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Tooth section technique and pain upon elevation in third molar removal
Int. J. Oral Maxillofac. Surg. 2010; 39: 98–99 ?available online at http://www.sciencedirect.com
Letters to Editor Tooth section technique and pain upon elevation in third molar removal Dear Sir, We read with interest the response about the Tooth section technique for wisdom teeth2 in lessening the nerve damage. We applaud the authors view regarding the pain upon elevation of impacted teeth and opinion regarding tooth removal in multiple segments to avoid nerve compression. Even we also routinely encounter the pain during elevation of the impacted tooth which was not sectioned, and we solely agree with the bone removal and sectioning method. After having read the article by Genu´ and Sconcelos1, we too agree with W.C. Ngeow’s2 view that the research may favor if tooth is split into several sections. However, in our day to day practice we prefer a different kind of 3 piece technique (we call it as Arakeri’s FMS technique), especially in case of mesioangular tooth with mesial cusp locked distal to second molar, which successfully avoids neurovascular bundle. In such mesioangular cases if we section the tooth into two halves (distal/upper and mesial/lower), the upper halve do not show any resistance for elevation but lower halve, which is locked under the maximum convexity of the distal surface of second molar strongly resists for elevation. If one tries to elevate such lower fragment, the root may hinge over the neurovascular canal leading to neurovascular complications. However, as per our opinion this happens only when the root is stout apically. If the fragment is thin or slender at the apex it will fracture upon elevation and avoids the hinge, thus neurovascular complications also. For the same reason with Arakeri’s FMS technique, we first split the tooth into two halve and elevate the upper/mesial fragment. Then dis-impact the lower fragment by sectioning the lower/distal fragment at 0901-5027/01098 + 02 $36.00/0
the CEJ (as it is easier to visualize and section the thin fragment). Root fragment is elevated fist followed by retrieval of crown fragment. With this method until today, we have not encountered neurovascular complications in any of such cases. However, there were some cases (less than 1%) which we attribute to the surgeon’s skill and experience. so we feel sectioning the tooth into more than three piece increases the instrumentation within the tooth socket along with bur usage which again may predispose to the neurovascular complication.With reference to the cause of pain upon elevation, we don’t consider it is because release of sodium and potassium from their channels as suggested by W.C. Ngeow.2 If it is the reason it should be reproduced in other cases like nerve sur-
geries under local anesthesia such as mental nerve surgeries (repositioning in preprosthetic surgery) etc. For this, we feel the reason may be compression of neurovascular plexus around the vessels from different nerve branches, which further needs to be evaluated.
Funding None.
Competing interests None declared.
Ethical approval Not required.
# 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Letters to Editor Gururaj Arakeri* Department of Oral & Maxillofacial, Surgery, Sri Sai College of Dental Surgery, Vikarabad and Consultant to FMS dental hospital, craniomaxillofacial Surgery unit, Hyderabad, India Veena Arali Sri Sai College of Dental Surgery, Vikarabad and Consultant to FMS dental hospital, Hyderabad, India *Address: Gangashri, Basaveshwara Nagar, Shahapur, Gulbarga 585223, Karnataka, India. Tel.: +91 9341428302/9347261640. E-mail address: [email protected]
References 1. Genu’ PR, Vasconcelos BCE. Influence of the tooth section technique in alveolar nerve damage after surgery of impacted lower third molars. IJOMS 2008: 37: 923– 928. 2. Ngeow WC. Tooth section technique for wisdom teeth. IJOMS 2009: 38: 908. doi:10.1016/j.ijom.2009.10.007
Response to ‘‘Tooth section technique and pain upon elevation in third molar removal’’ Dear Sir, 7 October 2009 I thank the authors for sharing their own experience with regards to tooth section technique and pain upon the elevation in third molar removal. Their experience with the latter confirms what I have noticed throughout my years of practice, something that I found not mentioned in any standard textbook on minor oral surgery. I thank the authors too for postulating that the pain felt during the elevation of the third molar was a result of the compression of the neurovascular plexus around the vessels that originate from different nerve branches. However, I beg to disagree as the only other nerve branches around the vessels are the sympathetic plexus. I have one other observation that was not mentioned in my earlier communication; that is, in cases of patients experiencing pain upon the elevation of the third molar, I normally see part of the exposed nerve bundle once the apical portion of the root was removed. In my early days of noticing this structure, I used to probe it gently with a periodontal probe to confirm my diagnosis (of an exposed nerve). Such a gentle probing did not cause paresthesia but inflicted a ‘painful’ stimulation to the patient. I have stopped doing this now as I have learnt by experience that I am dealing with an exposed nerve anytime I treated a patient who also complaint of pain upon tooth elevation. It is this experience with
99
the exposed part of the nerve that led me to postulate that the pain is caused by the release of sodium and potassium from their channels. I compare this to the mental nerve pain upon friction with a denture, as in cases of severe atrophy of the mandible. I welcome any other suggestions that may explain why patients feel pain upon the elevation of a wisdom tooth. Thank you. Sincerely yours,
Competing interests None declared
Funding None
Ethical approval Not required W.C. Ngeow* University of Malaya, Oral & Maxillofacial Surgery, Faculty of Dentistry, Lembah Pantai, 50603Kuala Lumpur, Wilayah Persekutuan KL, Malaysia *Tel.: +603 79674807; Fax: +603 79674534. E-mail address: [email protected] doi:10.1016/j.ijom.2009.10.008
Letters to Editor Tooth section technique and pain upon elevation in third molar removal Dear Sir, We read with interest the response about the Tooth section technique for wisdom teeth2 in lessening the nerve damage. We applaud the authors view regarding the pain upon elevation of impacted teeth and opinion regarding tooth removal in multiple segments to avoid nerve compression. Even we also routinely encounter the pain during elevation of the impacted tooth which was not sectioned, and we solely agree with the bone removal and sectioning method. After having read the article by Genu´ and Sconcelos1, we too agree with W.C. Ngeow’s2 view that the research may favor if tooth is split into several sections. However, in our day to day practice we prefer a different kind of 3 piece technique (we call it as Arakeri’s FMS technique), especially in case of mesioangular tooth with mesial cusp locked distal to second molar, which successfully avoids neurovascular bundle. In such mesioangular cases if we section the tooth into two halves (distal/upper and mesial/lower), the upper halve do not show any resistance for elevation but lower halve, which is locked under the maximum convexity of the distal surface of second molar strongly resists for elevation. If one tries to elevate such lower fragment, the root may hinge over the neurovascular canal leading to neurovascular complications. However, as per our opinion this happens only when the root is stout apically. If the fragment is thin or slender at the apex it will fracture upon elevation and avoids the hinge, thus neurovascular complications also. For the same reason with Arakeri’s FMS technique, we first split the tooth into two halve and elevate the upper/mesial fragment. Then dis-impact the lower fragment by sectioning the lower/distal fragment at 0901-5027/01098 + 02 $36.00/0
the CEJ (as it is easier to visualize and section the thin fragment). Root fragment is elevated fist followed by retrieval of crown fragment. With this method until today, we have not encountered neurovascular complications in any of such cases. However, there were some cases (less than 1%) which we attribute to the surgeon’s skill and experience. so we feel sectioning the tooth into more than three piece increases the instrumentation within the tooth socket along with bur usage which again may predispose to the neurovascular complication.With reference to the cause of pain upon elevation, we don’t consider it is because release of sodium and potassium from their channels as suggested by W.C. Ngeow.2 If it is the reason it should be reproduced in other cases like nerve sur-
geries under local anesthesia such as mental nerve surgeries (repositioning in preprosthetic surgery) etc. For this, we feel the reason may be compression of neurovascular plexus around the vessels from different nerve branches, which further needs to be evaluated.
Funding None.
Competing interests None declared.
Ethical approval Not required.
# 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Letters to Editor Gururaj Arakeri* Department of Oral & Maxillofacial, Surgery, Sri Sai College of Dental Surgery, Vikarabad and Consultant to FMS dental hospital, craniomaxillofacial Surgery unit, Hyderabad, India Veena Arali Sri Sai College of Dental Surgery, Vikarabad and Consultant to FMS dental hospital, Hyderabad, India *Address: Gangashri, Basaveshwara Nagar, Shahapur, Gulbarga 585223, Karnataka, India. Tel.: +91 9341428302/9347261640. E-mail address: [email protected]
References 1. Genu’ PR, Vasconcelos BCE. Influence of the tooth section technique in alveolar nerve damage after surgery of impacted lower third molars. IJOMS 2008: 37: 923– 928. 2. Ngeow WC. Tooth section technique for wisdom teeth. IJOMS 2009: 38: 908. doi:10.1016/j.ijom.2009.10.007
Response to ‘‘Tooth section technique and pain upon elevation in third molar removal’’ Dear Sir, 7 October 2009 I thank the authors for sharing their own experience with regards to tooth section technique and pain upon the elevation in third molar removal. Their experience with the latter confirms what I have noticed throughout my years of practice, something that I found not mentioned in any standard textbook on minor oral surgery. I thank the authors too for postulating that the pain felt during the elevation of the third molar was a result of the compression of the neurovascular plexus around the vessels that originate from different nerve branches. However, I beg to disagree as the only other nerve branches around the vessels are the sympathetic plexus. I have one other observation that was not mentioned in my earlier communication; that is, in cases of patients experiencing pain upon the elevation of the third molar, I normally see part of the exposed nerve bundle once the apical portion of the root was removed. In my early days of noticing this structure, I used to probe it gently with a periodontal probe to confirm my diagnosis (of an exposed nerve). Such a gentle probing did not cause paresthesia but inflicted a ‘painful’ stimulation to the patient. I have stopped doing this now as I have learnt by experience that I am dealing with an exposed nerve anytime I treated a patient who also complaint of pain upon tooth elevation. It is this experience with
99
the exposed part of the nerve that led me to postulate that the pain is caused by the release of sodium and potassium from their channels. I compare this to the mental nerve pain upon friction with a denture, as in cases of severe atrophy of the mandible. I welcome any other suggestions that may explain why patients feel pain upon the elevation of a wisdom tooth. Thank you. Sincerely yours,
Competing interests None declared
Funding None
Ethical approval Not required W.C. Ngeow* University of Malaya, Oral & Maxillofacial Surgery, Faculty of Dentistry, Lembah Pantai, 50603Kuala Lumpur, Wilayah Persekutuan KL, Malaysia *Tel.: +603 79674807; Fax: +603 79674534. E-mail address: [email protected] doi:10.1016/j.ijom.2009.10.008