A Novel Minimal Access Technique for Removal of Impacted Third Molars using Lasers - SMAL Technique

Abstract

Postoperative complications following third molar removal may interfere with the daily activities of patients, such as mastication, speech, and sleep. Various novel methods have been developed to reduce this postoperative discomfort, but these have their own advantages and disadvantages. This novel technique, Sunil's minimal access laser (SMAL) technique, aims to minimize the postoperative swelling and pain and improve healing by combining minimal access incision by using a diode laser.

INTRODUCTION

Mandibular third molars are the most frequently impacted teeth in the oral cavity owing to their location and being the last to erupt.[1]

Removal of the impacted third molar is one of the most commonly performed minor oral surgical procedures. The procedure is associated with postoperative complications such as trismus, pain, and edema. These postoperative complications may interfere with the daily activities of patients, such as mastication, speech, and sleep. Hence, it is imperative to devise a non-traumatic technique to achieve better postoperative results. Various novel methods[2,3] have been developed to achieve this, but these have their own advantages and disadvantages. This novel technique, Sunil's minimal access laser (SMAL) technique, aims to minimize the postoperative swelling, pain and accentuate healing by cleverly adapting combination of minimal access incision and diode laser.[1,4]

The use of laser in oral surgery started back in the 1980s; since then, it has become increasingly popular with the advent of small-sized and handy units. Laser devices offer numerous benefits compared to the conventional scalpel method. It helps to attain more precise excision of soft tissues as compared to the conventional scalpel method. Moreover, it causes coagulation, seals lymphatic vessels, and helps to keep the surgical site clean of bodily fluids. In addition to that, it sterilizes the wound during ablation, in turn resulting in minimal edema, eliminating the need for sutures.[5,6] This case series of 15 cases by using the SMAL technique has shown promising results in minimizing post-operative complications and discomfort.

MATERIALS AND METHODS

After careful radiographic examination [Figure 1a and b], a detailed plan for minimal access surgery was formulated for 15 cases out of which 2 cases are presented here as [Figure 2a and b], betadine 2% mouth rinse was given. A diode laser (ZOLAR-[Canada] 3 W, 110 V, 810 nm) was used for this procedure. The operator, assistant, and the patient were given laser protection goggles, which were provided with the laser unit. After laser tip activation [Figure 3a and b], a crestal incision was made (1 W, continuous mode) distal to second molar region which was extended distally as the distal releasing incision [Figure 4], following which a crevicular incision was made along the second molar and in the area of the exposed crown portion of the third molar tooth, if any. Molt's periosteal elevator was used to gently reflect the buccal and lingual flap. A 701 surgical bur along with a handpiece was used to section the mesial portion of the crown after buccal and distal guttering was done [Figure 5a and b]. Copious amount of saline was used during the sectioning. Care was taken to direct the bur toward the crown of the third molar to avoid any inadvertent damage to the crown of second molar. A front face endodontic mirror #5 (Addler) was used frequently to visualize the residual crown structure during the procedure. This was coupled with a probe to get proper orientation of the remaining crown structure of the third molar to be removed. The type of tooth sectioning was dictated by the location and type of impacted third molar tooth. Deeper-impacted cases required additional root sectioning. A mesial purchase point was made, and a periosteal elevator or crossbar elevator was used for the retrieval of the crown and root structure [Figure 6a and b]. A spoon excavator was used to curette and to remove any dental follicle or granulation tissue. Care was taken to thoroughly inspect the socket for any crown/root residue or calculus. Following the procedure, saline and betadine irrigation was done, and finally, suturing was done using 3-0 braided silk [Figure 7a and b]. Satisfactory postoperative healing was noticed after 1 week [Figure 8a and b].

Figure 1.

(a) Pre-operative clinical image. (b) Pre-operative clinical image

Figure 2.

(a) Pre-operative OPG. (b) Pre-operative OPG

Figure 3.

(a) Activated Diode Laser- distal releasing incision. (b) Activated Diode Laser- distal releasing incision

Figure 4.

Incision design

Figure 5.

(a) Buccal and DIstal guttering. (b) Buccal and DIstal guttering

Figure 6.

(a) Extraction Socket. (b) Extraction Socket

Figure 7.

(a) Post-operative Suturing. (b) Post-operative Suturing

Figure 8.

(a) Post operative satisfactory - Healing after 1 week. (b) Post operative satisfactory - Healing after 1 week

DISCUSSION

Conventionally, for all moderate to difficult tooth impactions, a releasing incision is given in various forms as seen in commonly used techniques such as Keener's, Ward's, and comma-shaped incisions.[7] Distal releasing incision aids in better visibility of the crown of the third molar along with distolingual spur of bone.[1] The use of a diode laser for distal incision in our technique helps attain better visibility due to little or no hemorrhage.[8] The crevicular incision of the second molar allows better visualization of the crown by providing adequate bucco-gingival reflection. The use of a front-faced endodontic mirror #5 (Addler) coupled with a straight probe provides the operator a clean picture of the crown to be sectioned constantly during the procedure. In our technique, we performed surgical removal of 15 impacted third molar teeth and found it to be more beneficial than the conventional technique. Excellent hemostasis along with reduced postoperative edema and pain aided in an uneventful post-extraction period, leading to greater patient acceptance. Compared to the conventional scalpel method, this technique provided excellent hemostasis along with great accessibility and visibility. By avoiding the anterior releasing incision, postoperative edema, scarring and apical migration of flap was prevented.[8,9] Laser also has as an added advantage that it disinfects the micro-flora in the vicinity where the tip is activated.[8,9,10] The use of additional light source can be negated with the fiber optics provided with the laser unit.

The SMAL technique has some limitations. This technique cannot be a panacea for all grades of impactions. In cases where the crown of the third molar is bucally placed, the mesial releasing incision becomes mandatory. Moreover, if laser specifications are not properly set, it may lead to the charring of tissues. The diode laser must be avoided for bone-exposed areas to avoid delayed healing and postoperative complications.[9]

CONCLUSION

This technique (SMAL) puts forward the beneficial effects of using laser and minimal access for the removal of impacted third molar over the conventional scalpel method. With the advantage of accessibility and visibility, the SMAL technique offers excellent hemostasis and disinfection of the micro-flora in the vicinity of the operating field, resulting in minimal edema and other postoperative complications. Thus, this novel technique must drive popularity compared to currently used conventional technique for removal of impacted third molars.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.