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Pre- and postoperative management of impacted third molars
Department of Oral Surgery PRE- A ND PO STOPERATIVE lvIANA GE:MENT OF IMPACTED THIRD :MOLARS FRANK W. Ro UNDS,· A.B. , D.D.S.,
BOSTON , M ASS.
T
H E last twenty years have shown a marked and favorable development in th e technic of removal of impacted third molars. Prior to 1913 these malpositions were all operated on in the same general way without much regard for trauma, usually involving unnecessary bone destruct ion and frequently by sacrificing sound second molars. Today, unfortunately, too much of the old-time modu s operandi is in evidence, but as a whole th e dental profession is handling these cases in a far saner manner. The credit for thi s progress is lar gely due to t he stimulus genera ted by r esearch workers in this field, most not ably Winter of St. Louis, who presented an ent irely new perspective when he developed his now st andardized classification of impactions. The journals and textbooks of recent years have been r eplete with information rcgarding the proper surgical approach to these abnormalities, and a discussion of individual operating methods is not in the province of this article. The preoperative care enter ing into t hese cases and the postop erative care given th em have been somewhat neglected but ar e of definite importance in at ta in ing successf ul results; hence thi s subject and thi s brief discu ssion. I ha ve ofte n been startled on hearing general practitioners in dentistry remark that th ey do not encounter impaction s in their practice, and I can only conclude th at they are unob serving or are not thorough in making mouth surveys. More complete radiographic study might be illuminating and informativ e. Granted that impactions are clinically evident or are disclosed only by the x-r ay examinat ion, they deserv e serious consideration by th e orthodontist , the periodontist, th e prosthodontist, t he pedi odonti st , th e general practitioner, and th e physician. Undoubtedly not all third molars in normal position, nor all impa ctions need t o be viewed from th e standpoint of surgical intervention, but a vast number which are now overlooked fall under the head of potential menaces to ora l health, mental balan ce, and ph ysical welfare. Far too oft en do the y cwne to th e dentist's attention only when acute pathologic inv olvements have so compli cat ed the situation that deep neck infections endanger t he patient 's life. A large proportion of such serious sequelae could have been avoided by an early diagnosis and elimination of the impaction. The old adage of the horse being stolen before the door is locked is wonderfully exemplified in the cases of pericoronal infections which get out of hand. It is a fair presumption that the third • For mer President Am erican Soci et y of Or al S urgeons and E x o dontists.
166
I mpacted Th ird Molm's
167
molar which does not assume it s normal position in the arc h at its ph ysiologic time of eruption constit utes a possible if not a probable trouble maker at some future period. If the evidence point s t o th e presumabl e removal of the offending t ooth at some tim e in an indefinit e fu ture, good judgment may indicat e early surgical interference thus forest alling dam age. Impactions in th e mouths of yout hful p ati ents are simpler to operate than thos e in middl e or old age; t he postoper ati ve r eacti ons are less, the convalescence is simplified and rege neration of ti ssue hast ened. It is not an uncommon occurrence to observ e successfully compl eted cases of orthodontia up set by t he pressure of un considered impactions. After reo tainers are finally removed, this constant for ce again disrupts the alignment , malocclusion recurs, and excellent regulative work goes for naught. Money has been spent in vain , the patient's cooperation has 'availed nothing, and th e orthodontist's reputati on suffers. Traumatic occlusions an d consequent pocket forma tion s which come under the periodontist's treatment may rea dily be influenced by third molar pressure. If such be th e case, is it not putti ng th e cart before the horse to scale teet h periodically and attempt to readj ust abnormal mast icatory sur faces and allow t he underlying pressure facto rs to go on without cor rect ion ~ Has not someone overlooked somet hing when the edentulous elderly pati ent find s th e comfort and f unctio n of a well-fitting dent ure disrupted by th e disturbances incidental to t he efforts of erupt ion of an overlooked t hird molar ? The extensive pathologic in volvement s commonly associated with the se happenin gs are disconcerting, t o say th e least, to both dentist and pati ent. It is regrettable that so man y second molars in normal occlusion are allowed to become hopelessly carious on th eir distal surfaces because of the seep ing of ora l debris under th e sof t tissue flaps of the so-called partial impacti ons. It is also regrettable th at erosions of second molal' distal roots by third molar pressure are not more frequent ly forestalled. In this connection it should not be overlooked that if a second molal' must be pr ematurely sacrificed , its antagonist on the opposing jaw elongates and often establishes pocket formation and malocclusion. Reflex nervous disturbances often bring imp actions into the medical field. These upsets may run the ga mut from headaches, neck aches, pseudo earaches, eye pains, and ant ral symp toms to the more serious neuros es. The partially er upted impacti on, in general, is a more common disturber of t he peace than are t he completely buried types. P eri coronal pathologic conditi on is a distinct menace. The r esidual pockets u nder t he overlying flap form an ideal locale for the breeding of Vincent's organisms an d should never be overlooked in the clini cal care of these cases. From these brief observa t ions is it not apparent that an early r ecogniti on of disastrous possibiliti es const itutes a definite obligation on the part of th e dent al practitioner ~ H is good judgment, or course, should be t he guide as to the indication of conserv ative or r adical measures. In th is survey it is well to note that sometimes ap paren tly radical procedure is t he more conserv ative.
J68
Frank W. R ounds
If th e decision is reach ed th at an impaction should be removed, th ere are cer tain tangible preoperat ive far-tor s to be ana lyzed :
Correctly an gulated and processed radiographs. A preoperative plan of p rocedure. The choice of the anestheti c to be employed. The office or t he hospi tal for carry ing out t he work . The genera l san itation of the mouth and freedom from sepsis in the oper at ing field. 6. Arrangement s for postoperative car e.
1. 2. 3. 4. 5.
1. Surgical interference for th e removal of an impa cted third molar is indefensible unless th e operator has obtained a complete an d accurate r ad iogr aphic visualization of th e offendin g tooth and it s contiguous st ructures. Aside from the clinical examination and the knowledge it imparts, he is able preoperatively to know exactl y th e tooth's position, its root format ions and direction, th e size and shape of its crown, it s relat ion t o th e second molar, it s proximit y to th e inferior dental nerve or antru m, the osseous resistan ce to be overcome, t he amount of bone dissection necessar y, t he pathologic in volvement of soft ti ssue, and the direction of th e force t o be ap plied. Without such ad van ce kn owledge his effor ts ar e purely experimenta l and result in unn ecessar y traum a and un warranted sequela e. Intraoral films ar e more defin ite and accur ate and less subject to distortion th an extraoral plates and shoul d be utilized unless the tooth in questi on is in such an abnormal position that the film cannot be used. A correctly an gulated buccolingual radiograph is made first. The film should not be bent on insertion. The front bord er of th e film should not be placed anterior to the mesial wall of th e first molar. The rays should be directed at ri ght an gles to t he film. Thi s pi cture properly processed will determine th e correct anteroposterior posit ion. If thi s examinat ion shows the tooth to be in a lin guoangnlar or lingual deflection, a second picture is mad e with the film in the same position an d t he ra ys directed as one would for x-ra yin g a maxill ary first molar. Thi s will show the root formations which must be visualized bef ore operation. An occlusal picture det ermines the buccolingual relationship and offers information as to th e mesiobuccal sur gical approach. Only with this complete an d trust wor thy radi ographic st udy is one j ustified in consi dering the operat ive factors. Th e average x-ra y pictures mad e by th e medical r ad iologist , the commereial laboratory, and, I am sorry to st at e, the dental praetitioners do not fulfill the r equirements ; and more attention to th ese det ails will r edound to the dentist 's credit and, more important, to his patient 's postoperative comfor t and safety. 2. When a correct and complete visualizat ion of the problem to be encountered is made, and only t hen, should opera tive measures be enter ta ined . Wi th this information obtained, the operator can then determine intelligently his instrumentation which should be so executed th at a minimum of trauma to sof t and osseous tissue is caused. The ideal to be reached in the r emoval of most impacti ons can be approximated only when th e preoperati ve st udy has been so compl ete and so true that the opera to r is ena bled to lay out his instruments in definite order and use them for a definite purpose in t hat order. The r esult may be
Impact ed Third 1l1olars
169
judged to a nicety, and empirical, time consuming, tissue destroying maneuvers eliminated. 3. The choice of the anesthetic should be made: first, in the patient 's physical and mental interest; second, according to the dentist's ability to administer it safely and satisfactorily. If these two conditions cannot be met satisfactorily, good judgment would indicate the employment of a professional anesthetist or the reference of the case to more competent hands. It is no disparagement on a dentist's ability when he recognizes that this operation is not in his realm, and certainly his reputation is enhanced among his clientele if he puts his cards on the table and affords his patient the same service that he would appreciate were he contemplating the same ordeal with himself on the receiving end. In a general way the anesthetic choice comes down to a novocaine or a nitrous oxide and oxygen anesthesia in office practice. My experience from twenty years in this work leaves no room for doubt in my mind that in experienced hands the latter method is preferable. This does not mean that there are not indications for local anesthesia. Novocaine has many limitations, however, and the operator must always consider the possibilities of psychic shock. This primarily not being a paper on anesthetics, I shall enter into no discussion of this subject other than to say that vinesthene and evipal are still in the experimental stage for this work, and ethylene offers no advantages to the man who is a competent anesthetist with nitrous oxide. Novocaine is the choice of the local agents. 4. Ether and avertin administration require the serv ices of an expert anesthetist trained in the employment of these agents aside from the operator, with the definite rule that th e patient must be hospitalized. My inclusion of this subject is only the necessity for its consideration in outlining the preoperative plans. 5. Probably it is surprising to every one how well oral wounds get along in the presence of such unsanitary surroundings as are necessarily existent even in well-cared-for mouths. Nature is kindly disposed to the dental surgeon. Unfortunate sequelae to extractions arc frequent enough, however, to make us more observant of contaminating influences, and it is a fair presumption that preoperative attention to every detail in asepsis can do no harm. With the totally buried impaction which registers no clinical manifestation of a pathologic condition aside from a prophylactic treatment, probably nothing can be done on our part to help the situation further than scrupulous avoidance of introducing bacteria into the field. As a whole we can minimize postoperative complications if we consider every impaction which has to any extent invaded the mouth as an infected case. I refer to the generally understood partial impaction. When the continuity of the mucous membrane has been disrupted, oral debris seeps under the pericoronal soft tissue, and there is a focus for postoperative complications. The old custom of incising these flaps often brings about reactions as severe as if the tooth had been removed. A medicated wick gently introduced into every nook and cranny of the area without traumatizing the
170
Frank W. Rounds
soft tissue accomplishes th e r esult as well as au incision and aids in a resolution of t hese infl ammato ry are as. A good fundam ental rule to follow is to avoid surgery if possibl e until the area is clinically as normal as can be attained. In acute manifestations, hot gargles, ice packs, restoration of good elimination, and general medic ation for discomfo rt should be carried on to aid in accomplishing the result. Certa in emergency t yp es, of course, need immediat e surgical interference. But, by and large, it has been noted th at man y denti sts inv ade these are as with out giving sufficient atte ntion to these details. Ald en of St . Louis recently brought out in a seri es of cases the f act that Vinc ent 's organisms are a frequent causative factor in deep neck infections of dental and particularly third molar ori gin. Some of t hese cases had not been operat ed. Arsph enamine introdu ced intravenously and x-ray therapy seem to have broadened the margin of safet y. Certainly evidence enough has been presented in the literature to warn us not to traumatize tissue in the presence of trench mouth. A sane r esume of th e forego ing is a warning to put t hese areas into as normal condi ti on as possible before executing exodontia measures. 6. F or satisfac tory r esults, adequate postoper ative attention is as much indicat ed as is opera tive skill. Th e case is by no means concluded on t he r emoval of t he tooth. Even under th e most exper t hands a wound has been crea ted which offers the possibilities of an immense amount of discomfort and pain, as well as affording an avenu e for the exte nsion of infection and its disastrous ramifications. If the case has not been op era ted cor r ectl y, these possibilities become probabilities and oft en certainties. In general, postoperative complicat ions are proporti onat e to overtraumatizat ion but the non-overtraumati zed case may pr oduce an unexpected aftermat h. With the tooth successf ully r emoved, th e first requisite is the toilet of the area. The field ha s, of course, been wall ed off during operation to prevent the ingress of saliva. All debr is is gently r emoved from the socket wit h suit able cure ttes; gra nulomatous masses are delicat ely dissected out; osseous margins are smoothed with r ongeurs, tiles or curc ttes; septal bone is cut down ; and soft tissue flaps ar e allowed to fall back to their ori ginal position. If torn or lacerated, they are repaired by suturing or by cutting away parts which may become necrotic as a resul t of insufficient circulation. If drainage is indicated, a wick of medicated gauze st r ip is li ghtly inserted. This accompl ished , th e area is immedi at ely isolated with a gauze compress to fur ther th e immedi at e form ation of a healthy blood clot. An ice bag applied at once forestalls much of th e commonly seen postoperative swelling and edema. The pati ent should bit e lightly on this compress until the area is sealed. Th e icc bag is utilized in intermittent periods of ten or fifteen minutes, as long as puffiness of t he cheek persists. Continuous nonintermittent ice applicat ion t ends to discomfort. Medication for cont rol of pain is utilized by the employment of general sedatives, barbiturates for nervous reactions, and opiates if necessary. If the result is what we expect, t he patient will be f ree fr om pain the next day, trismus will be absent, the cheek 1I0t at all or only slightly distended., and the operated area free from abnor mal congestion and slightly stiff. Further
Impacted Third Molars
171
postoperative care is devoted to scrupulous attention to sanitation, and the patient must be kept under periodic observation until ready for dismissal. If by chance, as now and then happens in spite of our preliminary measures, our operative care and our postoperative routine, the area does not respond properly, in addition to the above mentioned treatments it may become necessary to medicate the socket with sedative pastes, analgesic and antiseptic agents. In any case, the operator is negligent who does not keep his patient in as comfortable a condition as is humanly possible in the light of our present knowledge. Any dentist who undertakes to remove impacted teeth should be fully prepared to meet any of the possible consequences of his surgical interference. Adequate preoperative precautions and intelligent postoperative management combined with a non-overtraumatizing operating technic will greatly lighten his burden and react to his patient's welfare. 270 COMMONWEALTH AVENUE
BOSTON , M ASS.
T
H E last twenty years have shown a marked and favorable development in th e technic of removal of impacted third molars. Prior to 1913 these malpositions were all operated on in the same general way without much regard for trauma, usually involving unnecessary bone destruct ion and frequently by sacrificing sound second molars. Today, unfortunately, too much of the old-time modu s operandi is in evidence, but as a whole th e dental profession is handling these cases in a far saner manner. The credit for thi s progress is lar gely due to t he stimulus genera ted by r esearch workers in this field, most not ably Winter of St. Louis, who presented an ent irely new perspective when he developed his now st andardized classification of impactions. The journals and textbooks of recent years have been r eplete with information rcgarding the proper surgical approach to these abnormalities, and a discussion of individual operating methods is not in the province of this article. The preoperative care enter ing into t hese cases and the postop erative care given th em have been somewhat neglected but ar e of definite importance in at ta in ing successf ul results; hence thi s subject and thi s brief discu ssion. I ha ve ofte n been startled on hearing general practitioners in dentistry remark that th ey do not encounter impaction s in their practice, and I can only conclude th at they are unob serving or are not thorough in making mouth surveys. More complete radiographic study might be illuminating and informativ e. Granted that impactions are clinically evident or are disclosed only by the x-r ay examinat ion, they deserv e serious consideration by th e orthodontist , the periodontist, th e prosthodontist, t he pedi odonti st , th e general practitioner, and th e physician. Undoubtedly not all third molars in normal position, nor all impa ctions need t o be viewed from th e standpoint of surgical intervention, but a vast number which are now overlooked fall under the head of potential menaces to ora l health, mental balan ce, and ph ysical welfare. Far too oft en do the y cwne to th e dentist's attention only when acute pathologic inv olvements have so compli cat ed the situation that deep neck infections endanger t he patient 's life. A large proportion of such serious sequelae could have been avoided by an early diagnosis and elimination of the impaction. The old adage of the horse being stolen before the door is locked is wonderfully exemplified in the cases of pericoronal infections which get out of hand. It is a fair presumption that the third • For mer President Am erican Soci et y of Or al S urgeons and E x o dontists.
166
I mpacted Th ird Molm's
167
molar which does not assume it s normal position in the arc h at its ph ysiologic time of eruption constit utes a possible if not a probable trouble maker at some future period. If the evidence point s t o th e presumabl e removal of the offending t ooth at some tim e in an indefinit e fu ture, good judgment may indicat e early surgical interference thus forest alling dam age. Impactions in th e mouths of yout hful p ati ents are simpler to operate than thos e in middl e or old age; t he postoper ati ve r eacti ons are less, the convalescence is simplified and rege neration of ti ssue hast ened. It is not an uncommon occurrence to observ e successfully compl eted cases of orthodontia up set by t he pressure of un considered impactions. After reo tainers are finally removed, this constant for ce again disrupts the alignment , malocclusion recurs, and excellent regulative work goes for naught. Money has been spent in vain , the patient's cooperation has 'availed nothing, and th e orthodontist's reputati on suffers. Traumatic occlusions an d consequent pocket forma tion s which come under the periodontist's treatment may rea dily be influenced by third molar pressure. If such be th e case, is it not putti ng th e cart before the horse to scale teet h periodically and attempt to readj ust abnormal mast icatory sur faces and allow t he underlying pressure facto rs to go on without cor rect ion ~ Has not someone overlooked somet hing when the edentulous elderly pati ent find s th e comfort and f unctio n of a well-fitting dent ure disrupted by th e disturbances incidental to t he efforts of erupt ion of an overlooked t hird molar ? The extensive pathologic in volvement s commonly associated with the se happenin gs are disconcerting, t o say th e least, to both dentist and pati ent. It is regrettable that so man y second molars in normal occlusion are allowed to become hopelessly carious on th eir distal surfaces because of the seep ing of ora l debris under th e sof t tissue flaps of the so-called partial impacti ons. It is also regrettable th at erosions of second molal' distal roots by third molar pressure are not more frequent ly forestalled. In this connection it should not be overlooked that if a second molal' must be pr ematurely sacrificed , its antagonist on the opposing jaw elongates and often establishes pocket formation and malocclusion. Reflex nervous disturbances often bring imp actions into the medical field. These upsets may run the ga mut from headaches, neck aches, pseudo earaches, eye pains, and ant ral symp toms to the more serious neuros es. The partially er upted impacti on, in general, is a more common disturber of t he peace than are t he completely buried types. P eri coronal pathologic conditi on is a distinct menace. The r esidual pockets u nder t he overlying flap form an ideal locale for the breeding of Vincent's organisms an d should never be overlooked in the clini cal care of these cases. From these brief observa t ions is it not apparent that an early r ecogniti on of disastrous possibiliti es const itutes a definite obligation on the part of th e dent al practitioner ~ H is good judgment, or course, should be t he guide as to the indication of conserv ative or r adical measures. In th is survey it is well to note that sometimes ap paren tly radical procedure is t he more conserv ative.
J68
Frank W. R ounds
If th e decision is reach ed th at an impaction should be removed, th ere are cer tain tangible preoperat ive far-tor s to be ana lyzed :
Correctly an gulated and processed radiographs. A preoperative plan of p rocedure. The choice of the anestheti c to be employed. The office or t he hospi tal for carry ing out t he work . The genera l san itation of the mouth and freedom from sepsis in the oper at ing field. 6. Arrangement s for postoperative car e.
1. 2. 3. 4. 5.
1. Surgical interference for th e removal of an impa cted third molar is indefensible unless th e operator has obtained a complete an d accurate r ad iogr aphic visualization of th e offendin g tooth and it s contiguous st ructures. Aside from the clinical examination and the knowledge it imparts, he is able preoperatively to know exactl y th e tooth's position, its root format ions and direction, th e size and shape of its crown, it s relat ion t o th e second molar, it s proximit y to th e inferior dental nerve or antru m, the osseous resistan ce to be overcome, t he amount of bone dissection necessar y, t he pathologic in volvement of soft ti ssue, and the direction of th e force t o be ap plied. Without such ad van ce kn owledge his effor ts ar e purely experimenta l and result in unn ecessar y traum a and un warranted sequela e. Intraoral films ar e more defin ite and accur ate and less subject to distortion th an extraoral plates and shoul d be utilized unless the tooth in questi on is in such an abnormal position that the film cannot be used. A correctly an gulated buccolingual radiograph is made first. The film should not be bent on insertion. The front bord er of th e film should not be placed anterior to the mesial wall of th e first molar. The rays should be directed at ri ght an gles to t he film. Thi s pi cture properly processed will determine th e correct anteroposterior posit ion. If thi s examinat ion shows the tooth to be in a lin guoangnlar or lingual deflection, a second picture is mad e with the film in the same position an d t he ra ys directed as one would for x-ra yin g a maxill ary first molar. Thi s will show the root formations which must be visualized bef ore operation. An occlusal picture det ermines the buccolingual relationship and offers information as to th e mesiobuccal sur gical approach. Only with this complete an d trust wor thy radi ographic st udy is one j ustified in consi dering the operat ive factors. Th e average x-ra y pictures mad e by th e medical r ad iologist , the commereial laboratory, and, I am sorry to st at e, the dental praetitioners do not fulfill the r equirements ; and more attention to th ese det ails will r edound to the dentist 's credit and, more important, to his patient 's postoperative comfor t and safety. 2. When a correct and complete visualizat ion of the problem to be encountered is made, and only t hen, should opera tive measures be enter ta ined . Wi th this information obtained, the operator can then determine intelligently his instrumentation which should be so executed th at a minimum of trauma to sof t and osseous tissue is caused. The ideal to be reached in the r emoval of most impacti ons can be approximated only when th e preoperati ve st udy has been so compl ete and so true that the opera to r is ena bled to lay out his instruments in definite order and use them for a definite purpose in t hat order. The r esult may be
Impact ed Third 1l1olars
169
judged to a nicety, and empirical, time consuming, tissue destroying maneuvers eliminated. 3. The choice of the anesthetic should be made: first, in the patient 's physical and mental interest; second, according to the dentist's ability to administer it safely and satisfactorily. If these two conditions cannot be met satisfactorily, good judgment would indicate the employment of a professional anesthetist or the reference of the case to more competent hands. It is no disparagement on a dentist's ability when he recognizes that this operation is not in his realm, and certainly his reputation is enhanced among his clientele if he puts his cards on the table and affords his patient the same service that he would appreciate were he contemplating the same ordeal with himself on the receiving end. In a general way the anesthetic choice comes down to a novocaine or a nitrous oxide and oxygen anesthesia in office practice. My experience from twenty years in this work leaves no room for doubt in my mind that in experienced hands the latter method is preferable. This does not mean that there are not indications for local anesthesia. Novocaine has many limitations, however, and the operator must always consider the possibilities of psychic shock. This primarily not being a paper on anesthetics, I shall enter into no discussion of this subject other than to say that vinesthene and evipal are still in the experimental stage for this work, and ethylene offers no advantages to the man who is a competent anesthetist with nitrous oxide. Novocaine is the choice of the local agents. 4. Ether and avertin administration require the serv ices of an expert anesthetist trained in the employment of these agents aside from the operator, with the definite rule that th e patient must be hospitalized. My inclusion of this subject is only the necessity for its consideration in outlining the preoperative plans. 5. Probably it is surprising to every one how well oral wounds get along in the presence of such unsanitary surroundings as are necessarily existent even in well-cared-for mouths. Nature is kindly disposed to the dental surgeon. Unfortunate sequelae to extractions arc frequent enough, however, to make us more observant of contaminating influences, and it is a fair presumption that preoperative attention to every detail in asepsis can do no harm. With the totally buried impaction which registers no clinical manifestation of a pathologic condition aside from a prophylactic treatment, probably nothing can be done on our part to help the situation further than scrupulous avoidance of introducing bacteria into the field. As a whole we can minimize postoperative complications if we consider every impaction which has to any extent invaded the mouth as an infected case. I refer to the generally understood partial impaction. When the continuity of the mucous membrane has been disrupted, oral debris seeps under the pericoronal soft tissue, and there is a focus for postoperative complications. The old custom of incising these flaps often brings about reactions as severe as if the tooth had been removed. A medicated wick gently introduced into every nook and cranny of the area without traumatizing the
170
Frank W. Rounds
soft tissue accomplishes th e r esult as well as au incision and aids in a resolution of t hese infl ammato ry are as. A good fundam ental rule to follow is to avoid surgery if possibl e until the area is clinically as normal as can be attained. In acute manifestations, hot gargles, ice packs, restoration of good elimination, and general medic ation for discomfo rt should be carried on to aid in accomplishing the result. Certa in emergency t yp es, of course, need immediat e surgical interference. But, by and large, it has been noted th at man y denti sts inv ade these are as with out giving sufficient atte ntion to these details. Ald en of St . Louis recently brought out in a seri es of cases the f act that Vinc ent 's organisms are a frequent causative factor in deep neck infections of dental and particularly third molar ori gin. Some of t hese cases had not been operat ed. Arsph enamine introdu ced intravenously and x-ray therapy seem to have broadened the margin of safet y. Certainly evidence enough has been presented in the literature to warn us not to traumatize tissue in the presence of trench mouth. A sane r esume of th e forego ing is a warning to put t hese areas into as normal condi ti on as possible before executing exodontia measures. 6. F or satisfac tory r esults, adequate postoper ative attention is as much indicat ed as is opera tive skill. Th e case is by no means concluded on t he r emoval of t he tooth. Even under th e most exper t hands a wound has been crea ted which offers the possibilities of an immense amount of discomfort and pain, as well as affording an avenu e for the exte nsion of infection and its disastrous ramifications. If the case has not been op era ted cor r ectl y, these possibilities become probabilities and oft en certainties. In general, postoperative complicat ions are proporti onat e to overtraumatizat ion but the non-overtraumati zed case may pr oduce an unexpected aftermat h. With the tooth successf ully r emoved, th e first requisite is the toilet of the area. The field ha s, of course, been wall ed off during operation to prevent the ingress of saliva. All debr is is gently r emoved from the socket wit h suit able cure ttes; gra nulomatous masses are delicat ely dissected out; osseous margins are smoothed with r ongeurs, tiles or curc ttes; septal bone is cut down ; and soft tissue flaps ar e allowed to fall back to their ori ginal position. If torn or lacerated, they are repaired by suturing or by cutting away parts which may become necrotic as a resul t of insufficient circulation. If drainage is indicated, a wick of medicated gauze st r ip is li ghtly inserted. This accompl ished , th e area is immedi at ely isolated with a gauze compress to fur ther th e immedi at e form ation of a healthy blood clot. An ice bag applied at once forestalls much of th e commonly seen postoperative swelling and edema. The pati ent should bit e lightly on this compress until the area is sealed. Th e icc bag is utilized in intermittent periods of ten or fifteen minutes, as long as puffiness of t he cheek persists. Continuous nonintermittent ice applicat ion t ends to discomfort. Medication for cont rol of pain is utilized by the employment of general sedatives, barbiturates for nervous reactions, and opiates if necessary. If the result is what we expect, t he patient will be f ree fr om pain the next day, trismus will be absent, the cheek 1I0t at all or only slightly distended., and the operated area free from abnor mal congestion and slightly stiff. Further
Impacted Third Molars
171
postoperative care is devoted to scrupulous attention to sanitation, and the patient must be kept under periodic observation until ready for dismissal. If by chance, as now and then happens in spite of our preliminary measures, our operative care and our postoperative routine, the area does not respond properly, in addition to the above mentioned treatments it may become necessary to medicate the socket with sedative pastes, analgesic and antiseptic agents. In any case, the operator is negligent who does not keep his patient in as comfortable a condition as is humanly possible in the light of our present knowledge. Any dentist who undertakes to remove impacted teeth should be fully prepared to meet any of the possible consequences of his surgical interference. Adequate preoperative precautions and intelligent postoperative management combined with a non-overtraumatizing operating technic will greatly lighten his burden and react to his patient's welfare. 270 COMMONWEALTH AVENUE