Hey folks, (...?) allthingsdentistry.com. So we're continuing the series with Dr. Partridge, our experienced mentor who has given us a lot of guidance in exodontia. So, without further ado, Dr. Partridge.
Thank-you, Dr. Mark. And I'd like to remind you again that this is kinda a two-way street here, so we really appreciate your comments. That's the only way we can improve the program and address the things that you're concerned about, is if we get comments back.
We discussed some preliminaries. We're just about ready to clean up on the preliminaries during this one. One of the things you have to do is your hard-tissue considerations, during your plan of attack you want to look at the tooth anatomy. See how many roots there are, how it's spread out. And keep in mind that the radiographs are two-dimensional but all your teeth are three-dimensional, so be prepared for the unexpected there.
Location angle makes a big difference. I like to use a Pell-Gregory classification, but they can be straight up-and-down, buried below the C–J (?) or behind the ramus and things. And the Pell-Gregory is a good classification, it's nice when you're talking with your colleagues, it gives you a basic idea where the tooth is located.
and then boney access/reduction, look at the area around there see if they have any exscostosis have any tor-eye. course you want to look at anatomy structures around her incase of fear alvera, sinus or cell reduction or anything else thats around her. Look at the heart tissue considerations before you do your plan.
Okay this is a Pell Gregor classification, this is an old class classification system but it is very fundamental. If it's fully routed its A, if it's partially routed it's B, if it's buried below the C.J. on the next tooth it's a C. One it's in front of the ramos, two it's bisected by the ramos, three it's behind the ramos. If you got a 3c that's probably a neural surgeon referral, and while you're taking another 3c anyway unless it's systematic.
Ok, here's something kind of important when you're doing your design. In your mind's eye, or maybe some textbooks, you have a picture of a molar and it looks nice, symmetrical and all that, but it's not. And if you look at the one on the right, the real world, you'll see that most crowns are tilted about 15 degrees to your root, and they're not in line. The axis of the root is about 15 degrees off the axis of the crown. And that has two major consequences. Number one, if you dissect right down through the axis of the tooth, you're gonna cut off the mesial root. The other consequence is that the path of extraction is not straight out of the socket, so it's going to be curved dictated by the roots on the tooth-kind of like a curved path of insertion on a partial denture.
The other thing I want you to note is the little dotted line there and you see there's a significant cavity behind the second molar. And frequently when you have mesial (???) or horizontal impactions, you know where the crown's going to be, it's going to be right down here. [And so] people, especially when they start out, are a little tentative about getting down in there; but that's where the crown is, and that's where you have to go to section that tooth out.
Now this is an artist's rendition, it's highly exaggerated of course, but this is what I'm talking about here. There's a big gap in the con cavity(?) underneath the second molar. You want to do your buccle trough here... and one of the keys to extracting a tooth is you want to get pressure on this mesial buccle line angular. You want to get down there as deep as you can. You want to get towards the apex, not the crown, and [towards] the little distal trough, because this tooth isn't going to go straight out, it's going to make a curve here so you have to have a little room there. Just stay one (???) width behind, don't go too far back there, your lingual nerve and other anatomical features are out there.
The other thing I want to point out is preserve. Never take off the bone on the distal, that second molar if you can possibly preserve it. As I always say: Bone will grow horizontally across here, but it won't go vertically up. If bone were to go vertically up like this, we would probably need Paradine or something, so make sure you always try to preserve that little bone on the distal second molar or stay away from it.
Just before we go on, sir, I know that as general dentists... In our office, we typically have [ ] angled pieces.
Here we're using straight [pieces]. Now any thoughts, before we start talking more specific access, what are your thoughts on either?
A little bit is a personal thing. I actually use both handpieces, but for third molars I typically like the Striker or the Osteomed surgical burrs, they have a lot more torque, they're a little longer, you can use them to get down into deep areas and that.
But when I'm doing a surgical extraction like endomolars or biscuspids or things like that I like the Impact-Air. It has a lot less what we call collateral damage it can preserve a lot more bone, and you can can do a lot better job of trisecting a molar to extract it than you can with the Osteomed or the Striker.
Striker and Osteomeds are brands of surgical handpieces or big straight handpieces. Both of them are electrical, electrical motors.
The following is an auto-generated transcript from Youtube
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I usually is a 702 sometimes I use a 703 but
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I interest are not stay with the 702 703 takes off a lot a lot a material
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and yet to be really cautious in traditions when hughes et
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there some again engineering reasons why I like the 703 since it's got a bigger
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diameter it gets better it's got more fruits
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assist a sharper longer and area Charlize for 40 technical mechanical
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you're trying to preserve bone and careful he worries 702
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703 die 63 not worry about preserving it easy section anyways
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703 quicker so you can argue that either way but if you're starting out I would
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stick with seven to minimize collateral
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production cost you Taylor
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at this this is one
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trough in impacted tooth is this another ideal thing basically what you're doing
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is you're stuck on inner
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just taking a low bone you're following the contours are the two
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and the roots a basic you doing a crown prep on to screw you want to minimize
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amount Obama to take officer
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so just in your mind's eye whenever you're taking of bone just think you're
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just doing
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crown prep on to ship through to stay close can't
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structures minimize gonna take off
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okay flap considerations actors on your heart tissue
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then the I got takeoff section 23 how much bone a take-off
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I'll consider the tooth to write all those other things
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consider the degree of impaction then you do you're a soft tissue design
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and 10 things you have to think about soft tissue is make sure that the base
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of loud as always wider than the apex
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that sounds pretty simple on a flagship paper that's two-dimensional they
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remember all flaps are three-dimensional
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to go around hey man are not sure the rectum or pat around something out or
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so designer flaps real carefully make sure they have plenty over
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circulation covers always use expression
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measure twice and cut the board wants well maybe we ought to do
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just design your flat twice make incisions
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i sleepy situational slough of layer
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%uh this is a flat design to use a voice in a few other oral surgeon uses for
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accessing the poster areas
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I couple key points here to a lot of people use netbook level Galway up the
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first
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more maybe in the second bike us but a envelope flap sir good
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I think I don't like it envelope lapses every time you lay a flap you loser
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there's a risk you lose a half from a $1.4 mil mere attachment so
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a I like to preserve the paradox miss much as possible
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so why do they start I am between the contour
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per pill I like to spritzer per pill because ur important and answers for a
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sex with the poster other important for
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preventing accumulation of food per dollar zzzz down the pike psyche to
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propel intact good justice let
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and if you see this cut I'm doing here the bay it comes at a 45 degree angle
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toward the end here
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seat over here too and you see a little bevel I little dotted line
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blade is not held perfectly perpendicular to the
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to the bone to the mandible or maxilla till two blade slightly dish
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dis Lisa the blaze is going to sleep better handles going and territory do
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to the mouse so this is kinda undercut this latter the reason is you have a
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beveled flap
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so when it comes time to close at if you can't make a perfect but join in your
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flap you still have a double flap so they can slide one or two milliliters
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either way and you'll still get to a primary coverage on
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as extend a flap around a distance August go all the way to either
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distilling or distal pal age and then
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I come out a semi-circular cut like this out toward the buckle
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now up it goes through the usual angle cast
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writer the central Foshan over the distal bacchus like that others to know
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cut zones are on the liberal side guzzling owner also hear the greater
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lesser penalty frame and an artesian urs commit forgery west a way from these
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areas
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if you do have to remove this area to
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deliver the two can simply just reflect reeled really don't stretch it out cuz
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again linger
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may be under 5 percent cadaver studies show that a leveller comes almost
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immediately distal
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to the third molar and run along almost level surface a third more she wanna
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stay away from the lingual nerve
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it's bad enough to ensure all the learner but the labeler has Lowepro
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perception surgeon I'm not up every time I talk laugh Steve
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cough they'll remember you so you wanna you want to preserve that linger
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all costs there
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there's a couple anatomy drawings here and you can see this is a standard one
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which pretty close right there
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both easing ceiling lurve is real close the third more
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but again about 5 percent a cadaver station even goes closer almost
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immediately distal to a third more so stay way from
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former save yourself in your patient lot a mystery
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okay there's a lot of a gone through a lot of pre ops and preparatory things
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here in Orange
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to start surgery and a they're very important to do all those things which I
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to spend 45 min to an hour gone 2006
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what you get for fish you should be able to go through you know make sure your
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medical stuff really but to the medical history do your susman
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up to your planning make sure oh and to answer and plan your attack
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you'll be able to do that 15 or 10 minutes like problem watch
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what you get for fish but it is important to go through all the steps if
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you skip the step somewhere during that
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preparatory phase you may end up paying for earlier
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again what you professionally single go pretty quickly it seems like
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pretty lengthy wanna get this discussion which good you can slide right through
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the six british-born you do each step
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okay now we want to get into some the actual surgical cases of regress
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this is a visual angle which is what are your most common impaction
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ritual see shows good place to start
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now I in my mind's eye you know course being the oh and you're like the diagram
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stuff out real well so I'll look at that
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I read a graphic that musical analogues cancer it real quickly
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in SLI a tooth has color conscious so if it were straight up and down to pry
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extract right other unfortunately Richard the diner the it's a small
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route diameter the CJ should should extract acceptance lodge right on a sec
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on Kevin sec
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more so you look at the axes are the two and uses taxes the route again about 15
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degrees difference from
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actions the crown so if you come right down to the Crown
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actions when he undercut right now that he's a router
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I'll also elect point out the kinks it better
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a tree graph
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on the
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search going to occur path extraction can't picture
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I G
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as a side note here right older earlier Jersey 15 agree diverged sailor crowned
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a pretty straight vertical there or is on a local service look at the roots
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perverse about a 15 degree angle church just an ordinary
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so I'll dissect the route I'm not worried about dissecting the crown
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tomorrow dissect retract
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you can see if you get right down to the middle route is gonna come out on the
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easel cusp armies ok us not not to the firkin
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now another thing when I make a groove a Miller
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tip I like to make the girlies halfway to there are at least three fourths or
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maybe seventy to the way through the tooth if you only make it half way
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through to senior crockett you know where the cracks
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may not split the way you want to an email message
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have to retreat the other thing I do a I like to make the outside
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the group section wider the inside and that allows me to see
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instrument down deep if this
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extra seats up here on the crown you twisted are going to chip also an
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outbreak of the crown
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you want the binding point appear your elevator
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whatever reason to be down as in the center the pope fluoride in their
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savings but the route
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so you wanna make outside the group white on the inside to consider ensure
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all the way down to bomb a pop for
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and then you twist it you wanna find other than you can section router
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answers see searched
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this trough was
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story
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section ish
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if I can
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find a for Carl starter for can come up but a lot times
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you can see the for kids cover blind sectioning answer that
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that's why I liked uncover the crown or other things I use a little 15 scalars
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people follow all appeared all around a good
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give you the crown so I know I know where the booker's go on and I guess
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make where the Frick is
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I get I start on about the usual custom an angled outwards
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sometimes you're to blame because I for QA so far down in there you have to
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remove a tremendous about bone
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actually see other time to actually get down with the scariest looked under
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a little 15 scares real small scale or use a lot I use
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almost like my six fingers gets laid down in the PD alert can
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for so that's a little tip
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okay here's another are
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rendition as you can see that section groove is in front love buckle group if
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you get right down to the buckaroo
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problems and gets a slight angle to the crown
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and this is a sequence watches section obvious amis 01 is locked underneath the
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second
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more the concavity take out the first one and is gonna come out
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it's like her like that and why do as I get up purchase a national missile book
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a lying on just tilted this little bit and then
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will come out
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okay now let's whereas section to scour for the phone for
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well I you have to do a little bit over buckle groove around here
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again just a single burr pass on a desolate usual room flat disc
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Disley again this yellow line here %um preserve that especially
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at the back to distal took more
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the Mitchell book a room like to say it's ki gotta get got a good realtor
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down as far down is a vocal I now get good leverage to LA dodger
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this year cinch points up here are going to just break off a piece
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the crown I might add an admin noticed my third edition or change your game
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different background color and sometimes over for two yellow line its orange and
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sometimes refer to an orange line it's perform
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some areas I head over Blackburn are written I'm not sure how Microsoft at
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pigments to block make it turn out red
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from how they did it so the colors and narrative may not exactly match the
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the radio grasp operation for graph tax
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okay now into how the bony access is done
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how to weave I get a flop to get the bony access
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this is a case where use the a and tear
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releasing incision the tipper the crowd is almost fell Gregory three straight as
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a bill gregory 3i I tend to use this
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access rather than take an envelope flap wallet to buy cusp again
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you see the base the flap is wider than the apex to undercut here's a little bit
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leery right in there
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does have to be personally but joined you can catch lay around to make a good
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juncture primary coverage take answers are in the distal im gonna come across
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Europe Central foster disallowing going to come out almost a 90 degree angle
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not your survey the start line is your axis angle sonya for flat back all this
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will be exposed from here
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up to realign and there's quite an area leadership play very top researcher
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also noted the Don liner in Jax is a much wider the apex you should have good
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circulation flout the church rival problems
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okay we'll go to another common one the distal angular literacy quite free
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again
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in my mind I'll just do a quick survey on this guy and again you'll see it come
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check to the roots are near and CJ so
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Hill traditional ice cream cone should pop right out there when she gets good
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elevation
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the rear angle again as a little bit on axis a little bit an angle to the
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to crown axis consider that the proper encounter when this comes up her body
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run anti run into
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the little the Ramos urs let's go by and writers are going to elevate as long as
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you got
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just a crown down against the Rangers
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there
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what I do as a
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I'll just take a little distal section other Krauser about to me xoxo spengler
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come down here
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toward the distal Margeret I like this cut to extend down to below the CJ right
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at the CJ
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and mental disorder right here just take this part completely other
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as you see I have a good
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to get spacer that used to be blocked somehow Microsoft earned
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riordan I have to go back and study my picnics and I
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thing that the BlackBerry the team s but what other side like I might answer here
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makes you better that's that's we want to take that out in the two should
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extract router
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spotter
17:00
missed the boat
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action sorry by reduction again I just a simple buckle trough here
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global distiller nationally playroom to access the 26 section to properly
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and your flap again are you near A&T release answers on this Isabel Gregory
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be so you don't need an anti relations
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just go around local the store where and make a releasing
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the story she incision there's your hands actors play lax is in there
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should not have any problem accessible that flap good circulation
17:29
like to point out a couple other things on regression quickly or Sears
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Seattle body interceptor bone in their your mother's it's kind of an island
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it's cut off for the root tips teachers when you see a bony islander
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interceptor bone that's almost inconsequential by not attach anything
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it's really not a consideration
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as larger roots are narrow down here than there are two top
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compare that to the jewish into three a long skinny financial
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Boehner's up a bone is connected to the to the mandibular that may be a problem
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have long routes like this I it didn't come out real
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quickly I go in Section it is because if it breaks as I gonna break up here is
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gonna break about halfway down roots Rocket Summer
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Angeles big difference to an island a very subtle bone
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well-connected financials that's something to consider
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wonder taken is out
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okay I think it's about the endeavor time for today I hope we can simply
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dollar
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again I we appreciate your comments and feedback on it it really only way we can
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prove program so for the new stockmark
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her thanks for your time sir and
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will be back with more
I usually use a 702, sometimes I use a 703; but if you're starting out, I'd stay with a 702. The 703 takes off a lot of material, and you have to be really cautious and judicious when you use that. There are some, again, engineering reasons why I like the 703, since it's got a bigger diameter, it cuts better, it's got more flutes so it stays sharper longer, and... area ......???......as far as a technical mechanical thing
if you're trying to preserve bone and careful, you want to use a 702. 703 dissects teeth, you're not worried about preserving the teeth, you're going to section them anyway, so a 703's a lot quicker there, so... You can argue that either way, but if you're starting out, I would stick with the 702 to minimize the collateral damage, reduction of osteo material there.
And, this, this is what I'm talking about troughing an impacted tooth. This is just another ideal thing. Basically what you're doing, you're just not going in there and taking out a lot of bone. You're following the contours of the tooth and the root so basically you're doing a crown prep on the tooth and root. You want to minimize the amount of bone that you take off there. So just in your mind's eye, whenever you're taking off bone, just think that you're doing a crown prep on the tooth and the root and stay close as you can to those, uh, those structures and minimize the amount of, uh, bone you take off.
Okay, flap considerations. After you've designed your hard tissue, then, uh, how you're gonna take off a section of tooth, how much bone are you gonna take off, uh, consider the tooth, tori, and all those other things. Consider the degree of impaction. Then you do you're, uh, soft tissue design, and, uh, one of the things you have to think about soft tissue is make sure that the base of the flap is always wider than the apex. And that sounds pretty simple on a flat sheet of paper that's two dimensional, but remember that all flaps are three-dimensional. They go around the handler notch, over the retromolar pad, around something in the tori, so design your flaps real carefully. Make sure they have plenty of, uh, circulation. Carpenters always use the expression measure twice and then cut the board once. Well maybe we ought to do that. Just, uh, design your flap twice and then make one incision so that you don't, uh, isolate a piece of tissue that'll sluff off later.
Uh, this is a flap design that I use, I've only seen a few other oral surgeons use it. It's for access in the posterior areas. Um, a couple of key points here, uh, a lot of people will use an envelope flap will go all the way up the first molar, maybe even the second bicuspid. Uh, e-envelope flaps are good, the only thing I don't like about envelope flaps is the only time you lay a flap, you lose, you lose a risk a half or maybe a full millimetre of attachment, so...
I like to preserve the peridontin as much as possible. So what I do is I start in between the contour in the papilla. I like to preserve papilla because they're important in the anterior for aesthetics but in the posterior they're important for preventing accumulation of food and peridontal disease down the pike. So I keep the papilla intact [just like that?]. And you'll see this cut that I'm doing here... the [bay]... it comes out at a 45 degree angle toward the anterior. See it over here too.
And you see that little beveled line - that little dotted line - the blade is not held perfectly perpendicular to the bone - to the mandible or the maxilla. I tilt the blade slightly distally. So the blad is going distally, but the handle is going anteriorally toward - through the mouth. So this is kinda undercut... this flap here. Now the reason is you have a beveled flap, so when it comes time to close that, if you can't make a perfect [but] join in your flap, you still have a buffalo flap so that can slide one or two millimeters either way and you'll still get primary coverage on that area. As I extend the flap around, I just stay in the sulcus and go all the way to either the distal lingual or the distal parallel edge. And then I cut out a semicircular cut like this toward the buccal. Now, it goes through the mesolingual cusps, right over the central fossa and over the distal buccal cusp like that.
There's two no-cut zones here on the lingual side because of the lingual nerve, and also you have the greater and lesser pallatine foramens and arteries and nerves coming forward. So you want to stay away from these areas. If you do have to remove this area to deliver the tooth, you can simply just reflect it real gently. But don't stretch it out, because again the lingual nerve may be in there. Five percent of cadaver studies show that the lingual nerve comes almost almost immediately distal to the third molar and right along almost the lingual surface of the third molar. So you want to stay away from the lingual nerve. It's bad enough curtting through the alveolar nerve, but the lingual nerve has a lot of proprioception, so if you numb that up, every time they talk, laugh, sneeze or cough, they'll remember you...
So you want to [you want to] preserve that lingual nerve at all costs there. Now here's a couple of anatomy drawings here and you can see this it is a standard one where it's pretty close right there. Both [ of ] these you can see how the lingual nerve is really close to the third molar but, again about 5 percent of cadaver studies shows that it even goes closer almost immediately distal(?) to the third molar, so stay away from that lingual nerve. You will save yourself and your patient a lot of misery.
Okay, [there's a lot of] we're gone through a lot of pre ops a preparatory things here in order to start surgery and they're very important that you do all these things by you don't have to spend forty five minutes going through all of these things. Once you get proficient, you should be able to [go through the] you know make sure your medical stuff's ready. Go through the medical history, do your assessment, do your planning, make sure all of your instruments [are] there, and plan your attack. You ought to be able to do that in fifteen or ten minutes without any problem once you get proficient, But it is important that you go through all the steps.
If you skip a step somewhere during that preparatory phase, you may end up paying for it later on. So again, once you get proficient with these things it'll go pretty quickly. It seems pretty lengthy when we go through this discussion, but once you get good at it you can slide right through those thing but it is important [that] you do each step.
Okay, now we want to get into some of the actual surgical cases off of radio graphs. This is a mesial angle which one of your most common impactions that you will see, So this is a good place to start. Now in my mind's eye you know of course being the old engineer I like the diagram stuff out (?) real well. So... I'll look at that radio graph at that mesial angle and I'll just kind of survey it real quickly, and you will notice that the outline of the tooth is kind of cone shaped. So, if it were straight up and down, you could probably extract it right out of there. Unfortunately, [you know the roots are] the diameter of the roots is smaller than [the roots] the diameter of the CDJ, so it should extract except it's lodged right underneath that cancavity in the second molar.
So you look at the axis of the tooth and you see that the axis of the root is again about fifteen degrees difference from the root axis to the crown. So, if you come right down to the crown axis, what are you going to do? You're going to cut right into that mesial root.
Also, I'd like to point out that- I think you can see it better on the next radio graph - [notice also that] it's going to be a curved part to extraction. You can't take it straight out. Just as a side note here remember what I told you earlier there's usually a 15 degree divergence. See how the crown is pretty straight and vertical
