Quality content, learnt alot from your channel Dr! Can we have a video on incisions for third molar surgery too since you covered flap reflecting and bone guttering?
I remembered teething my bottom wisdom teeth out when I was 18 years old. They both came out of the gums. I got the both pulled out a month of each other 29 years ago. My top ones came in in my mid 20’s. I even got those pulled out about 25 years ago. I was awake when my wisdom teeth being pulled. I was lucky for having them out in my 20’s something. I think it was easy for the dentist at that time,too. I was young enough to get them out. I was sore for the 1st wisdom tooth pulled for 3 weeks. The other 3 about a week of soreness. I was numbed and even having a little of gas to calmed me down,too. I watched these video of these teens after getting their wisdom teeth pulled and they were so out of it. Even had ice packs on the sides of their faces. I was a little bit tougher or something. Even my grandmother had a molar pulled out and she had a big bruise on that side of her face. I never gotten a bruised face when I had my wisdom teeth pulled. Maybe it was her age. My mother never went through it. My father has went through it,too. My parents never had their wisdom teeth in. Sometimes people get them or not. My sister has a smaller mouth so they are still impacted or never came out. I’m not sure on her if she got them or not.
Hi Hasan! Thanks for watching. If you're ever faced with a hematoma that becomes evident during the surgery, it's best to apply pressure and then have the patient rest and ice/compress the area intermittently for the first 48 hours. Beyond this it's advantageous to get some blood flow to the area to help resolve the hematoma. This would involve intermittent heat compresses. Generally this speeds the resolution. You want to watch for secondary infection as this can be possible. As far as a seroma goes, I realize that I discuss this as a surgical complication for anatomical 'dead spaces', however in practice I can't say I've ever knowingly run across it and that being said, have never treated it. Generally a seroma may be treated via drainage to help it resolve, but I can't say I've ever heard of this being necessary following routine third molar removal. Perhaps another doctor could enlighten us on this if they see our convo! All the best!
I wish I knew! I bought it years ago on eBay and it was fantastic. I’ve wanted another but cannot locate it anymore. The model in the video was altered by me however to add the ‘gum tissue’ and impacted teeth. All the best!
I'm not a dentist nor am I training to be one. I don't know how I ended up here and I don't know why I watched the whole thing. Liked and subscribed!!!. Do you have a patreon or a merch store? I'd love to get my hands on one of those Minnesota retractors.
Thanks Jonny! They're readily available on Ebay for cheap if you just want to check one out. All the best and thanks for your support! PS - I am not on Patreon, but have heard of it. Should I be on there?
@@OnlineExodontia You should definitely look into Patreon! It allows for your viewers to support you monetarily if they wish, and I definitely think your videos deserve it! :)
Potentially yes. This is one argument against the envelope flap. In reality, assuming proper tissue handling and decent OH during healing, there is minimal to no resulting recession. Many surgeons use this design. Thanks for watching!
One thing I still struggle with is protecting the lingual tissue around the third molar when I section the tooth. I use a Minnesota to reflect, but my assistant struggles to reflect the tissue, protect the tongue, suction and irrigate. I only have access to an impact air, hence why I need the assistant to irrigate. Any advice?
Try getting the Isolite system from Zyris. You can use this thing and cut the buccal portion off the mouthpiece. This protects the airway, retracts / protects the tongue and suctions all at once. It's terrific for lower third molars. www.zyris.com/ Worth every penny! All the best! Jason
Great video! I have a question, how do you suture your envelope flap, for example, the papilla between first and second molar, since only the buccal flap is reflected? Thanks!
You always start with the first suture just distal to the second molar. Get that one cinched in perfectly and you will avoid that tissue bunching that you sometimes get when the flap rides up the buccal surfaces of the teeth. Once that one is in, you can do one behind it for the release (or two, every provider has a different preference). After that, if the papilla is sitting nicely I will put some 4x4 gauze over the extraction site, the wrap the gauze around the buccal surface to apply pressure to the flap...hopefully that makes sense. The fibrin will begin to adhere the papilla without the need for a suture here. Hope that helps!
Thank you so much for the informative reply! From the video, it seems like the incision goes from 45 mesial to 47distal. Just to be sure, do you mean the interdental papilla between 45,46 and 46,47 do not need be sutured? With firm pressure from the gauze in addition to the suture distal to 47 is going to stabilize the flap in these area?
In school we were taught to do an envelope flap starting from second molar mesial to the retromolar area. Sometime I feel it’s not enough unless a vertical incision is made on second molar mesial. But if we extend the envelope flap mesially, I run into the problem of whether or not to suture the papilla since the lingual side isn’t reflected, and it’s tough to pass the needle lingually. Hope I explain the problem clearly.
@@naixie Yes I understand what you're saying. There are all different flap designs, this is just one of them and you need to modify them as needed based on the type of impaction. A deeper impaction may require a larger flap and more access than say a partly erupted third molar. The vertical release certainly helps with access, but can be harder to reapproximate and often results in more edema and post-op discomfort. Extending the envelope more mesial also releases tension on the flap to get more access. Really no right or wrong just a matter of personal preference and being sure to select the proper flap for the procedure. You should have this figured out before you make an incision. Hope that helps?
@@naixie Some providers don't even suture the lowers believe it or not and patients still heal okay. I rarely suture the upper and always do the lower. There is no step-by-step answer for placing sutures in other words, it won't be the same every time necessarily. You need to understand why you are placing sutures and that will dictate whether you need them on a case-by-case basis. You are placing them to reapproximate the tissue. So if the tissue is doing that naturally without assistance from a suture, you're likely okay to leave it.
Online Exodontia Brilliant! More videos on flap designs i.e upper impacted wisdoms, maxillary and mandibular molar retained roots would be helpful, especially live patient demos. Thank you 👍
This is a great lecture. I've always been interested in knowing the flap design that leads to the least post op morbidity. I've had issues with triangular flap and the access that it provides me. I wonder if you've tried the Heitz incision?( a vertical incision is placed starting from the second molar. Then a horizontal incision is placed well far buccal. The flap is elevated toward the lingual side
I have never approached a tooth in this manner and will be certain to check out that technique! Always looking for interesting new material to add to the site. All the best!
Hi there, I had genioplasty and the surgeon used this technique to access my chin rather than making an incision below the gum. Is this dangerous? I'm still numb 6 months after the surgery.
That's interesting. I'm not an oral surgeon so I'm not comfortable commenting on this. The way they open the tissue for a genioplasty would be different than what's illustrated in this video as the geniopasty require access to the chin. If you're still numb it's imperative that your surgeon knows this as there is a time-window in which you may receive help to resolve the numbness in some cases. If you leave it too long, sometimes there are no options to fix it.
@@OnlineExodontia yes that's why I'm a little concerned cause usually it is done by making an incision below the gumline. Not by creating a flap. But does this method put the nerves at at higher risks? So if it was done on the front lower teeth will that be dangerous for the nerves?
This is a Minnesota retractor in the video. You can use many different ones, but here in Canada / USA I would say it's the most commonly employed retractor. All the best!
Great video! Just a quick question, how far is too far for the distal releiving incision? I am always a bit suspicious about injuring the long buccal nerve when making the distal incision. I understand the incision needs to be from the DB aspect of the lower second molar but what are the chances of injuring the long buccal nerve? Looking at illustrations from textbooks the long buccal nerve is in very close proximity to the erupted lower second or third molar. Thank you!
Great question, you are without a doubt cutting some branches of this nerve, however you will not typically see any lasting effects from doing so. As a guide when starting you may choose to cut about 15mm-20mm, but over time you will learn to rely more on the anatomy that you see and palpate as well as the access you'll require for extracting the tooth. What I mean is you may not always need 15-20mm on the DB, you might just have to cut 5-10mm to get enough tissue open to deliver the tooth. Hopefully that's helpful for you!
@@OnlineExodontia Thank you for your reply, much appreciated. Lets say if I incise the long buccal nerve through and through ( hopefully never happens) are there any long lasting functional effects that the patient may find it difficult or may affect their daily routine over time? I understand its case by case but just want to get a better understanding of what the consequences are. Thanking you again!
@@SK-vx3nu I have been told by an oral surgeon whom I respect greatly that if this nerve is ever compromised patients do not find it to be a big problem. It's a bit different than severing the lingual nerve for example where now the patient can feel their tongue! All the best and thanks for watching!
I don't generally do flaps for these teeth anymore. I used to, but if you section them properly you can remove them with the help of your cryer elevators and heidbrink root picks. Some removal of interradicular bone is helpful too should the tooth break. If you choose to do a flap, then do an envelope flap. Release one papilla mesial and distal to the site. If you need more access, release two papilla's mesial to the tooth. This flap is easy to create and reapproximate. All the best!
@@abhachhabra2762 You can measure the distance on your radiograph as long as you have a properly angled exposure, then measure your bur. A surgical length FG 702 bur has about 12mm of bur length once it's inserted in the handpiece. Alternatively, sink your bur then with magnification and good light, rinse the area and have your assistant suction with a small tip suction. If you see blood entering between the roots apical to the furcation, you're through, if blood is only going between the roots from the lingual / buccal, it's likely that you're still not through the furcation. Hope that helps! If you're sectioning a lower impaction, use the length of the bur flutes to determine how deep you are cutting.
Hello! Your channel is very helpful, keep the work going. I have a question about my own teeth. I have 2 partially erupted wisdom teeth at the bottom jaw. They both are covered by the gum flap, I clean it well everyday, Its been like this 2-3 years now, no infection, I can even clean between, but I had some headaches when they were growing. They are both properly aligned, but I have small crowding in the front. Should I only surgicly remove the gum flap or is it necesseary with extraction when I want to fix my crowding? I am 28 so I think both of roots are grown and they are close to the nerves, so I am afraid of removing them :( One orthodontist offered me to pull them up with bracers, but he said it would take 6 months and would be painful.
That's a tough call for me to make here with the information available to me. What I can tell you is generally if they are impacted as you describe, the gum flap (operculum) will grow back after it's removed. At 28 you're still at a reasonable age to get them removed. The risk must be assessed however as you don't appear to be having pain at the moment. It's unlikely that they're terribly close to the inferior alveolar nerve as you can see a portion of them in the mouth, but that would be for your provider to decide. Moving them in via orthodontics will likely create a difficult area to clean as the space is limited and it's a lot to go through. If it were me I would have them assessed by an oral surgeon or a general dentist that does these procedures and if the risk to the nerve is minimal, I'd remove them. Hopefully that helps. All the best!
I would try a different scalpel blade as perhaps it has become dull. You should press with enough pressure to act as if you're scoring the bone and the periosteum should cut. All the best!
Great thank u doctor in case i have fully impacted 3rd molar is it better to use triangular or trapezoidal flap? What are the most commonly used flaps for surgical extraction for lower third molars envelope and triangular flaps?
Thanks for watching! I can tell you that you must do what you are comfortable with as both styles are widely accepted and used successfully. Triangular flaps can be a bit more conservative over time, but there are reports of them leading to more post-operative edema and dehiscence. Envelope flaps are nice, however they are often knocked for at times contributing to attachment loss or recession upon healing. Both are good choices. This link here is a paper that shows lots of flap designs bit.ly/2L1qO4e. All the best!
I had my wisdom teeth removed recently and noticed that when I pull my gums back that flap you make in the video peels back from the teeth when will this heal?
Tissue heals in 10-14 days, however these flaps can persist much longer if you're opening them or moving them around. I would try to leave the areas alone as best as you can. After a few weeks you should start to see some improvement. All the best!
I am young so my second molars have been growing recently and these gum flaps have been appearing for every single one that grew in (4) but they have all gone away after all of them fully grew, I was worried but I looked into it a little more and realized that I'm fine.
Hi Doc. In extending incision distolaterally towards anterior border of mandible could you comment on what anatomical structures are likely involved? In particular could you define the retromolar triangle, retromolar fossa, retromolar trigone and temporal groove. It seems the distolateral extension would cut through the buccal nerve, temporalis tendon, buccinator insertion and the retromolar foramen vessels (if and where the latter exist). My main concern is obviously the temporalis tendon and any blood vessels in this area. Is there some landmark I can use to ensure I avoid these structures? Please advise, I just cant seem to get a good answer on this question. Enjoying your videos.
DK - the course covers some of these issues, however to try and sum it up for you, you cut laterally (never straight distal) to avoid the lingual nerve as I imagine you know. You will inevitably transect some fibres of the buccal nerve, but this is of little to no consequence. If you look at Pell & Gregory you'll see the varied positions of the impactions. When they're further anterior to the ramus, it's easier to flap and have less tissues involved distally. The further back the impaction is however, you'll sometimes be faced with thicker more tenacious tissue to contend with. If you're into the buccinator you're too far and you shouldn't be in the tendon of the temporalis. bit.ly/3vE19nc That link shows an image of the retromolar triangle. The medial aspect of the triangle shown is not a bad line for the incision, only you'd probably only go half that distance of that line. Generally I find the anterior edge of the ramus and palpate the buccal shelf...also don't be shy to palpate the medial of the mandible to help gauge the flare of the mandible so you can better assess whether you'll be over bone and not encroaching on distal tissue or the lingual nerve region. Feel free to email me and I can try to offer more help, but hopefully this is a start!
@@OnlineExodontia thank you for sharing Doc. So the tighter the impaction (up under the ramus), the more lateral we make the "distolateral" incision? For this incision do you press hard on the scalpel to ensure you sever periosteum? It seems all considered the most pertinent risk is if a retromolar foramen and associated vasculature exist, which some studies indicate they do in 10- 20% of some populations (Indian and Chinese, if I recall), would you agree? Would this be profuse bleeding and if yes how would you control?..would you abandon procedure and suture tightly? Would a good guide be a 1cm distolateral incision, hard on bone, from DB of 3rd molar heading just distal to anterior border of mandible? I requested your email on your site, will be looking into the course for sure, many thanks again.
@@dkkhan4536 Each case of course will be a bit different, but yes an incision like you've described would be reasonable. You should imagine trying to score the bone with the scalpel to ensure you get through the periosteum. In short, most bleeding is controlled via sustained pressure and usually that will suffice for any procedure a general dentist is doing. I reached out to you, but haven't heard back so maybe check your junk folder if you haven't seen anything! All the best!
Hi Abby! Surprisingly, many third molars can be removed and not sutured and will still heal just the same. Some surgeons prefer the area water tight, others leave it partially open and some choose to leave the site as is without sutures. All the best!
Surgeons who don’t do this are incompetent. I love the minnesota, seldon or periosteal being used for retraction is not ergonomic. Thanks for hearing my rant. Good video.
Thank you. It should have been taught in dental school, but honestly, I am learning more from you than I ever did in school.
That was my goal! Thanks Jay for your kind words. All the best. Please spread the word.
That's scary
I totally agree!
In USSR they used to teach like this.
That’s really scary
Quality content, learnt alot from your channel Dr! Can we have a video on incisions for third molar surgery too since you covered flap reflecting and bone guttering?
I remembered teething my bottom wisdom teeth out when I was 18 years old. They both came out of the gums. I got the both pulled out a month of each other 29 years ago. My top ones came in in my mid 20’s. I even got those pulled out about 25 years ago. I was awake when my wisdom teeth being pulled. I was lucky for having them out in my 20’s something. I think it was easy for the dentist at that time,too. I was young enough to get them out. I was sore for the 1st wisdom tooth pulled for 3 weeks. The other 3 about a week of soreness. I was numbed and even having a little of gas to calmed me down,too. I watched these video of these teens after getting their wisdom teeth pulled and they were so out of it. Even had ice packs on the sides of their faces. I was a little bit tougher or something. Even my grandmother had a molar pulled out and she had a big bruise on that side of her face. I never gotten a bruised face when I had my wisdom teeth pulled. Maybe it was her age. My mother never went through it. My father has went through it,too. My parents never had their wisdom teeth in. Sometimes people get them or not. My sister has a smaller mouth so they are still impacted or never came out. I’m not sure on her if she got them or not.
Please do a video with lower molar odontectomy, with each type of incision.
Hey doc awesome video ..do know any channel that could help me up my endo?
thank you, informative and helpful tips,
can you pls post a video about lingual nerve damage?
It's on there now my friend!
Hi doctor
I have 2 questions
1 how can I recognize a hematoma from septoma
2 how to manage each one of them
Thank you
Hi Hasan! Thanks for watching. If you're ever faced with a hematoma that becomes evident during the surgery, it's best to apply pressure and then have the patient rest and ice/compress the area intermittently for the first 48 hours. Beyond this it's advantageous to get some blood flow to the area to help resolve the hematoma. This would involve intermittent heat compresses. Generally this speeds the resolution. You want to watch for secondary infection as this can be possible. As far as a seroma goes, I realize that I discuss this as a surgical complication for anatomical 'dead spaces', however in practice I can't say I've ever knowingly run across it and that being said, have never treated it. Generally a seroma may be treated via drainage to help it resolve, but I can't say I've ever heard of this being necessary following routine third molar removal. Perhaps another doctor could enlighten us on this if they see our convo! All the best!
Hi, can you tell what's style of bur did you use in surgery of the 3rd molar. Thanks
1703L! All the best!
Greatest video on TH-cam!
Thanks for the kind words Manny. I appreciate your support. All the best!
THANKS FOR SHARING
I would like to ask about the manufacturer of the dental model.
If you could share the manufacturers info?
I wish I knew! I bought it years ago on eBay and it was fantastic. I’ve wanted another but cannot locate it anymore. The model in the video was altered by me however to add the ‘gum tissue’ and impacted teeth. All the best!
I'm not a dentist nor am I training to be one. I don't know how I ended up here and I don't know why I watched the whole thing. Liked and subscribed!!!. Do you have a patreon or a merch store? I'd love to get my hands on one of those Minnesota retractors.
Thanks Jonny! They're readily available on Ebay for cheap if you just want to check one out. All the best and thanks for your support! PS - I am not on Patreon, but have heard of it. Should I be on there?
@@OnlineExodontia You should definitely look into Patreon! It allows for your viewers to support you monetarily if they wish, and I definitely think your videos deserve it! :)
Would you expect any recession on the first molar or second premolar from the flap design?
Potentially yes. This is one argument against the envelope flap. In reality, assuming proper tissue handling and decent OH during healing, there is minimal to no resulting recession. Many surgeons use this design. Thanks for watching!
One thing I still struggle with is protecting the lingual tissue around the third molar when I section the tooth. I use a Minnesota to reflect, but my assistant struggles to reflect the tissue, protect the tongue, suction and irrigate. I only have access to an impact air, hence why I need the assistant to irrigate. Any advice?
Try getting the Isolite system from Zyris. You can use this thing and cut the buccal portion off the mouthpiece. This protects the airway, retracts / protects the tongue and suctions all at once. It's terrific for lower third molars. www.zyris.com/
Worth every penny!
All the best!
Jason
Great video! I have a question, how do you suture your envelope flap, for example, the papilla between first and second molar, since only the buccal flap is reflected? Thanks!
You always start with the first suture just distal to the second molar. Get that one cinched in perfectly and you will avoid that tissue bunching that you sometimes get when the flap rides up the buccal surfaces of the teeth. Once that one is in, you can do one behind it for the release (or two, every provider has a different preference). After that, if the papilla is sitting nicely I will put some 4x4 gauze over the extraction site, the wrap the gauze around the buccal surface to apply pressure to the flap...hopefully that makes sense. The fibrin will begin to adhere the papilla without the need for a suture here. Hope that helps!
Thank you so much for the informative reply! From the video, it seems like the incision goes from 45 mesial to 47distal. Just to be sure, do you mean the interdental papilla between 45,46 and 46,47 do not need be sutured? With firm pressure from the gauze in addition to the suture distal to 47 is going to stabilize the flap in these area?
In school we were taught to do an envelope flap starting from second molar mesial to the retromolar area. Sometime I feel it’s not enough unless a vertical incision is made on second molar mesial. But if we extend the envelope flap mesially, I run into the problem of whether or not to suture the papilla since the lingual side isn’t reflected, and it’s tough to pass the needle lingually. Hope I explain the problem clearly.
@@naixie Yes I understand what you're saying. There are all different flap designs, this is just one of them and you need to modify them as needed based on the type of impaction. A deeper impaction may require a larger flap and more access than say a partly erupted third molar. The vertical release certainly helps with access, but can be harder to reapproximate and often results in more edema and post-op discomfort. Extending the envelope more mesial also releases tension on the flap to get more access. Really no right or wrong just a matter of personal preference and being sure to select the proper flap for the procedure. You should have this figured out before you make an incision. Hope that helps?
@@naixie Some providers don't even suture the lowers believe it or not and patients still heal okay. I rarely suture the upper and always do the lower. There is no step-by-step answer for placing sutures in other words, it won't be the same every time necessarily. You need to understand why you are placing sutures and that will dictate whether you need them on a case-by-case basis. You are placing them to reapproximate the tissue. So if the tissue is doing that naturally without assistance from a suture, you're likely okay to leave it.
Your videos are excellent!! Well done 👍 watching from UK
That's awesome to hear! Thanks so much. I've been working on more so there will be more to come in the near future. All the best!
Online Exodontia Brilliant! More videos on flap designs i.e upper impacted wisdoms, maxillary and mandibular molar retained roots would be helpful, especially live patient demos. Thank you 👍
@@DE51B0Y Appreciate the feedback. All the best!
Crisp and very detsiled video!Amazing
Thanks so much! All the best!
Thank you very much for the great work
This is a great lecture. I've always been interested in knowing the flap design that leads to the least post op morbidity. I've had issues with triangular flap and the access that it provides me. I wonder if you've tried the Heitz incision?( a vertical incision is placed starting from the second molar. Then a horizontal incision is placed well far buccal. The flap is elevated toward the lingual side
I have never approached a tooth in this manner and will be certain to check out that technique! Always looking for interesting new material to add to the site. All the best!
Hi there, I had genioplasty and the surgeon used this technique to access my chin rather than making an incision below the gum. Is this dangerous? I'm still numb 6 months after the surgery.
That's interesting. I'm not an oral surgeon so I'm not comfortable commenting on this. The way they open the tissue for a genioplasty would be different than what's illustrated in this video as the geniopasty require access to the chin. If you're still numb it's imperative that your surgeon knows this as there is a time-window in which you may receive help to resolve the numbness in some cases. If you leave it too long, sometimes there are no options to fix it.
@@OnlineExodontia yes that's why I'm a little concerned cause usually it is done by making an incision below the gumline. Not by creating a flap. But does this method put the nerves at at higher risks? So if it was done on the front lower teeth will that be dangerous for the nerves?
Thank you so much
thank you teachers
May I know the name of retractor used?
This is a Minnesota retractor in the video. You can use many different ones, but here in Canada / USA I would say it's the most commonly employed retractor. All the best!
wow, i got tons out of this! thanks!
Great to hear Brad! All the best!
Great video! Just a quick question, how far is too far for the distal releiving incision? I am always a bit suspicious about injuring the long buccal nerve when making the distal incision. I understand the incision needs to be from the DB aspect of the lower second molar but what are the chances of injuring the long buccal nerve? Looking at illustrations from textbooks the long buccal nerve is in very close proximity to the erupted lower second or third molar. Thank you!
Great question, you are without a doubt cutting some branches of this nerve, however you will not typically see any lasting effects from doing so. As a guide when starting you may choose to cut about 15mm-20mm, but over time you will learn to rely more on the anatomy that you see and palpate as well as the access you'll require for extracting the tooth. What I mean is you may not always need 15-20mm on the DB, you might just have to cut 5-10mm to get enough tissue open to deliver the tooth. Hopefully that's helpful for you!
@@OnlineExodontia Thank you for your reply, much appreciated. Lets say if I incise the long buccal nerve through and through ( hopefully never happens) are there any long lasting functional effects that the patient may find it difficult or may affect their daily routine over time? I understand its case by case but just want to get a better understanding of what the consequences are. Thanking you again!
@@SK-vx3nu I have been told by an oral surgeon whom I respect greatly that if this nerve is ever compromised patients do not find it to be a big problem. It's a bit different than severing the lingual nerve for example where now the patient can feel their tongue! All the best and thanks for watching!
@@OnlineExodontia Awesome and thank you so much for getting back to me. Much appreciated!
@@SK-vx3nu Anytime my friend! All the best!
MORE!!!!!!!!!!!
someone give me tips, i just got my wisdom teeth removed and have these super annoying flaps on my molars.
Yeah okay so now I’m terrified
how to raise a flap for endodontically treated 2nd molar when 1st and 3rd molar are present?
I don't generally do flaps for these teeth anymore. I used to, but if you section them properly you can remove them with the help of your cryer elevators and heidbrink root picks. Some removal of interradicular bone is helpful too should the tooth break. If you choose to do a flap, then do an envelope flap. Release one papilla mesial and distal to the site. If you need more access, release two papilla's mesial to the tooth. This flap is easy to create and reapproximate. All the best!
Thanks for your reply. how do you gauge that you have cut through the furcation and removed the interradicular bone.
@@abhachhabra2762 You can measure the distance on your radiograph as long as you have a properly angled exposure, then measure your bur. A surgical length FG 702 bur has about 12mm of bur length once it's inserted in the handpiece. Alternatively, sink your bur then with magnification and good light, rinse the area and have your assistant suction with a small tip suction. If you see blood entering between the roots apical to the furcation, you're through, if blood is only going between the roots from the lingual / buccal, it's likely that you're still not through the furcation. Hope that helps! If you're sectioning a lower impaction, use the length of the bur flutes to determine how deep you are cutting.
@@OnlineExodontia thanks a ton!
@@abhachhabra2762 Anytime my friend!
Hello! Your channel is very helpful, keep the work going. I have a question about my own teeth. I have 2 partially erupted wisdom teeth at the bottom jaw. They both are covered by the gum flap, I clean it well everyday, Its been like this 2-3 years now, no infection, I can even clean between, but I had some headaches when they were growing. They are both properly aligned, but I have small crowding in the front. Should I only surgicly remove the gum flap or is it necesseary with extraction when I want to fix my crowding? I am 28 so I think both of roots are grown and they are close to the nerves, so I am afraid of removing them :( One orthodontist offered me to pull them up with bracers, but he said it would take 6 months and would be painful.
That's a tough call for me to make here with the information available to me. What I can tell you is generally if they are impacted as you describe, the gum flap (operculum) will grow back after it's removed. At 28 you're still at a reasonable age to get them removed. The risk must be assessed however as you don't appear to be having pain at the moment. It's unlikely that they're terribly close to the inferior alveolar nerve as you can see a portion of them in the mouth, but that would be for your provider to decide. Moving them in via orthodontics will likely create a difficult area to clean as the space is limited and it's a lot to go through. If it were me I would have them assessed by an oral surgeon or a general dentist that does these procedures and if the risk to the nerve is minimal, I'd remove them. Hopefully that helps. All the best!
What should I do if I can’t cut through the periosteum?
I would try a different scalpel blade as perhaps it has become dull. You should press with enough pressure to act as if you're scoring the bone and the periosteum should cut. All the best!
Great thank u doctor
in case i have fully impacted 3rd molar is it better to use triangular or trapezoidal flap?
What are the most commonly used flaps for surgical extraction for lower third molars envelope and triangular flaps?
Thanks for watching! I can tell you that you must do what you are comfortable with as both styles are widely accepted and used successfully. Triangular flaps can be a bit more conservative over time, but there are reports of them leading to more post-operative edema and dehiscence. Envelope flaps are nice, however they are often knocked for at times contributing to attachment loss or recession upon healing. Both are good choices. This link here is a paper that shows lots of flap designs bit.ly/2L1qO4e. All the best!
I had my wisdom teeth removed recently and noticed that when I pull my gums back that flap you make in the video peels back from the teeth when will this heal?
Tissue heals in 10-14 days, however these flaps can persist much longer if you're opening them or moving them around. I would try to leave the areas alone as best as you can. After a few weeks you should start to see some improvement. All the best!
@@OnlineExodontia thank you
I am young so my second molars have been growing recently and these gum flaps have been appearing for every single one that grew in (4) but they have all gone away after all of them fully grew, I was worried but I looked into it a little more and realized that I'm fine.
The gum flap is called an operculum. Totally normal! All the best!
Love u sir appreciated from Pakistan ,,,what an explanation
Thanks Sayed!
Very good.allah helps you.my best wishes to be a muslim
Hi Doc. In extending incision distolaterally towards anterior border of mandible could you comment on what anatomical structures are likely involved? In particular could you define the retromolar triangle, retromolar fossa, retromolar trigone and temporal groove. It seems the distolateral extension would cut through the buccal nerve, temporalis tendon, buccinator insertion and the retromolar foramen vessels (if and where the latter exist). My main concern is obviously the temporalis tendon and any blood vessels in this area. Is there some landmark I can use to ensure I avoid these structures? Please advise, I just cant seem to get a good answer on this question. Enjoying your videos.
DK - the course covers some of these issues, however to try and sum it up for you, you cut laterally (never straight distal) to avoid the lingual nerve as I imagine you know. You will inevitably transect some fibres of the buccal nerve, but this is of little to no consequence. If you look at Pell & Gregory you'll see the varied positions of the impactions. When they're further anterior to the ramus, it's easier to flap and have less tissues involved distally. The further back the impaction is however, you'll sometimes be faced with thicker more tenacious tissue to contend with. If you're into the buccinator you're too far and you shouldn't be in the tendon of the temporalis. bit.ly/3vE19nc That link shows an image of the retromolar triangle. The medial aspect of the triangle shown is not a bad line for the incision, only you'd probably only go half that distance of that line. Generally I find the anterior edge of the ramus and palpate the buccal shelf...also don't be shy to palpate the medial of the mandible to help gauge the flare of the mandible so you can better assess whether you'll be over bone and not encroaching on distal tissue or the lingual nerve region. Feel free to email me and I can try to offer more help, but hopefully this is a start!
@@OnlineExodontia thank you for sharing Doc. So the tighter the impaction (up under the ramus), the more lateral we make the "distolateral" incision? For this incision do you press hard on the scalpel to ensure you sever periosteum? It seems all considered the most pertinent risk is if a retromolar foramen and associated vasculature exist, which some studies indicate they do in 10- 20% of some populations (Indian and Chinese, if I recall), would you agree? Would this be profuse bleeding and if yes how would you control?..would you abandon procedure and suture tightly?
Would a good guide be a 1cm distolateral incision, hard on bone, from DB of 3rd molar heading just distal to anterior border of mandible? I requested your email on your site, will be looking into the course for sure, many thanks again.
@@dkkhan4536 Each case of course will be a bit different, but yes an incision like you've described would be reasonable. You should imagine trying to score the bone with the scalpel to ensure you get through the periosteum. In short, most bleeding is controlled via sustained pressure and usually that will suffice for any procedure a general dentist is doing. I reached out to you, but haven't heard back so maybe check your junk folder if you haven't seen anything! All the best!
tq
I had this done last week and they never stitched me back up lol 😂😂… is that normal?
Hi Abby! Surprisingly, many third molars can be removed and not sutured and will still heal just the same. Some surgeons prefer the area water tight, others leave it partially open and some choose to leave the site as is without sutures. All the best!
Surgeons who don’t do this are incompetent. I love the minnesota, seldon or periosteal being used for retraction is not ergonomic. Thanks for hearing my rant. Good video.
I’m not watching this because I need to know how to do this, but because I’m about to have this done to me
Good luck and all the best!
@@OnlineExodontia thank you 🥲
😊☺️☺️😊
Mmm