That was my goal! Thanks Jay for your kind words. All the best. Please spread the word.

That's scary

I totally agree!

In USSR they used to teach like this.

That’s really scary

Thanks so much! All the best!

Thanks for the kind words Manny. I appreciate your support. All the best!

Great to hear Brad! All the best!

That's awesome to hear! Thanks so much. I've been working on more so there will be more to come in the near future. All the best!

Online Exodontia Brilliant! More videos on flap designs i.e upper impacted wisdoms, maxillary and mandibular molar retained roots would be helpful, especially live patient demos. Thank you 👍

@@DE51B0Y Appreciate the feedback. All the best!

It's on there now my friend!

I have never approached a tooth in this manner and will be certain to check out that technique! Always looking for interesting new material to add to the site. All the best!

Thanks Sayed!

Thanks Jonny! They're readily available on Ebay for cheap if you just want to check one out. All the best and thanks for your support! PS - I am not on Patreon, but have heard of it. Should I be on there?

@@OnlineExodontia You should definitely look into Patreon! It allows for your viewers to support you monetarily if they wish, and I definitely think your videos deserve it! :)

That's a tough call for me to make here with the information available to me. What I can tell you is generally if they are impacted as you describe, the gum flap (operculum) will grow back after it's removed. At 28 you're still at a reasonable age to get them removed. The risk must be assessed however as you don't appear to be having pain at the moment. It's unlikely that they're terribly close to the inferior alveolar nerve as you can see a portion of them in the mouth, but that would be for your provider to decide. Moving them in via orthodontics will likely create a difficult area to clean as the space is limited and it's a lot to go through. If it were me I would have them assessed by an oral surgeon or a general dentist that does these procedures and if the risk to the nerve is minimal, I'd remove them. Hopefully that helps. All the best!

Hi Hasan! Thanks for watching. If you're ever faced with a hematoma that becomes evident during the surgery, it's best to apply pressure and then have the patient rest and ice/compress the area intermittently for the first 48 hours. Beyond this it's advantageous to get some blood flow to the area to help resolve the hematoma. This would involve intermittent heat compresses. Generally this speeds the resolution. You want to watch for secondary infection as this can be possible. As far as a seroma goes, I realize that I discuss this as a surgical complication for anatomical 'dead spaces', however in practice I can't say I've ever knowingly run across it and that being said, have never treated it. Generally a seroma may be treated via drainage to help it resolve, but I can't say I've ever heard of this being necessary following routine third molar removal. Perhaps another doctor could enlighten us on this if they see our convo! All the best!

DK - the course covers some of these issues, however to try and sum it up for you, you cut laterally (never straight distal) to avoid the lingual nerve as I imagine you know. You will inevitably transect some fibres of the buccal nerve, but this is of little to no consequence. If you look at Pell & Gregory you'll see the varied positions of the impactions. When they're further anterior to the ramus, it's easier to flap and have less tissues involved distally. The further back the impaction is however, you'll sometimes be faced with thicker more tenacious tissue to contend with. If you're into the buccinator you're too far and you shouldn't be in the tendon of the temporalis. bit.ly/3vE19nc That link shows an image of the retromolar triangle. The medial aspect of the triangle shown is not a bad line for the incision, only you'd probably only go half that distance of that line. Generally I find the anterior edge of the ramus and palpate the buccal shelf...also don't be shy to palpate the medial of the mandible to help gauge the flare of the mandible so you can better assess whether you'll be over bone and not encroaching on distal tissue or the lingual nerve region. Feel free to email me and I can try to offer more help, but hopefully this is a start!

@@OnlineExodontia thank you for sharing Doc. So the tighter the impaction (up under the ramus), the more lateral we make the "distolateral" incision? For this incision do you press hard on the scalpel to ensure you sever periosteum? It seems all considered the most pertinent risk is if a retromolar foramen and associated vasculature exist, which some studies indicate they do in 10- 20% of some populations (Indian and Chinese, if I recall), would you agree? Would this be profuse bleeding and if yes how would you control?..would you abandon procedure and suture tightly? Would a good guide be a 1cm distolateral incision, hard on bone, from DB of 3rd molar heading just distal to anterior border of mandible? I requested your email on your site, will be looking into the course for sure, many thanks again.

@@dkkhan4536 Each case of course will be a bit different, but yes an incision like you've described would be reasonable. You should imagine trying to score the bone with the scalpel to ensure you get through the periosteum. In short, most bleeding is controlled via sustained pressure and usually that will suffice for any procedure a general dentist is doing. I reached out to you, but haven't heard back so maybe check your junk folder if you haven't seen anything! All the best!

Potentially yes. This is one argument against the envelope flap. In reality, assuming proper tissue handling and decent OH during healing, there is minimal to no resulting recession. Many surgeons use this design. Thanks for watching!

You always start with the first suture just distal to the second molar. Get that one cinched in perfectly and you will avoid that tissue bunching that you sometimes get when the flap rides up the buccal surfaces of the teeth. Once that one is in, you can do one behind it for the release (or two, every provider has a different preference). After that, if the papilla is sitting nicely I will put some 4x4 gauze over the extraction site, the wrap the gauze around the buccal surface to apply pressure to the flap...hopefully that makes sense. The fibrin will begin to adhere the papilla without the need for a suture here. Hope that helps!

Thank you so much for the informative reply! From the video, it seems like the incision goes from 45 mesial to 47distal. Just to be sure, do you mean the interdental papilla between 45,46 and 46,47 do not need be sutured? With firm pressure from the gauze in addition to the suture distal to 47 is going to stabilize the flap in these area?

In school we were taught to do an envelope flap starting from second molar mesial to the retromolar area. Sometime I feel it’s not enough unless a vertical incision is made on second molar mesial. But if we extend the envelope flap mesially, I run into the problem of whether or not to suture the papilla since the lingual side isn’t reflected, and it’s tough to pass the needle lingually. Hope I explain the problem clearly.

@@naixie Yes I understand what you're saying. There are all different flap designs, this is just one of them and you need to modify them as needed based on the type of impaction. A deeper impaction may require a larger flap and more access than say a partly erupted third molar. The vertical release certainly helps with access, but can be harder to reapproximate and often results in more edema and post-op discomfort. Extending the envelope more mesial also releases tension on the flap to get more access. Really no right or wrong just a matter of personal preference and being sure to select the proper flap for the procedure. You should have this figured out before you make an incision. Hope that helps?

@@naixie Some providers don't even suture the lowers believe it or not and patients still heal okay. I rarely suture the upper and always do the lower. There is no step-by-step answer for placing sutures in other words, it won't be the same every time necessarily. You need to understand why you are placing sutures and that will dictate whether you need them on a case-by-case basis. You are placing them to reapproximate the tissue. So if the tissue is doing that naturally without assistance from a suture, you're likely okay to leave it.

Great question, you are without a doubt cutting some branches of this nerve, however you will not typically see any lasting effects from doing so. As a guide when starting you may choose to cut about 15mm-20mm, but over time you will learn to rely more on the anatomy that you see and palpate as well as the access you'll require for extracting the tooth. What I mean is you may not always need 15-20mm on the DB, you might just have to cut 5-10mm to get enough tissue open to deliver the tooth. Hopefully that's helpful for you!

@@OnlineExodontia Thank you for your reply, much appreciated. Lets say if I incise the long buccal nerve through and through ( hopefully never happens) are there any long lasting functional effects that the patient may find it difficult or may affect their daily routine over time? I understand its case by case but just want to get a better understanding of what the consequences are. Thanking you again!

@@SK-vx3nu I have been told by an oral surgeon whom I respect greatly that if this nerve is ever compromised patients do not find it to be a big problem. It's a bit different than severing the lingual nerve for example where now the patient can feel their tongue! All the best and thanks for watching!

@@OnlineExodontia Awesome and thank you so much for getting back to me. Much appreciated!

@@SK-vx3nu Anytime my friend! All the best!

Try getting the Isolite system from Zyris. You can use this thing and cut the buccal portion off the mouthpiece. This protects the airway, retracts / protects the tongue and suctions all at once. It's terrific for lower third molars. www.zyris.com/ Worth every penny! All the best! Jason

The gum flap is called an operculum. Totally normal! All the best!

That's interesting. I'm not an oral surgeon so I'm not comfortable commenting on this. The way they open the tissue for a genioplasty would be different than what's illustrated in this video as the geniopasty require access to the chin. If you're still numb it's imperative that your surgeon knows this as there is a time-window in which you may receive help to resolve the numbness in some cases. If you leave it too long, sometimes there are no options to fix it.

@@OnlineExodontia yes that's why I'm a little concerned cause usually it is done by making an incision below the gumline. Not by creating a flap. But does this method put the nerves at at higher risks? So if it was done on the front lower teeth will that be dangerous for the nerves?

Thanks for watching! I can tell you that you must do what you are comfortable with as both styles are widely accepted and used successfully. Triangular flaps can be a bit more conservative over time, but there are reports of them leading to more post-operative edema and dehiscence. Envelope flaps are nice, however they are often knocked for at times contributing to attachment loss or recession upon healing. Both are good choices. This link here is a paper that shows lots of flap designs bit.ly/2L1qO4e. All the best!

I wish I knew! I bought it years ago on eBay and it was fantastic. I’ve wanted another but cannot locate it anymore. The model in the video was altered by me however to add the ‘gum tissue’ and impacted teeth. All the best!

I would try a different scalpel blade as perhaps it has become dull. You should press with enough pressure to act as if you're scoring the bone and the periosteum should cut. All the best!

This is a Minnesota retractor in the video. You can use many different ones, but here in Canada / USA I would say it's the most commonly employed retractor. All the best!

Tissue heals in 10-14 days, however these flaps can persist much longer if you're opening them or moving them around. I would try to leave the areas alone as best as you can. After a few weeks you should start to see some improvement. All the best!

@@OnlineExodontia thank you

I don't generally do flaps for these teeth anymore. I used to, but if you section them properly you can remove them with the help of your cryer elevators and heidbrink root picks. Some removal of interradicular bone is helpful too should the tooth break. If you choose to do a flap, then do an envelope flap. Release one papilla mesial and distal to the site. If you need more access, release two papilla's mesial to the tooth. This flap is easy to create and reapproximate. All the best!

Thanks for your reply. how do you gauge that you have cut through the furcation and removed the interradicular bone.

@@abhachhabra2762 You can measure the distance on your radiograph as long as you have a properly angled exposure, then measure your bur. A surgical length FG 702 bur has about 12mm of bur length once it's inserted in the handpiece. Alternatively, sink your bur then with magnification and good light, rinse the area and have your assistant suction with a small tip suction. If you see blood entering between the roots apical to the furcation, you're through, if blood is only going between the roots from the lingual / buccal, it's likely that you're still not through the furcation. Hope that helps! If you're sectioning a lower impaction, use the length of the bur flutes to determine how deep you are cutting.

@@OnlineExodontia thanks a ton!

@@abhachhabra2762 Anytime my friend!

Good luck and all the best!

@@OnlineExodontia thank you 🥲

Hi Abby! Surprisingly, many third molars can be removed and not sutured and will still heal just the same. Some surgeons prefer the area water tight, others leave it partially open and some choose to leave the site as is without sutures. All the best!