This blog post is based on a talk by Julie Cross at the Young Dentist Conference

Like endodontics, oral surgery can be a source of anxiety for young dentists. As mentioned in my previous post about oral surgery (see here), it can be difficult to assess what treatments you are competent to perform in practice, and those which should be referred to secondary care. 

Common pitfalls in oral surgery in practice

So what does a simple extraction look like?

• Periodontally involved teeth
• Orthodontic extractions
• Intact teeth

What may be a difficult extraction?

• Broken down teeth
• Subgingival caries
• Bulbous roots
• Divergent roots
• Root treated teeth
• Cervical caries
• Dense bone

So when should I refer? 
Where most likely, a surgical approach is required and you do not feel confident doing this

Surgical removal of teeth

Flap design:

• Think about the anatomy e.g. mental nerve in lower premolar region, lingual nerve in wisdom tooth extractions
• Either envelope, 2 or 3 sided
• Always cut perpendicular to tissues
• Cut down to bone i.e. through periosteum
• Lift flap with periosteal elevator, Howarth/Mitchell's trimmer or curved Warwick-James elevator

Bone removal

• May not be required if can apply elevators/forceps once flap is raised 
• Use a tungsten carbide fissure or rosehead bur with saline irrigation
• Make sure you protect the soft tissues from burns
• Remove a gutter of bone buccally to gain application point - try to be as minimal as possible whilst going through the cortex
• If no movement on bone removal, you should consider sectioning the tooth

Luxators

• Often used incorrectly as elevators
• Used to create space between bone and root for application of elevators or forceps
• Take care when using in posterior maxillary region

Complications of oral surgery

Root in antrum/OAC

Haemorrhage

1. Check the patient's medical history (this needs to be done prior to treatment anyway)
2. Is there an underlying medical reason for bleeding? 
3. Maintain pressure with gauze
4. Use LA with adrenaline
5. Haemostatic agent e.g. Surgicel, and horizontal mattress suture
6. Bone wax
7. Refer onto A and E

Fractured Tuberosity

1. Usually occurs with upper wisdom teeth or lone-standing molar - if tooth and tuberosity are minimally displaced, take an impression for vacuum formed splint and support and allow for healing
2. Surgically remove tooth at least 6 weeks later
3. If tooth and tuberosity are mobile, they need to be removed
4. Carefully dissect out - do not just pull as risk of damaging blood vessel and causing haemorrhage
5. Once you've removed the tuberosity, check for OAC
6. Primary closure with sutures

Ultimately, you shouldn't take on treatments that you don't feel confident with! Always refer for a second opinion if you are unsure as complications with oral surgery can be serious!

Do you find knowing when to refer for oral surgery difficult? Please leave your comments in the section below.