
2. Maxillary third molars
3. Maxillary canine
4. Mandibular premolar
5. Maxillary premolar
6. Mandibular canine
7. Maxillary central incisors
8. Maxillary lateral incisors

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 Causes of impaction of Teeth

• Inadequate Space in the Dental Arch

• Phylogenic theory: Due to evolution, the
human jaw size is becoming smaller and since
the third molar tooth is last to erupt, there
may not be room for it to emerge in the oral
cavity.
• Mendelian theory: genetic variations
• Local and systemic causes

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LOCAL FACTORS SYSTEMIC FACTORS
Density of bone Genetic factors
Lack of space in dental arch Ricket ,anemia ,TB,Syphilis,
Non resorbing alveolar bone malnutrition
Too early or too late 1ry teeth Endocrine diseases
extraction
Ectopic position & trauma to Clet palate, down syndrome
tooth bud
Soft tissue and bony Osteopetrosis
lesion,oral habits

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 Indications for removal
of Impacted Teeth
• Reccurrent pericoronitis
• Deep periodontal pocket
• Orthodontic reason
• Prevention of dental caries
• Prevention of cyst and tumors
• Prevention of pathologic fracture

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• Preparation of orthognathic surgery
-Prior to sagittal split osteotomy of ramus ,lower
third molars are extracted.
-Maxillary third molars are removed during
LeFort I osteotomy procedure
• Management of preprosthetic concerns—before
fabricating prosthesis, impacted teeth should be removed
• Impacted teeth in the line of fracture
• Prophylactic removal
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 Risk of Nonintervention of impaction

• Crowding of dentition based on growth

prediction
• Resorption of adjacent tooth and periodontal
status
• Development of pathological conditions such
as infection, cyst, tumor.

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 Risk of Intervention of impaction

• Minor transient defects

-Sensory nerve alteration, alveolitis,trismus
- Infection,Hemorrhage, dentoalveolar fracture
• Minor permanent: Periodontal injury, adjacent
tooth injury , temporomandibular joint injury.
• Major defect ; Altered sensation, vital organ
infection, fracture of the mandible, maxillary
tuberosity

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 Classification of Impacted Teeth

Maxillary and mandibular third molars are

classified radiographicaly
• By angulation, depth and arch length
• Relationship to the anterior aspect of the
ascending mandibular ramus

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 Winter’s Classification
Depends on angulation of the impacted third
molar to the long axis of the second molar.
1. Mesioangular – commonest
2. Horizontal/transverse/ Inverted
3. Vertical .
4. Distoangular
5. Buccoangular
6. Linguoangular
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 CONT …….

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 Depth of Impaction
• As per the relationship to the occlusal surface
of the adjacent second molar to the
impacted maxillary or mandibular third molar,
the depth of impaction can be identified.

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• Class A: The highest position of the impacted
tooth is on a level with or below the occlusal
line of second molar
• Class B- impacted tooth is below the occlusal
plane but above cervical line of 2nd molar
• Class C -impacted tooth is below the cervical
line of 2nd molar

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 Pell &Gregory Classification
Depends on the space available distal to the
second molar.
• Class I: Sufficient space available between the
anterior border of the ascending ramus and the
distal side of the second molar
• Class II: The space available between the
anterior border of the ramus and the distal side
of the second molar is less than the mesiodistal
width of the crown of the third molar.
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• Class III: The third molar is totally embedded
in the bone from the ascending ramus
because of absolute lack of space.

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• Difficulty of extraction of impacted tooth is
evaluated by radiograph and depth of impaction
is assessed by winter lines
• White line…. Drawn on Occlusal plane from 2nd
molar to ramus
• Amber line drawn from interdental gingival
crevice to asending ramus and shows the alveolar
bone covering and not covering impacted tooth

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• Red line drawn perpendicularily from amber
line to point elevator application
• If red line depth is greater than 5mm, there
will be more difficulty of extraction

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 Steps of surgical removal
Of Impacted Teeth

1. Asepsis and isolation

2. Local anesthesia/sedation + LA/GA
3. Incision—flap design
4. Reflection of mucoperiosteal flap
5. Bone removal
6. Sectioning (division) of tooth
7. Elevation

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8. Extraction
9. Debridement and smoothening of bone
10. Control of bleeding
11. Closure—suturing
12. Medications—antibiotics, analgesics, etc.
13. Follow up

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 Flap design for Impaction removal
The main factors for a successful surgical outcome
 Correct flap design which must be based on
the clinical & radiographic examination for
position of tooth, relationship of roots to
anatomic structures, root morphology.
 Ensuring the pathway for removal of the
impacted tooth with as little bone removal as
possible via sectioning &segmenting tooth
causing less trauma possible
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• Envelope &Triangular flap is common used
for surgical removal of impacted tooth
• Envelope flap is done from anterior border of
ramus to first molar along cervical lines
-For superficial Impaction
• Triangular flap is done from anterior border
of ramus to distal of 2nd molar and releasing
incision is done vestibularily on 2nd molar

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 Surgical extraction of impacted
mandibular 3rd molar

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 Impacted mandibular
premolar removal

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 Impacted mandibular canine removal

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 Maxillary 3rd molar Impaction removal

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 Maxillary canine Impaction
Labial approach

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 Impacted maxillary canine
palatal approach

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 Palatal approach for Impacted maxillary
premolar

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 Ectopic maxillary canine removal

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 Bone removal techniques
• High speed hand pieces
• Chisel and mallet
• Lingual bone split method
• Guttering method

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 Wound debridement &closure
• Irrigate socket with copious saline
• Remove any foreign body and fragment
• Make homeostasis
• Close by sutures silk 3.0 for one 1 week

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 • In case of molars, suture distal to second
molar should be placed first & should be
water tight to prevent pocket formation.
• In case of palatally impacted canines, incisive
papilla should be sutured carefully to reduce
postoperative bleeding.

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 Complication of Surgical removal
of Impacted tooth

Bleeding due to Injury

• Buccal artery, facial artery
• Greater palatine artery,incisal papillary vessel
• Lingual, inferior alveolar artery,mental nerve
injury

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• Mandibular bone fracture, TMJ dislocation
• Maxillary tuberosity fracture
• Oro antral &oronasal fistula
• Swelling ,trismus& pain

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 References
• Fragiskos , Oral surgery
• Neelima text book of Oral &Maxillofacial
surgery
• Contemporary Oral &Maxillofacial surgery

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