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IMPACTION

SPECIAL SURGICAL PROCEDURE


Clinic 4

GARCIA, Zara Denisse G.


DDM 6-B

Personal Data

Name: Beau Shinehah Orleans


Age: 21 years old
Religion: Latter Day Saint
Sex: Female
Nationality: Filipino
Address: Jaro, Iloilo City

CHIEF COMPLAINT:
Gusto ko ipakwa wisdom tooth k okay
nasabadan ako.

HISTORY OF PRESENT ILLNESS:


3months PTC, the patient felt uncomfortable with the most posterior area of her jaw..
The tooth no. 48 and 38 upon Panoramic Examination is impacted.
MEDICAL HISTORY:
The patient has not been into any serious injuries nor have neither any allergies to
food nor any medications.
DENTAL HISTORY:
Amalgam: Tooth #37
SOCIAL AND ENVIRONMENTAL HISTORY:
The patient does not engage in smoking or drinking alcoholic beverages.

CLINICAL EXAMINATION:
1. GENERAL SURVERY OF THE PATIENT
A. Stature: normal
B. Gait: normal
C. Speech: normal
D. Hands: normal
E. Temperature: normal

2. EXAMINATION OF THE HEAD AND NECK


A. Size and Shape of the head: normal
B. Hair and skin: normal
C. Facial Symmetry: symmetrical
D. TMJ: no crepitus; normal
E. Eyes: normal
F. Ears: good sense of hearing
G. Nose: normal
H. Neck: no abnormalities

Oral Diagnosis:
Class II Position A, Horizontal Impaction of tooth number 48
Class I 3rd molar impaction: half of tooth is situated within the ramus of the mandible
Position A mandible 3rd molar impaction: the occlusal plane of the impacted tooth is at the same level
as the adjacent tooth

Treatment Plan:
SURGICAL REMOVAL OF TOOTH no. 48
Recall is a must.

Principles:
ORAL SURGERY

Asepsis
Atraumatic Injury
Maintenance of patient airway
Good Anesthesia
Control of Infection

FLAP
1.
2.
3.
4.
5.
6.
7.

The base of the flap should be wider than the free margin or apex for good blood supply
Should be adequate size to provide good visibility and accessibility to the area
Should cover the entire thickness of the periosteum
Incision should be made over intact bone to prevent dehiscence e.g. 6 8mm away from
where bone removal will end
Must avoid injury to vital structures
Releasing incision should be done only when necessary
Incise the tissue with one stroke towards bone

SUTURING
1.
2.
3.
4.

Needle holder should grasp approximately 2/3 the length of the needle.
The needle should enter the tissue perpendicular to the surface.
The needle should be passed through the tissue following the curvature of the needle.
The suture should be placed at an equal distance of 2 -3 mm from the incision line on both
sides at an equal depth.
5. The sutures should be placed approximately 3 4mm apart.
6. If one tissue side is free and the other is fixed, the needle should be passed from the free end
of the tissue to the fixed end.
7. If one tissue plane is deeper than the other, then the needle should be passed from the deeper
to the superficial planes.
8. If one tissue is thinner, then the needle should be passed the thinner to the thicker for ease of
coaptation.
9. The distance that the needle is passed into the tissue should be greater than the distance from
the tissue edge.
10. Sutures should not be closed under tension.
11. The knot should not be placed over the incision line.
12. The suture should be tied so the tissue is merely approximated, not blanched.

Pell and Gregory Classification (impacted 3rd molar)


-based on the amount of tooth covered by the anterior border of the ramus (1, 2 or 3)
-the depth of the impaction relative to the adjacent tooth (A, B or C)
-helpful in predicting surgical difficulty.
*class I 3rd molar impaction: situated anterior to the anterior border of the ramus.
*class II 3rd molar impaction: crown covered by the anterior border of the ramus.
*class III 3rd molar impaction: crown fully covered by the anterior border of the ramus.
*class A maxilla 3rd molar impaction: the occlusal plane of the impacted tooth is at the same level as
the adjacent tooth.
*class A mandible 3rd molar impaction: the occlusal plane of the impacted tooth is at the same level as
the adjacent tooth.

*class B maxilla 3rd molar impaction: the occlusal plane of the impacted tooth is between the occlusal
plane and the cervical line of the adjacent tooth.
*class B mandible 3rd molar impaction: the occlusal plane of the impacted tooth is between the
occlusal plane and the cervical line of the adjacent tooth.
*class C maxilla 3rd molar impaction: the occlusal plane of the impacted tooth is apical to cervical line
of the adjacent tooth.
*class C mandible 3rd molar impaction: the occlusal plane of the impacted tooth is apical to cervical
line of the adjacent tooth

ARMAMENTARIUM
BASIC INSTRUMENTS
1.
2.
3.
4.

Mouth Mirror
Cotton Pliers
Spoon Excavator
Anesthetic Syringe

FLAP TRAY

Scalpel
Blade no. 15
2 curved needles
Straight needle holder
Tissue forceps
1% Betadine solution (Oral antiseptic)
Topical Anesthesia
Sterile Gauze
Dental Syringe needle
Anesthetic cartridge
Normal Saline Solution
3-0 black braided silk with cutting needle

PRIMARY INSTRUMENTS

Mucoperiosteal Elevator
Minnesota Retractor
Gum Separator
Bone Rongeur
Bone file
Allis Forceps
Hemostat
High Speed Handpiece
Bone curette
Surgical Scissors
Short needle
Suction Tip
Kidney basin
Elevators
Forceps no. 17 and 16
Surgical Burs: Round and Tapered

PROCEDURE
1. Make sure the patient is calm.
2. Take the blood pressure of the patient.
3. Have the patient mouthwash or gargle with any antiseptic agent to reduce the intra oral bacterial
count.
4. Wash the area around the mouth with an antiseptic solution.
5. Dry the patients mouth then apply topical anesthesia for 2 -3 minutes.
6. By using the mandible nerve block technique, inject the anesthetic solution and keep the patients
mouth open for 20-30 seconds.
7. After 5-7 minutes ask the patient for tingling or numbness in areas innervated by mandibular nerve
such as lower lip or tip of the tongue.
8. Use the patients cast to review the envelope flap outline then palpate the tissues to keep incision
over the bone and by using the blade #15 with single stroke it is made back of the buccal cusp of the
2nd molar into buccal tissues or it is important that posterior extension of incision should diverge
laterally to avoid injury of lingual nerve.
9. Use the suction machine to isolate the operative site from blood and saliva for easy visualization.
10. Irrigate the flap with NSS to lessen the incidence of dry socket.
11. When the operative site is widely exposed, a retractor is placed under the flap and held against the
bone.
12. By using surgical round bur #8, remove the bone on the occlusal aspect and on the buccal and
distal aspect down to the cervical line of impacted tooth.
13. Mesial cusp should be suctioned using the chisel or bur.
14. Use the straight elevator to deliver the sectioned part of the tooth out of the alveolar process
15. After removal of the impacted tooth, use a hemostat to remove any remnant of bone chips and
debris.
16. Use bone file to smoothen sharp or rough of bone.
17. Irrigate with NSS.
18. The suturing thread soaked in antiseptic solution for interrupted suturing technique.
19. Final irrigation with NSS.
20. Apply antiseptic solution on a sterile gauze over closed incision

PREOPERATIVE INTRUCTIONS
The patient must be WELL RESTED A NIGHT BEFORE THE SURGERY.
The patient will be prescribed with the following medications:
o Take 1 tab of NAPROXEN SODIUM (FLANAX FORTE) 500mg, 1hour before the
procedure.
o Take 1 cap of AMOXICILLIN TRIHYDRATE 500mg, 1hour before the procedure.
o Take 1 cap of TRANEXAMIC ACID (HEMOSTAN) 500mg, 1hour before the
procedure.

POST-OPERATIVE INSTRUCTIONS:
Do not rinse or spit for 24 hours after surgery.
Keep fingers and tongue away from socket or surgical area.
Use ice packs on surgical area (side of face) for the 1st 24hrs, apply cold compress for
20 minutes.
For mild discomfort take Tylenol or Ibuprofen every 3-4hrs.
For severe pain use the prescription given to you.
Drink plenty of fluids (dont use a straw).
If the muscles of the jaw become stiff, chewing gum at intervals will help relax the
muscles as well as the use of the warm, moist heat to the outside of your face over
these muscles.
After the first post-operative day, use warm salt water rinse following meals for the
first week to flush out particles of food and debris, which may lodge in the surgical
area. (1/2 teaspoon of salt in a glass of warm water. Mouthwash can be added for
better taste.).
Diet may consist of soft foods which can be easily chewed and swallowed.
A certain amount of bleeding is to be expected following surgery. Bleeding is
controlled by applying pressure to the surgical area using a small rolled gauze for 60
minutes. After that time remove the gauze and then you may eat or drink. If bleeding
persist, a moist teabag should be placed in the area of the bleeding and bite firmly
for one hour straight. This will aid in clotting blood. Repeat if necessary.
Do not smoke for at least 5 days after surgery. Nicotine may break down the blood
clot and cause a dry-socket, which is an undesirable side effect.