Techniques for Extraction of Impacted Lower Third Molars

Techniques for Extraction of Impacted Lower Third MolarsAbstractObjectives m both a(prenominal) series of perspective of meat military units will be produced with the inception of force lower tripletly mill which including throe in the ass, pompousness, inflammation, and trismus. Flap invent is important to every last(predicate)ot good visibility, field to the impact tooth, and for heal of the running(a)ly created defect. This find out aims at the evaluation and comparison of type flutter public figure with comma butterfly butterfly guinea pig of pluck design apply in the surgical extraction of impacted mandibular third hoagie and to nonsubjectively evaluate the merits and demerits of individual scramble design.Study Design In this study 200 patient with bilateral mandibular third submarine sandwichs impaction of age group of 18-30yrs were selected for the study, To reflect the mucoperiosteal reel On one side stock(a) excoriation and on new(a)( prenominal) side comma putz were employ and , after which the steps argon commonality in the removal of impacted third heros. Immediately on the post in force(predicate) mean solar daylights 1, 3 and 7 the post operative parameters (pain, swelling and backtalk inauguration were recorded. And periodontal status were recorded pre operatively, beginning(a) month and 2nd month respectively.Results Conclusion The pain and swelling tally were found to be significantly lower in the surgical sphere of influence with comma scratchings which was recorded on days 1, 3 and 7 as compared to the the area where standard gelts were make. In mouth opening There was a sufficiently great rest seen betwixt the deuce cocksuckers on 1 post-operative day, but though at that place was clinical difference mingled with the ii shits on day 3 and 7 there was no statistical significance.The results of the study shows no lingual nerve paresthesia or any other morbidity, hence the new incis ion design should in all likelihood be made the conventional method, considering the less degree of post operative complications encountered. although it whitethorn supplicate some practice initially.Key words Standard Incision, comma butterfly Incision, Mandibular Impaction, disimpaction,Visual Analog caseClinical Implications-third molar impactions are common and usually associated with surgical complications like pain, swelling, trismus and take formation. Incision and flap design is important in healing wound and minimizing post-operative complications. Comma incision design has shown less post-operative complication in compare to standard incision foundationImpaction is defined as cessation of the eruption of a tooth ca employ by a clinically or radio graphically detectable corporeal barrier in the eruption path or by ectopic position of the tooth. at least one impacted third molar will be present in 33% of the population which requires surgical removal of impacted third molar hence disimpaction is the one of the approximately frequently performed procedure.1Lower third molars constitute a major mountain of teeth that are impacted in the oral cavity2. Many series of side effects will produced with the extraction of impacted lower third molar which including pain, swelling, inflammation, and trismus 3. Flap design is important to allow good visibility, reach to the impacted tooth, and for healing of the surgically created defect.Many different incisions have been utilise to raise the flap, like Wards Incision, modified cellblocks incision, envelope, S molded incision Bould Henry etc4. Wards and modified wards incision are more commonly apply and it was observed that Wards and modified Wards incision provide excellent visual and mechanical access and can be closed by means of a suture inserted between the buccal and lingual soft tissues alone5 , so far when a releasing incision is made a small buccal artery is sometimes encountered and this may be mildly bothersome during the early portion of surgery, and also the suture is usually placed on a bone defect and non on healthy bone this may act additionally pain, delayed healing are also seen.6Nageshwar has tried a new type of incision- comma shaped incision and has compared it with the modified wards technique (Figure 1). as yet the be of cases in his study were very less n=15, hence this study was underinterpreted to compare this new comma shaped incision with wards incision victimization more objective and subjective parameters with a larger sample size.Material and Methods200 patients between the age group of 18-30yrs, having completely impacted bilateral mandibular third molars or partially erupted third molar, with good oral hygiene, without any symptoms of pain or swelling were included for the study. Patient on any medication, pregnancy, double-dyed(a) Pericoronitis, soft tissue impaction, medically compromised, Missing mandibular second molars was the exclusion criteria for the study and were excluded from the study.The instruments used to compare two flap designs wereWilliams probe to stripe pocket depth.Visual analog scale of 0 to 10 was used to estimate pain by subjectively a barkg the patient to post the nocioceptive experience7.Swelling was assessed by mensuration by the distance between theTragus passing game and a reproducible soft tissue pogonion a long the skin surface.Tragus notch to angle of mouthTragus notch to ala baseTragus notch to outer(prenominal) surface on lateral wall of eyeAngle of lower jawbone to outer surface of lateral wall of eyeThe percentage difference between the postoperative and preoperative measurements was calculated.Mouth opening was evaluated by bill the maximum inter incisal distance.After obtaining honorable clearance from the hospital ethical committee, written consent was obtained from all the patients who satisfied the inclusion criteria. Preoperative radiographs were taken to assess the posi tion, depth and angulation of the third molars and to exclude any local pathosis such(prenominal) as a cyst, tumor etc. pain, swelling, mouth opening and pocket depth were recorded Preoperatively . One side of impacted mandibular molar is surgically removed under local anesthesia Using standard flap (figure 2). pain, swelling and mouth opening were measured Postoperative on day 1, 3 and 7 respectively. The extraction on the opposite side was do with the alternate flap design-Comma incision (figure 3). The follow up and postoperative complications of patients on day 1, 3 and 7 were recorded for the parameters studied.After flap reflection standard procedural steps were followed. Flap was sutured with 30 tissue silk sutures. Post operative instructions were given and patients with a standard antibiotic regimen ofCap. Amoxicillin 500mg TDS* 5daysTab. Ibuprofen 400mg TDS* 5 daysTab. Metronidazole 400mg TDS* 5 daysBilateral The pocket depth is recorded after month. info management and AnalysisThe post-operative complications for each subject for both incisions were recorded and all data was entered in Microsoft Excel. Data was analyzed using computer software, statistical Package for Social Sciences (SPSS) version 10. Data are expressed in its frequency and percentage as well as mean and standard deviation. To elucidate the associations and comparisons between different parameters, Chi square (2) test was used as nonparametric test. Students t test was used to compare mean values between two groups. For all statistical evaluations, a two-tailed probability of value, ResultsOut of 200 extractions through with(p) using wards incision 107 were non erupted and 93 were partially erupted,Out of 200 extractions done using comma incision 111 were non erupted and 89 were partially erupted, table 1In extractions done with standard incision 26.67%of subjects had parte pain on day 1 where as only 13.33% of subjects had heavy pain on the exaction side done by comma incisio n. There is a luxuriously statistically significant difference between the two type of incision on day 1 in comparing the pain. (Chi -Square=15.627, P=0.0062) in like manner the pain was severe for 6.67% of the patients extracted with wards incision and there was no pain on other side where comma incision was used on the 7th post operative day (Chi -Square=28.799, P=0.000) mesa 2In extractions done with standard incision 46.47%of subjects had severe swelling on day 1 whereas only 33.33% of subjects had severe swelling on the exaction side done by comma incision. But the difference seen was statistically significant difference between the two type of incision on day 1 in comparing the swelling, (Chi -Square=2.4762, P=0.2889). the swelling was sever for 20% of the patient extracted with wards incision and there were no patient with sever swelling on comma incision side, (Chi -Square=8.6872, P=0.0365). on 7th day there were no patient with severe swelling in both the groups but 40%of the patients experienced check into pain in wards incision group where as only 13.33% had reserve swelling in comma croup. There is a statistically significant difference between the two groups on day 7 (Chi -Square=18.879, P=0.0158).Table 3The mouth opening on day 1 in wards incision side is between 29-25mm where 33.33% where as only 13.33% of the patients in comma group. There was super statistical significant difference between the inter incisal measurements to check for mouth opening on day 1 (Chi -Square=24.658, P=0.000). but though there was clinical difference between the two incisions on day 3 and 7 there was no statistical significance.Table 4 There is significant statistical difference between wards and comma incision in relation to pocket depth recorded after root month and the second month in scratch month is (t=2.684, P=0.025), and in second month is (t=4.937, P=0.000). and even when wards and comma incision are compared separately everyplace time there was stati stical significance between the pocket depth in first and the second month was seen, Ie (wards incision t=5.176, P=0.000) and (comma incision t=6.812, P=0.000) in second month. Table 5DiscussionThird molar surgery has been associated with a variety of complications, flap design is one important factor influencing the severity of these complications . The incisions used in surgical treatments of impacted 3rd molars can be grouped in to envelop and triangular varients.all incisions irrespective of there variations, were extended from the distal grimace of second molar towards ramus. These standerd incisions have been modified by galore(postnominal) surgeons.the incision modified by Groves and Moore started distal to the distobuccal line angle of the second molar to conserve the periodonsium8. Berwick designed a lingually based flap using an incision line that was tongue shaped and did not lie over the bony defect.9. Comma shaped incision was designed by Nageshwar to strangle the po st operative pain and swelling.Post operative pain of moderate to severe intensity is usually noticed after third molar surgery, the pain usually begins as the effect of local anesthesia fades off. The bang intensity of pain is noticed after about 6 hours. The pain then disappears slowly within a few days if it heals normally.10In our study, pain was assessed by using a Visual Analogue Scale (VAS) as it takes little time to describe to the patient and it is easily still by the patient. The results showed less pain scores on comma incision side as compared to wards incision side which is analogous to that of the study of Nageshwar. (This may be because small mucoperiosteal flap was elevated during comma incision, the drainage in comma incision is good and this is single flap hence it will give a tight closure on occlusal surface distal to second molar.) This result is not in correlational statistics with the results of Gool et al as they have seen that severity in pain is not rel ated to the type of incision.11trauma and infection are the main cause for postoperative swelling. The truma to the tissues associated with oral surgical procedures is the usual cause of early postoperative swelling. It is most marked after 19-24 hrs and then diminishes after about septenary days.12Swelling in cases with comma incision was comparatively lees than cases with standard incision was done. This study results compliments the study by Nageshwar.1 but the method of measuring swelling was not satisfactory in that study because the swelling is triplet dimensional hence it is measured by marking on 6 different points on the face as described earlier.Salata L.A et al and Szmyd et al reported that restricted mouth opening peaks on the day of surgery. This study is in agreement to this statement too13. The comma incision encountered less number of subjects with limited mouth opening when compared with the standard incision side which is in agreement with the study of Nageshwars result The inter relation between trismus and pain have been reported in many studies. It might therefore be expected that mouth opening after the removal of impacted mandibular third molars is painful and consequently reduced to its full extent. The possibility has been confirmed by an electromyographic study which proved that restricted mouth opening is a voluntary action to avoid pain.14There was a statistical difference in the postoperative probing depth between the two types of incision after the first and second months. These results are contradictory with many studies, by Rosa et al, Quee et al and Schofield et al which show no differences in pocket depth related to flap designs15. But A.A. Krausz, E.E.Machtei,M.Peled suggest that increase second molar pocket may be related to osteotomy16. However others believe that the flap design and the patients age might have an effect on second molar periodontal status. When removal of impacted molars was done during developmental sta ge of the tooth faster regrowth of the alveolar bone crest . However as all our subjects were in the age group of 18 -30 we tint that age was not a major factor and the difference in pocket depth is related to the type of flap.ConclusionThe results of the study shows that no(prenominal) of the patients in the study developed lingual nerve paresthesia or any other morbidity, hence the new incision design should probably be made the conventional method, considering the less degree of post-operative complications encountered. although it may require some practice initially. Further research with newer flap designs like the comma design, which will minimize the post operative complications, should be considered in the extraction of impacted third molar surgery.