tips and tricks

 Today I had difficulty with the extraction of a lower premolar. It was part of a lower dental clearance and I had removed all the teeth except this one. The lingual, mesial and distal tooth structure was remaining but there was deep caries subgingivally on the buccal. I mobilised the tooth initially by elevating it against the adjacent roots but this purchase point was removed as I wanted to focus on removing the canine as I predicted this would cause me more headaches to remove. The remaining premolar was mobile and I knew it would be easy to remove i I gould get a firm grip on it but due to the deep caries, it kept crumbling when placing the forceps. Due to the angle the caries sheared off, there was no parallel or undercut tooth tissue for the forceps to grip onto. I struggled with this for a while but after a moment of realisation, I just turned the forceps 90 degrees and grabbed onto the tooth on the mesial and distal aspect and made short work of the tooth from there on out....

 Yesterday I observed one of the OMFS at work remove a sialolith about 8mm diameter from a sublingual duct. He said it was quite rare to see such a large one make it so far distal down the duct. It was almost near the midline so had made it to the exit of the duct but was too large to escape.  The aetiology is a calcification forms in the duct and gathers more calcium and phosphate as it travels down the duct and eventually becomes too large to escape and gets stuck. This stone was quite superficial and so was palpable intraorally. A very superficial mucosal incision was made not directly over the stone as scar tissue would form over the duct exit. He then used curved hemostats to blunt dissect the mucosa off the gland tissue and separate the gland tissue apart until the stone was located in the duct. Prior to the procedure starting he put in quite a lot of anaesthetic, a whole cartridge was put in underneath the stone's position causing quite a bit of swelling to the area. th...

 This is just a reminder for myself to know when to call it quits for extractions. I've set a rule for myself in the past that if I'm trying a strategy e.g luxation for 5 minutes or 3 times and have made no progress then I should progress to the next best strategy e.g sectioning the tooth or raising a flap. Pushing on especially when there is some mobility can be tempting but when there is mobility and it is not changing after 5 minutes, there is some bulbosity, root curve, dense bone or path of removal issue that is holding me up. Pushing through can sometimes be successful but if you haven't made any progress in five minutes it is likely that you will just draw out the extraction and stress yourself and the patient out. Instead, make the procedure easier on yourself and progress the procedure on. Today I was wrestling with a difficult wisdom tooth and kept trying different instruments for elevation with no avail. I knew after a while it became ridiculous and yet kept on w...

Oral surgery in the dental region requires a good knowledge of the histological layers as manipulation of these layers can be used to serve different purposes. The connective tissue layer is formed of loose collagen, contains blood vessels that run parallel to the surface in the deeper layers. Periosteum is a thin layer of non stretchable fibres that attach directly to the bone. If it is raised as a flap or as part of a full thickness flap, the non stretchable nature of periosteum hinders advancement of the flap unless the periosteum is released with horizontal incisions or split from the superficial tissues. If the flap needs to be advanced to close an extraction site, close an implant site or make room for bone graft material, you may want to release the flap. If you are going to be splitting a flap, it may be beneficial in cases where a bone graft is required as well as advancement of the flap. Splitting the flap allows separation of the connective tissue which allows advancement of...

Today I had a very difficult extraction case which I struggled with. I knew it would be from the preoperative xray and by looking at the patient. My recognition of the difficulty of cases is improving but I do find myself looking at most of the extraction cases and judging them as difficult. This is partly a reflection of my wary nature. I think it is useful to analyse the case properly beforehand and recognise the difficulties for the purpose of planning contingencies. I don't think that planning should produce fear of the procedure but instead reinforce that things can go wrong and that when they do you will be prepared for it. It is also useful to recognise when a case may beyond your skills and referral or guidance is warranted. In this case, a lower 6 had curved roots and the patient had a massively thick jaw and tongue. The large tongue is always a difficulty with the administration of a IDN block. Getting the patient to relax their tongue is useful but not always possible. H...

The greater palatine artery provides blood supply to the posterior palate. There is accessory supply to much of the head and neck so cutting this artery will not result in any long term issues and it is often ligated. Most arteries in the head and neck can be ligated with no consequences due to the density of accessory supply. Exceptions include the internal carotid artery. Surgery around the palate including upper posterior extractions, periodontal surgery on posterior teeth and palatal graft harvests can affect this artery. The artery is always located at around the anterior-posterior level of the upper 7 at the transition of the vertical and horizontal slope of the palate. Iif you cut the palatal artery: 1. Take a deep breath, don't panic 2. Inject a whole catridge of local anaesthetic at the side of bleed. Will cause temporary haemostasis due to pressure and vasoconstriction 3.  Find the site of the artery by pressing your mirror handle firmly at the expected site. You will...

With the hospital on higher restrictions we have shifted to emergency only and I spent a day in the extraction clinic today. I had some successes and some challenges and I will put my thoughts about some particular challenges below: - When a lower molar is heavily carious and the caries on the buccal or lingual is subgingival, it can be difficult to get forceps around the tooth. If you still have one root that has solid buccal and lingual tooth structure i.e the caries is on the distobuccal aspect subgingivally, you may be able to fit a set of lower universal forceps on this good root to try and move the whole tooth. The upside is that you may be able to extract the tooth straightforwardly if the roots are fairly straight or there is bone loss. The downside is that if the caries on the weak root is too extensive, the tooth may section unfavourably and make access difficult. - When you break a root tip you can use an Endo file to remove it when the canal is visible. I had difficult with...

 After seeing Tom Giblin's example of sectioning the premolar during a difficult extraction I decided to try the same today. He sectioned the tooth when the crown fractured off to avoid fracturing the buccal plate as he was grafting the site for a future potential implant. Today I had a carious upper premolar that fractured when I put forceps on it. The patient was elderly and the arch was slightly crowded so the premolar was lingually placed. What this meant was that althought I could fit forceps on the tooth, the force to the buccal was hindered as it pushed against the adjacent teeth. In hindsight I would've just gone straight to cutting the interproximal contacts to give space for the tooth to move into and avoid pressure on the adjacent teeth. Instead, the crown fractured off. In hindsight this is a benefit as it removes the interference of the adjacent teeth and allows an elevator to fit 360 degrees around the tooth. In my eagerness to try the new technique I went straigh...

 Today I spent the day observing in the specialist clinics upstairs. I am in a transition period  with my part time private hours and am yet to start a teaching position so I still had the free weekday to do this. In the morning I watched in the OMFS clinic which was mainly post operative reviews and pre-surgical consultations. The students that were rostered to the OMFS rotation got the preference to watch in theatre so I didn't get any exposure there. Some things they mentioned were: - Trauma signs: CSF leak will result in a halo sign i.e the fluid will have blood in the centre and clear CSF around it which resembles a halo -With a vertical ramus fracture, displacement of the bone opening the fracture will be due to the lateral pterygoid and temporalis which pull in different directions whereas the masseter and medial pterygoid will act as a stabiliser  - Titanium jaw plates will generally stay in situ for the rest of the patient's life but can occasionally show through...

I would argue that the preoperative planning and post operative complication management are aspects of surgery that are just as important to learn as the procedure itself. One thought that has come to mind lately about planning an extraction is to start planning with the patient, not the tooth. Look at their age, gender, medical status. Young, females will have lower density bone on average and extractions that at a glance appear difficult may prove simpler. As a guide, as we grow older, over the age of 25, our bone will increase in density and the teeth will become more brittle due to increased mineral content in the dentine. After the age of 50, we are dealing with glass set in concrete. When planning from the xray, I like to imagine what would happen with the tooth if we were dealing with a dry skull. If the periodontal ligament was gone, would the tooth drop out from gravity? If so, it is likely to be a straight forward extraction. If not, then there are tooth or bony undercuts t...

http://dental-tidbits.blogspot.com/2016/10/managing-dental-fractures.html This works but I don't do it anymore.  I don't trust the bond between composite resin and a liner. I would rather have less interfaces and composite resin only sealing the tubules. You could probably use a self etching primer and bond to seal the dentine which will remove sensitivity but ideally you pumice clean and etch enamel for an ideal long term bond. If you're going to do something then do it properly. Numb the patient up and restore in composite resin. If you want to temporise till a later time then bog it up in GIC till a later date. http://dental-tidbits.blogspot.com/2017/02/radix-entermolaris-and-radix-paramolaris.html I think i've seen 3radix teeth in 4 years. 1 was an incidental finding on a PA and 2 I had to extract. Of the ones I had to extract, one I saw before hand and it came out whole due to perio. The other I was lucky to notice a foreign body in the socket after I extracted...

I was assisting a colleague sectioning a bridge the other day and had a few thoughts: -Sectioning a bridge is a procedure done in an attempt to salvage the prosthodontic work. You should never promise that this is possible, only that you will try. In this case, the tooth that was to be extracted was the abutment that was holding on the whole bridge and the remainder of the bridge dislodged showing severe caries and food packing around the other abutments. This needs to be part of your consent process! You will try and preserve the remainder of the bridge and teeth but this may not be possible. If they don't want to proceed knowing this then you don't take the risk. -Tie a floss tight around the part of the bridge that you want to keep. In this case once the bridge section was complete the remainder of the bridge dislodged and fell to the back of the patient's throat. We caught it before it was swallowed but this risk is unnecessary. Tying floss around one of the connecto...

I had a question in the past about how to extract canines without fracturing the buccal plate. Due to their bulkier buccolingual dimension, canines tend to stick out of the arch at the neck. This couple with the generally thin dimension of bone at the maxillary anterior region, extraction of maxillary canines often result in the loss of the buccal plate of bone which results in a significant defect after healing. Today I performed a full clearance including the extraction of 2 maxillary canines and 1 mandibular canine. Despite the loss of almost 60% of bone height, the canines still provided a challenge to extract. One maxillary canine I managed to fracture a large portion of the buccal plate and the other one I didn't. Anecdotally, this is what I did differently between them: -Fractured the buccal plate: Luxated all around the tooth, Moved to forceps once there was slight mobility. Mainly my force was towards the buccal and the extraction was quick after the buccal plate fract...

So the other day I was rostered in the extraction clinic, my first one of this for the year which means it was the first time extracting teeth other than perio teeth for about 3 months. Below are some thoughts that I had during the day: - I probably broke the roots on about 3 teeth that day and I felt no panic or at least a lot less than if the same thing had happened fresh out of uni. Successful exodontia doesn't involve having straight forward procedures all day every day but requires the skills and knowledge to manage complications and surprises as they come. I dug these roots out with different methods: elevation, root picks and endo files. Some advice I would give to a fresher grad is that you will break plenty of roots, don't be surprised when it happens.  If something happens that you don't expect, step back, take a deep breath and plan out what you will do next. -Most of the appointment is talking, the fastest part is often the extraction itself. 10 minutes of ta...

Suturing is vital to the success of aesthetic and functional soft tissue work. The handling and theory of soft tissues is something that is terribly taught in dental school. The exposure to this subject should be through oral surgery and periodontics experience but this is something that is often absent either due to the lack of appropriate patients, lack of appropriate training staff or due to interdisciplinary politics. The placement, direction and tension of sutures matters hugely to how well the soft tissues react in the healing process. When primary closure is possibly this will result in the fastest healing and sutures can be removed earlier. Loss of primary closure can result in poor or failed grafts. Below are some tips I picked up at the course on how to go about the suturing process. -There are two types of suture : Anchoring and approximating. Anchoring sutures are far from the wound edge >1cm (approximately the length of the needle) where there is more blood supply ...

Some information about socket grafting from the implant course. -Socket grafting is a procedure that is done immediately post extraction aimed at preventing bone resorption to preserve bone and soft tissue volume. This is most commonly prior to planned implant placement. The aims of the procedure are to pack the socket with bone grafting material, secure the material so it doesn't move and protect the blood clot around the graft material. -Xenografts are heated at high temperatures which denatures porcine proteins essentially turning the bone into ceramic. This is not recognised as bone and will not resorb. However, the blood clot between graft particles will eventually differentiate into bone.  Histologically it will appear as particles of ceramic with human bone interspersed between. -When using allograft, as it is technically human bone, the graft material will be resorbed by the body and replaced by autogenous bone. However, you must use allograft that is processed with sup...

Not sure if I've made a post about this before. I am treating a case at the moment where premolar extractions and orthodontics in the past has resulted in root resorption of the remaining premolars and incisors. The combination of this and perio has resulted in very early mobility of the teeth in question. Orthodontics and root resorption is a separate issue but I wanted to make a post on the possible causes I could think of of short roots on an xray. In this case I noted the short premolar roots but didn't question it until I noticed that 4 premolars were missing. I then questioned about orthodontics and put two and two together. Other differential reasons I could think of were: -Apical periodontitis causing apical resorption: As far as I have seen, it is more likely that this resorption is oblique as the apical foramen tends to occur away from the radiographic apex whereas orthodontic resorption seems to occur symmetrically resulting in a generalised flattening of the roo...

Dentistry is a profession that undertakes procedures that would satisfy the most anally retentive person. We deal in microns and millimetres and therefore demand a certain level of quality and finesse in our day to day practice. However there is a time for finesse and a time for haste in our work. The two tend to be inversely related. Yesterday I watched a new graduate colleague attempt to section a splinted 5 unit bridge where all three of the abutment teeth were to be extracted. It was 4:45pm when he started to section with a work day supposedly ending at 5pm. The speed at which he was sectioning was painfully slow and we would have been there till 6pm if no adjustments were made. In this case my advice would be that the bridge sectioning should be the fast part of the procedure as the bridge is going in the bin. There is no need to make precise cuts and minimal consequences of cutting too deep (what is below the bridge? Soft tissue. This will heal well even if you cut too deep a...

A little while ago I posted on detecting and managing curved roots in premolars. http://dental-tidbits.blogspot.com/2019/06/premolar-extractions.html I recently extracted an upper molar with fairly curved buccal roots. One thing I noticed was the xray exposure happened to obscure the curvature of these roots. One tip I would suggest is to spend adequate time inspecting your preoperative xrays before starting the extraction. This can be before the appointment if the procedure is planned or during waiting for local anaesthesia  to settle in if it is not. Play with the contrast and brightness and sharpness filters if your program has one. Thicker or thinner bone can obscure root features and thin roots can be burnt out by higher exposures. Slowly follow or trace the external boundaries of the root surface to describe the root shape and never underestimate the variability of posterior root forms. The good thing about upper molar roots is that the form is usually quite defined o...

Premolar extractions can be tricky because on conventional radiography it can sometimes be hard to determine the proper root structure to plan your extraction. This is because there can be one, two or even three roots superimposed on one another and you can't gain detail about the convergence or divergence of these roots. One tip to determine the number of roots is to carefully examine the PA radiograph and carefully count the number of root borders. This number divided by two will give you the likely number of roots present. If there are multiple roots and they appear quite short of the Xray there are a few possibilities. Your Xray angulation may have forshortened the tooth, the tooth may actually be short or there is a large buccal-lingual divergence of the teeth which has resulted in their occluso-apical dimension appearing short. You can attempt to take a tube shift xray from a different misal-distal angulation. This may give more information of the number and angulation of the...