Tooth section technique and pain upon elevation in third molar removal

We read with interest the response about the Tooth section technique for wisdom teeth 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 Genú and Sconcelos , we too agree with W.C. Ngeow’s 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 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. If it is the reason it should be reproduced in other cases like nerve surgeries 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

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Feb 8, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Tooth section technique and pain upon elevation in third molar removal
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