Preoperative Assessment in Minor Oral Surgery

1. Preoperative Assessment in
Minor Oral Surgery

2. Content
What is impaction
Indications for surgery
Patient assessment
Tooth assessment

3. Minor oral surgeries
The term "Minor oral
surgery" refers to smaller
operations and include
removing wisdom teeth,
impacted teeth, and
severely broken-down
teeth, as well as
apicectomies, biopsies
and other procedures.

4. Impaction
Impacted tooth is a tooth
which is completely or
partially unerupted and is
positioned against another
tooth, bone or soft tissue so
that its further eruption is
unlikely, described according
to its anatomic position.

5. Indications for removal of
impacted 3rd Molars
Guidance
• 1.1The practice of
prophylactic removal of
pathology-free impacted
third molars should be
discontinued in the NHS.

6. • 1.2The standard routine programme of dental
care by dental practitioners and/or
paraprofessional staff, need be no different, in
general, for pathology free impacted third
molars (those requiring no additional
investigations or procedures).

7. • 1.3Surgical removal of impacted third molars
should be limited to patients with evidence of
pathology. Such pathology includes unrestorable
caries,
• non-treatable pulpal and/or periapical pathology,
• cellulitis, abscess and osteomyelitis,
• internal/external resorption of the tooth or
adjacent teeth,
• fracture of tooth,
• disease of follicle including cyst/tumour,
• tooth/teeth impeding surgery or reconstructive
jaw surgery, and
• when a tooth is involved in or within the field of
tumour resection.

8. Evidence
• 3.1There is no reliable research evidence to
support a health benefit to patients from the
prophylactic removal of pathology-free
impacted third molar teeth.

9. • 3.2Every procedure for the removal of an
impacted third molar carries risk for the
patient, including temporary or permanent
nerve damage, alveolar osteitis, infection and
haemorrhage as well as temporary local
swelling, pain and restricted mouth opening.
There are also risks associated with the need
for general anaesthesia in some of these
procedures, including rare and unpredictable
death. Such patients are therefore being
exposed to the risk of undertaking a surgical
procedure unnecessarily.

10. Evidence-based clinical data collected from
prospective investigations show that an
asymptomatic third molar does not necessarily
reflect an absence of disease.

11. Practitioners typically should consider removing
erupted and impacted third molars when they
cause considerable pain, are infected, are
associated with bone destroying pathology, are
carious or adversely affect the health of adjacent
teeth.
In addition, practitioners should remove third
molars that are expected to be problematic
under dentures, are located at sites of planned
osteotomies or interfere with planned orthodontic
movements.

12. Current data are not sufficient to refute or support
prophylactic removal of third molars versus
active surveillance.
Although third-molar management usually is
straightforward, the evidence supporting
extraction versus retention of asymptomatic,
disease-free third molars is lacking.
Active surveillance, a prescribed program of follow-
up and reassessment at regular intervals are
recommended for retained third molars rather than
waiting for the onset of symptoms to initiate follow-
up.

13. Why Preop. Assessment
• Risk assessment
• To minimize
complications
• For patient preparation
• To determine type of
anaesthesia
• Costing
For Planning the Surgery

14. What to assess
Patient
General
Local
Tooth

15. General medical condition
• Allergies
• Bleeding problems and related diseases
• CVS
• Drugs
• Endocrine disorders / DM
• Fits
• GI
• Etc.…………………………...

16. • Previous history of Dental treatments
• Past surgeries
• Previous Hospitalizations
• General build
• Age

17. Bleeding Disorders
• The use of variable “safe INR levels” for minor
surgery continues to lack of full consensus .
• The optimal INR value for minor oral surgery
procedures is between 2.0 and 3.0.
• Procedures may safely be done while
maintaining an INR value level of 3.0 to 4.0 as
long as local haemostatic measures are taken.
• Surgery is contraindicated with an INR value of
greater than 5.0.

18. Periprocedural recommendations
Presumed bleeding risk
of procedure
SAPT/DAPT with ASA ±
clopidogrel
VKA DOACs
Unlikely to cause
bleeding
Perform dental
procedure without
interruption
Perform dental
procedure without
interruption. if INR is
≤3.5 24 hours before
the intervention.
Continue therapeutic
anticoagulation, perform
dental procedure at trough
concentrations
Low bleeding risk
dental procedures
Perform dental
procedure without
interruption
Perform dental
procedure without
interruption if INR is
≤3.5 24 h before the
intervention. Delay if
INR >3.5 and adjust
VKA dose until INR ≤3.5
Continue therapeutic
anticoagulation, perform
dental procedure at trough
concentrations
High bleeding risk
dental procedures*
Perform dental
procedure without
interruption
Perform dental
procedure without
interruption if INR is
≤3.5 24 h before the
intervention. Delay if
INR >3.5 and adjust
VKA dose until INR ≤3.5
Delay (rivaroxaban,
edoxaban) or skip (apixaban,
dabigatran) one dose on the
morning of the dental
intervention

19. Platelets
1) Dental extraction is safe in thrombocytopenic
patients with greater than 50,000 platelets/µl.
Bleeding complications are easily managed with
local measures.
2) Because there is little evidence to support the
safety of dental procedures for severely
thrombocytopenic patients with less than
50,000 platelets/µl, physicians and their patients
should consider platelet transfusions to reach
50,000 platelets/µl for dental extractions

20. Infective Endocarditis Prophylaxis
Antibiotic prophylaxis with dental procedures is reasonable for patients with cardiac
conditions associated with the highest risk of adverse outcomes from endocarditis,
including:
• Prosthetic cardiac valves,
• Previous endocarditis
• Congenital heart disease (CHD) only in the following categories:*
–Unrepaired cyanotic CHD, including those with palliative shunts and
conduits
–Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or catheter intervention, during the first six
months after the procedure†
–Repaired CHD with residual shunts or valvular regurgitation at the site or
adjacent to the site of a prosthetic patch or prosthetic device (which inhibit
endothelialization)
• Cardiac transplantation recipients with valve regurgitation due to a structurally
abnormal valve
*Except for the conditions listed above, antibiotic prophylaxis before dental procedures is no t
recommended for any other form of CHD.

21. Local Assessment
• Mouth opening
• Cheeks and retractability of tissues
• Tongue size
• Oral Hygiene
• Alveolar bone thickness
• 2nd Molar condition
• Restorations / Crowns etc...

22. Tooth examination
Clinical
Radiographic

23. Clinical
• Complaint
• Previous episodes of infections
• Eruption status
• Angulation
• Local soft tissue condition ( infected/
inflamed)
• Available space between 2nd molar to ramus
• Caries

24. Radiological
What type of x-ray
IOPA
OPG
Lateral oblique
Cone beam CT

25. Good IOPA
Should show
Full 3rd molar
Full 2nd Molar
½ of 1st Molar
Distal Bone cover
ID nerve relationship

26. Type of impaction

27. Depth of impaction

28. Ramus relationship

29. Winter’s Lines (WAR)

31. What else with IOPA
Distal Bone cover and trabecular pattern
Size of the follicle
Other pathologies
Root number, size, angulations
Distance from roots of 2nd molar
Status of 2nd molar tooth
Relationship with ID canal

32. Distal bone cover

33. • Large follicle – easy
removal

34. Pathology
Root form

35. Caries of 2nd Molar

36. Root / Nerve relationships

37. Cone Beam CT

38. Coronectomy

40. Parallax technique