Lingual split bone technique – Revisited as a standard operating procedure for surgical removal of third molar during COVID pandemic

INTRODUCTION

The lingual split bone technique is a quick and clean technique introduced by Sir William Kelsey Fry in 1933 and popularized by Terence G Ward in1956.^[1] This technique takes advantage of the lingual plate by fracturing it; thus, preventing the buccal plate and external oblique ridge. It is highly indicated in those young patients with elastic bone and it has been the best alternate option for bone guttering during the COVID era. Sir Davis opted for a modification in 1983 to overcome the drawbacks encountered in Kelsey Fry’s technique. However, the technique has not gained much acceptance apparently and fallen out of favor over the decades. However still, it was much revisited during COVID as a standard operating procedure (SOP) for surgical removal of mandibular third molar.

MATERIAL AND METHODS

The basic armamentarium required for the removal of impacted mandibular third molars is as follows; 2% lidocaine with adrenaline, mouth prop; BP blade (No:15); 0.9% saline solution; retractors; Gardner chisel 4 mm and Chandler chisel 5 mm; Mead mallet (17 cm); osteotome; sutures (3–0 silk); and curved needles.

The methods of interest here are

1. Kelsey Fry’s lingual split bone technique^[2]

2. Davi’s lingual split bone technique^[2]

At our institution; during COVID time, 27 cases were operated using Davi’s modified lingual split technique under strict COVID protocol [Table 1]. Pre-operative OPG and IOPA were taken, and the level of difficulty in impaction removal was assessed. Routine blood investigations were carried out and the patient was directed toward surgical removal of impacted tooth. The patient was painted and draped with drape sheets under all aseptic conditions. Local anesthesia was achieved using standard inferior alveolar nerve block and long buccal nerve block. Both Ward’s and Modified Ward’s incisions were used depending on the type of impaction; then, full-thickness mucoperiosteal flap was raised.

Table 1: List of patients treated by Davi’s technique.

S. No.	Name	Age	Sex	Impaction type	Time taken for removal (minutes)	Intraoperative bleeding	Post-operative complications
1.	Punitha	34	F	Mesioangular	17	Within normal limits	Evident
2.	Raja	26	M	Horizontal	16	Within normal limits	Evident
3.	Shankar	25	M	Horizontal	16	Within normal limits	Not evident
4.	Sruthi	18	F	Mesioangular	13	Within normal limits	Not evident
5.	Devi	39	F	Mesioangular	15	Within normal limits	Not evident
6.	Pradhap	33	M	Horizontal	14	Within normal limits	Not evident
7.	Kavin	21	M	Distoangular	19	Mild bleeding	Evident
8.	Sundhar	37	M	Horizontal	19	Within normal limits	Not evident
9.	Ramalingam	38	M	Horizontal	15	Within normal limits	Not evident
10.	Priya	41	F	Mesioangular	17	Within normal limits	Not evident
11.	Deepthi	22	F	Horizontal	15	Within normal limits	Not evident
12.	Ravi	40	M	Mesioangular	19	Mild bleeding	Evident
13.	Kishore	35	M	Mesioangular	17	Within normal limits	Not evident
14.	Sarath	35	M	Horizontal	20	Excessive bleeding	Evident
15.	Ashwin	25	M	Vertical	14	Within normal limits	Not evident
16.	Sowmiya	39	F	Mesioangular	19	Within normal limits	Not evident
17.	Basheer	19	M	Horizontal	16	Within normal limits	Not evident
18.	Surya	24	M	Vertical	20	Mild bleeding	Evident
19.	Sam	22	M	Horizontal	16	Within normal limits	Not evident
20.	Bhuvana	21	F	Distoangular	17	Within normal limits	Not evident
21.	Divya	32	F	Mesioangular	17	Within normal limits	Not evident
22.	Sofiya	37	F	Horizontal	15	Within normal limits	Not evident
23.	Vishwa	23	M	Horizontal	16	Within normal limits	Not evident
24.	Ramya	23	F	Mesioangular	17	Within normal limits	Not evident
25.	Karan	29	M	Horizontal	15	Within normal limits	Evident
26.	Tamilselvan	33	M	Horizontal	15	Within normal limits	Not evident
27.	Karthik	23	M	Mesioangular	19	Within normal limits	Not evident

A point of purchase was made in the buccal side, to place the elevator. Distolingual split was made by placing the chisel parallel to the external oblique ridge, few taps were given using mallet. Thus, a window was created on distolingual side. Tooth was luxated by elevating it on buccal side, it was thus delivered on lingual side; without fracture of lingual plate. Thus, lingual bone loss and lingual nerve damage were avoided in this Davi’s method.

Of those 27 cases operated at our institution, 10 cases were of mesioangular type; 2 were of distoangular type; 13 were of horizontal type; and 2 were vertically impacted [Graph 1]. Among those 27 cases, almost 17 patients were male and the remaining were female. Furthermore, the images of a case, operated using Davi’s method for removal of a mesioangular impaction, are added here [Figures 1-8].

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Graph 1:

Types of impaction.

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Figure 1:

Pre-operative IOPA

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Figure 2:

Pre-operative intraoral view.

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Figure 3:

Mucoperiosteal flap raised.

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Figure 4:

Vertical stop cut.

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Figure 5:

Horizontal stop cut.

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Figure 6:

Distolingual cut.

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Figure 7:

Extracted tooth.

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Figure 8:

Wound closure.

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RESULTS

All impacted mandibular third molars were successfully removed; the success rate was 100%. The average time of operation was 13 min. No major intraoperative complication occurred during the procedure.

Furthermore, with regard to post-operative complication [Graph 2], 3 patients had nerve injury (11%), 2 patients had lingual paresthesia (7.6%), 1 patient had alveolar osteitis (3.8%), 2 patients had post-operative infection (7.6%), and 3 patients had trismus (19%).

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Graph 2:

Incidence of post-operative complications.

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Two cases with lingual nerve paresthesia were reassessed, they achieved full recovery within 2 months by neurotrophic drug treatment. Two cases developed post-operative infection and recovered by draining and antibiotic administration within 1 week. Using visual analog scale, intraoperative pain was recorded, in which three patients had severe pain, eight patients had moderate pain, and 16 patients had mild pain.

Two charts, one on impaction type and other on postoperative complication rate, are also added here.

DISCUSSION

Although multiple options are available for the removal of impacted tooth; lingual split bone technique is our topic of concern, this lingual split bone technique has not gained much appreciation because of the associated disadvantages such as lingual nerve damage and lingual soft-tissue hemorrhage. Although many oppositions were stated against this technique, Davi’s technique was the talk of town at COVID time as it was stated as a SOP under COVID guidelines. The major advantages were minimal periosteal reflection; preservation of lingual periosteum and lingual nerve; minimal bone loss; and socket saucerization which result in reduced size of the residual clot.

Studies have shown that aerosols from highly virulent pathogens like severe respiratory syndrome-coronavirus (SARS-CoV) can travel more than 6 feet. In such instance, while performing dental procedures like bone guttering, water coolant could generate aerosols. When combined with body fluids like saliva, they become bioaerosols. These bioaerosols are source of infection in general but to be specific; aerosols from the patients who are carriers of this SARS-CoV virus are highly life threatening for the dental professionals. Hence, we thought of revisiting this old technique of chisel and mallet as an alternative for bone guttering.

The reason behind opting this as an SOP is that; it makes use of hand instruments like chisel and mallet; wherein, the aerosol production is almost nil [Table 2].^[3] Also many exponents point out that the technique is safe, timesaving and causes minimal tissue injury and minimal complications as long as it is used correctly.^[4]

The present topic of interest, Davi’s method, was used at COVID time in the removal of 27 impacted 3^rd molars and it even expressed a very low complication rate. Some earlier reports have mentioned about post-operative sequelae like the incidence of alveolar osteitis; labiomental paresthesia; lingual paresthesia; and infection in about 598 extractions of impacted lower molar by Davi’s method.^[5]

Here is a list of reviews regarding the lingual split bone technique from various authors.

W. Howard Davis stated that, in Davi’s method, the principle involved is to provide a distolingual split and leaving the lingual plate attached to the periosteum. Only those portions of bone that is not attached to the periosteum are removed

Chin-Jyh Yeh offered for a new idea while using lingual split technique in which he stated that, in this technique, impacted third molar is to be removed in one piece, and may be used as a donor tooth to replace an unrestorable molar

David A Hochwald insisted that the complications encountered during lingual split bone technique were transient and resolved within 5 months

Kanwar Inderjot Singh made a comparative study and stated that, Davis method is comparatively less time consuming, also clinically presents less swelling, and associated with less pain

Ge, Jing, Yang, Chi made an advanced study on lingual split bone technique using piezo surgery and stated that it is an effective and minimally invasive procedure for lingual positioned bony impacted mandibular third molars extraction.

CONCLUSION

Here in this paper, we have emphasized the importance of lingual split bone technique during the COVID pandemic. Although it has been in practice since a century; it has been revisited highly during the pandemic. The reason behind adopting this technique is its least chance in transmitting the airborne infection. As the aerosol production is almost nil here, dentist can opt for surgical removal of third molar even during the pandemic. Any surgery can be approached in multiple ways; though one half of the door is shut, the other half is always ready to welcome us.

So be it COVID or any other pandemic; surgery always has a backup option; so we should always try to remember that every technique is unique in its own way, be it a conventional one or a recent trending one. Thus, this article aims in emphasizing the hope of carrying out dental emergencies with full confidence even during pandemic days.