A tricky Third molar surgery can humble even the most experienced of Oral Surgeons. Surgical removal of Wisdom teeth has become somewhat of a post-graduate discipline, with many Dentists lacking the confidence or even the appetite for their removal. We have today the very enthusiastic Dr Nekky Jamal who is a GDP that lives and breathes third molar surgery. He shares with us his top tips for the planning and execution of M3Ms surgery!
Protrusive Dental Pearl: When you are sectioning a mesio-angular impacted tooth, start your section 1-2 millimeters more mesial to where you think the furcation is – you will have a tendency to drift distally and therefore more likely to HIT that furcation which is when the magic begins.
(Regarding disto-angular third molars) “If you lose your crown, you almost lose your ability and your orientation of where that tooth is.” Dr Nekky Jamal
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In this episode, I asked Dr Nekky about:
- What clinical and radiographic features suggest an easier third molar? 9:51
- Main features that identify a tricky third molar worthy of referal 15:15
- The two characteristics to determine the difficulty of third molar removal 16:37
- Things to look out to determine a high risk of inferior alveolar nerve damage 20:15
- Does CBCT help in planning tooth removal for Wisdom Teeth 24:19
- When to consider a coronectomy? 26:37
- Tips and Tricks on how to get cleaner flaps 30:54
- The Hydraulic flap Technique 32:34
- Armamentarium for wisdom tooth removal 35:30
- Three magic Nekky tips 38:33
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If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth with Dr Chris Waith
Click below for full episode transcript:Opening Snippet: The situations where I failed in, I noticed when the third molar roots are directly touching the second molar roots. Okay? That's what makes it difficult and if you look at at the classification of that, that's a distal angular impaction. But what makes it so difficult is you can't get your instruments between the second and the third molar. And if you break off the crown of that third molar, you can't even see the mesial root because you can't see past that second molar crown.
Jaz’s Introduction: In this episode, Dr. Nekky Jamal will cover all the points you need to know as a GDP if you’re extracting wisdom teeth, and that’s surgically what makes it an easy case, what makes it complex case. What about those cases where you’re worried about nerve damage? When do you need take a CB CT? What about coronectomy? How to get cleaner flaps so you could take out wisdom teeth in a much more cleaner field, what equipment to use, and how to get cleaner flaps as well as Nekky’s main tips to improve your success rates with surgical third molars. Hello, Protruserati. I’m Jaz Gulati, my journey with wisdom teeth began when I was a DCT, a Dental Core Trainee at Guys hospital, I was doing my oral surgery post. And that’s when I started to see my consultants the way they were moving it. But when I got to do some easier cases, it felt good. And then a few times I got stuck and I needed rescuing. Now when I went to Singapore, the fascinating thing about practicing in Singapore and how that’s so different to UK when it comes to wisdom teeth is like in the UK, we have the nice guidelines and we touched on that in this episode. But in Singapore, I felt as though like the only people that wouldn’t have third molars removed is that if you actually had hypodontia, if you didn’t have a wisdom tooth, that’s the only time you weren’t having it removed like it was pretty intense and extreme as about the cases that you’d have wisdom teeth out. So I got a lot more exposure and a lot more experience of taking out wisdom teeth, but I still was staying within my comfort zone or just slightly beyond so that I can improve as a clinician. Now one thing that really helped me was a 45 degree handpiece and again, we cover a little bit about equipment and how to get the right armamentarium to improve your extractions. But when I came back to the UK, I was doing less and less. I’m doing less and less, I’m still happy to take on surgical wisdom teeth, but you see less because of the NICE guidelines, right? So we have to really careful and judgmental about when we take on these third molars. Now, my colleague John, he referred me a case recently, and I shied away from it. I looked at it and I thought, ‘Oh, this is just beyond my comfort zone.’ I’ll share that radiograph if you’re watching this, if you’re listening, it was a mesio-angular and the distal root had a little kink in it and I shied away. So then I was looking at Okay, how can I improve my wisdom teeth because I, it was kind of bugging me that I wasn’t ready to take on a case like this. So I found Nekky Jamal, his course is on course karma. So it was mine splint course and RBB masterclass. So I started to watch the reviews and some clinical videos of his and so I signed on and I’ve been really enjoying it. I mean, can you learn wisdom teeth online? Well, you know, I have to eat my hat because you can. There were so many clinical videos like when I was in Singapore, I was literally relying on YouTube videos, and there was only a handful of good ones. Now to have like a bank of 60 plus surgical extraction videos from flaps to actual elevation to closure was absolutely brilliant. So that’s what really helped me, so I invited Nekky on today to share with you the main ways that we can improve your wisdom teeth extraction, whether you’re starting out and you’re looking at Okay, how can I pick the low hanging fruit versus if you’re already extracting out third molars? I know he shares a few gems in there like the hydraulic flap technique to make your flat bracing easier and your sectioning more successful. The Protrusive Dental Pearl I have for you is very relevant to wisdom teeth and it’s actually when I listen to this episode again, it wasn’t covered in the main interview. So it’s like a another big gem that can reveal to you that I learned from Nekky’s course, which is this when you are sectioning a wisdom tooth. Now obviously we spoke about sectioning and elevating molars with Chris Waith, what a brilliant episode Chris, what great job he did for us. So if you haven’t listened to that already, or if you want us to more extraction based episodes, do check out that episode with Chris Waith. Now when it comes to wisdom teeth, let’s say you are going to be sectioning a mesio-angular tooth, right? When I have section before, sometimes the section goes off plane and you don’t get exactly to the furcation. The big tip here that Nekky taught me is that you want to go one to two millimeters more mesial than you think. So you want to start that sectioning a couple of millimeters more mesial than you think. So by time you actually get to the furcation, you probably going to be a bit more distal. If you start where you think is the middle of the tooth, you end up being a bit more distal and then we start to section the tooth, you get a chunk of the distal part of the crown, you don’t actually get to separate the roots. So that for me was a massive takeaway from the course. So I want to share that with you go one to two millimeters more mesial to where you think the furcation is when you are sectioning these mesio-angular impacted teeth. Now let’s just join Nekky for so many gems. It’s a really nice gem packed concise episode so hope you like it and I’ll catch you in the outro.
[Jaz] Nekky Jamal, welcome to the Protrusive Dental podcast. How are you my friend?
Dude, I’m so pumped to be here today. This is a dental dream for me. This is awesome. So thank you so much, man. [Jaz]
Man, it’s an honor to have you on, man. I mean, I one thing I’m really pissed off about, right? is where the hell were you in my life in 2016? I was doing more wisdom tooth, I was doing more wisdom teeth in 2016 than I ever had, and maybe more wisdom teeth in 2016, 2017 than I ever will do my entire life. I’ll tell you why, Nekky and for those listening [Nekky] What is that? [Jaz] I was in Singapore. I don’t know how much you know about the way they work in Singapore. Probably very similar to Canada, based on what I’ve seen the videos that you post and stuff is that the only people that don’t have wisdom teeth out in Singapore is that if you had agenesis of or hypodontia of the wisdom teeth, right? If there’s a wisdom tooth in your body, they will find it and they will take it out, right? So I took advantage of that because I had a little bit of surgical experience and I was really stepping out of my comfort zone and man I was relying on like the sketchy YouTube videos like where the hell were you in my life back then, man. But I mean that just tell me what, Tell me about your journey, when did you qualify? How did you get into so much passion and experience with wisdom teeth? [Nekky]
You know, that’s so complicated. I always found the hardest part about dentistry was connecting with patients so many patients were anxious, so many patients were nervous and I found that you know, by looking people in the eye, I was able to calm them down and they knew I was there to actually care for them which you know, I think is a missing part in oral surgery period. And it’s just knowing, the patient knowing that we’re here to help them and so that’s how we started getting into taking your teeth and I always had a passion for helping out so I started volunteering around the world. I’ve been on 19 Dental brigades all over Central and South America taking out teeth and helping those that don’t have access to a dentist and you know my skills just grew and grew and grew and you know what led me to this but I really you know started this without a mentor to help me I was frustrated, I failed over and over and over again. And you know, I thought why does this have to be that way so I developed systems you know, I took every single course I could, I talked to every single dentist I could pick up lots of tips and tricks, and yeah, it got me to where I am today and now it’s kind of all I do all day, every day is take care of anxious patients and take out third molars [Jaz]
So you’re limited to just wisdom teeth as is that we all you do now. [Nekky]
Yeah, mainly Yeah, in limited to extractions basically. Yeah, and I’ll do implants too but it’s mainly sedation and extractions and implants, but it’s mostly extractions and third molars. Yeah. [Jaz]
But are you a like Board Certified Oral Surgeon or not? [Nekky]
No, I’m a proud general dentist. I love being a general dentist because I get to learn everything man, I get to take Jaz’s splint course and apply those principles. I get to do restorative, I get to see kids, I get to you know, see facial traumas. And you know the same kids I get to coach in basketball, and you know, fix their teeth when they’re a kid, I’m taking out their wisdom teeth when they’re 18 years old. And so for me, I’m proud to be general dentist. [Jaz]
Amazing. I love your story. And I love your enthusiasm and I love the fact that you’re a GDP flying the flag for GDPs but you know, you’re an example of someone who’s really found their calling, found their niche within general dentistry. And I love the fact that you’re not a specialist but all the videos I’ve seen them you extract I mean, you’ve taught it to me better than any specialist could could ever do. So thank you so much and for all you do for the dental community. So let’s dive right in buddy and help the GDPs who are commuting to work or sat on the beach. You know, I once I always tell my who’s listening from you know, around the world, and I love, two places that really resonate with me and really stuck in my mind forever is that in one month, two people from the Maldives listened to my podcast. So I can just imagine like these two dentists on the beach in the Maldives like, you know, they just say, I just listen to a podcast, which is amazing. And then two people from Afghanistan, listen to me, and I you know, I was born in Afghanistan, and I came as a refugee to the country so Afghanistan’s got a huge special place in connection with me. So I was amazed in one month. So wherever you are in the world listening right now, I hope that Nekky and I are gonna take you on a journey to help you to remove wisdom teeth, more proficiently, better surgical technique, and to avoid failures, just like you experienced many failures. I experienced so many failures as well. Lots of frustrations, messy flaps and stuff. We’re going to get into that, but no more after today’s episode. So first question for you Nekky is, let’s start with easy cases. Like if you’re a new grad, right? And sometimes you’re like looking at it and you’re just automatically scared because it has that label, right? Wisdom tooth. What are the features clinically and radiographically to look at that, that made that deeemed these wisdom teeth as low hanging fruit. What are the easy ones? What are the features that we should look out for? [Nekky]
For sure. And you know and to your point i think it’s embarrassing that our dental education or dental schools aren’t teaching us how to safely and efficiently take out third molars and it’s almost like a letdown to us it’s a disservice to our patients. So no, I’m glad to share a bunch of secrets today and a bunch of tips and tricks but if I was gonna say a low hanging fruit for new grads, you know, you want to start with younger patients. One of the main complicating factors with third molars, especially taking out third molars, is older patients tend to have you know, more dense bone, their roots are fully developed and we know third molars, they tend to have big curvatures or dilacerated roots and you know, those older patients are gonna have more postoperative complications as well so when you’re getting into third molars maybe stay away from some of those. If you want to dive into third molars, maybe take on cases with younger patients. So my favorite time to take a third molars is anywhere between 14 and 25 years old. 14 are like you know developed already, but you want to go after conical roots you don’t want to have you know, multiple roots that are divergent and they’re just you know grabbing in there because those aren’t cases to start out with, you want to start with conical roots maybe not fully formed roots. So you know, if a tooth just isn’t coming in the right way and the roots aren’t fully formed and they still have a bit of a follicle around them. That’s a great time to get those third molars out of there because they’re only going to cause problems and so if you want to get into third molars just stick to younger patients because chances are you’re gonna have more success. [Jaz]
I mean, I had flashbacks of you mentioned about conical roots and I remember being a DCT. So it’s like one or two years out of dental school I was in a Guy’s hospital and I started doing this wisdom teeth and had one on my list, one of my first ones and at the time like I wasn’t so great at assessing radiographs or what makes a simple extraction versus a complex one and I had one with conical roots and literally took the luxated to it pop right out and at that day I felt like yeah I’m a champion you know and then you see other teeth and you’re really in the depths of despair, you’re really struggling and you feel like the worst like in you know too well that difficult wisdom tooth can humble even the most experienced oral surgeon, right? So yes conical roots on young people. Now, people listening around the world right now would have heard you say you know 14-25 age and anywhere else in the world but yeah, that makes sense. But in the UK we have these NICE guidelines, right? [Nekky] I was just gonna say that totally [Jaz] They messed up, man. Nekky, you know, they’re messed up, the amount of people I see on a monthly basis who absolutely have the second molars destroyed from caries from these third molars is ridiculous. So yeah, in the UK we’re in a crappy situation which is why I said that in Singapore I was taking out more wisdom teeth than I am in UK at the moment even though I’m like far more skilled and knowledgeable now compared to how I was back then. [Nekky]
Absolutely. And it comes down to caries, periodontal concerns you know association of potential cysts in tumors external root resorption like there’s so many reasons why we don’t need to have those third molars in our mouth and then you know when that patient is 40 has a bombed out second molar mesio-angular or horizontally impacted third molar, you end up taking out an extra tooth there when you know that tooth probably wouldn’t have to come out anyway. And so to do it younger, that patient heals so much faster, they don’t have the pain and you know all the associated postoperative complications of waiting so I understand the NICE guidelines and I have full respect for all the clinicians in all the parts of the world but you know here in Canada and in North America we follow the AAOMS-White Paper and that’s you know, put out to say all the reasons why third molars should stay or should or they should be removed and not every third molar needs to be removed, but the ones in certain positions may need to be so [Jaz]
What does that White Paper, Nekky, say about people who are struggling to keep the area clean and they’re not necessarily getting like full blown pericoronitis but it’s a irritation, inflammation may be an episode of pericoronitis would that be good enough? [Nekky]
I absolutely think so. Because you know, just because you don’t have symptoms, that doesn’t mean pathology isn’t there. And so that’s really what it comes down to and that’s the same thing for periodontal concerns just because you have a six millimeter pocket distal to the second molar and you don’t know it’s there that doesn’t mean that that’s a full breeding ground of bacteria that’s you know harboring bacteria that can go all over and so I I’m a firm believer in you know, taking out third molars as they need to be taken out, especially you know, if you consider where all the bacteria is, and pericoronitis it’s only going to get worse. And so the younger the patient is I think just the better it is to get those out of there, especially in cases like that, [Jaz]
Which is why the NICE guidelines are so frustrating but let’s not, you know delve too deeply, that’s out of our control. Hopefully in the UK, we can improve that. But still we can you know we can improve our technique when the time comes to do it, but we shouldn’t fall into the trap of that really difficult one that perhaps we think okay, we should referred. So what are the main features in a radiograph or clinically, that you that help us to know that Whoa, this one’s may be really tricky. And we should refer this, [Nekky]
You know, this took me years to develop, and I kind of made my own guidelines. And, you know, I read a ton of research papers. I’ve done a ton of third molars, I’ve failed on a lot of third molars. And I started to go back and see like, what about this x ray did I find so difficult? What about this patient, did I find so difficult? So honestly, let’s just break it down. Okay? So let’s look at angulation. If you’re going to take on third molars, everyone’s looking at angulation first, okay, so mesio-angular is a lot easier to take out than a disto-angular, and we’ll talk about the reason for that in a sec. And a lot of like, GDPs, they get stuck, right away, they can see a third molar, and they’re like, Oh, I can take that out. I can see it. But if that tooth is disto-angular, that’s what makes it so difficult. So that’s where a lot of GDPs get stuck. Age, right off the bat. Older patients, like we said before going to be much more difficult. Root development, is the roots fully developed? Are they partially developed? Or you know, are there any roots at all? You know, fully developed roots are going to be much more difficult. PDL space, is there, you know, a tiny PDL? Is there a PDL? Especially on older patients, no PDLs, that makes it more difficult. But these two characteristics right here, which I want to talk to you about these really set the stage for me in looking at third molars and easily being able to determine is this going to be easy? Or is this going to be hard. So the first one I want to tell you about is proximity to the second molar. And no one taught me this but experienced myself. And so I, you know, I failed over and over again. And the situations where I failed in, I noticed when the third molar roots are directly touching the second molar roots. Okay, that’s what makes it difficult. If you look at at the classification of that, that’s a disto-angular impaction. But what makes it so difficult, is you can’t get your instruments between the second and the third molar. And if you break off the crown of that third molar, you can’t even see the mesial root because you can’t see past that second molar crown. So that played a huge role for me, have you found that too? [Jaz]
100% but the way you taught it to me was different or better than any other way like people would say, Oh, disto-angular is difficult. Yeah, remember DD Disto-angular Difficult. But it’s a whole, looking at the root and the lack of space that you have to put your instrument. And then when you know, when you taught me about keeping a lever, it is that term you write, the handle, sorry, keeping a handle [Nekky] keeping a handle [Jaz] mesial handle on, that was exactly. So just explain about what you mean by keeping the handle? [Nekky]
Yeah, so a lot of it like to be honest, there’s multiple different ways to take out a tooth as long as the tooth comes out, that’s the right way. I like to teach keeping the mesial part of the tooth for as long as possible, especially when you have that you know, close proximity when the roots of the third molar are touching the roots of the second molar. And so keeping that mesial part of the handle gives you almost an, or gives, the mesial part of the tooth gives you almost like a map to the tooth, if you lose your crown, you almost lose your ability and your orientation of where that tooth is. And so I find by removing the distal half of the tooth, I can create space in the socket to manipulate that tooth to you know, extract the tooth but a lot of GDPs you know, they go after that mesial part because they feel like that’s what’s holding it up. And I find it’s always the distal part, you know, that’s either hitting distal bone, or it’s, you know, caught up in the soft tissue. So I tried to keep my mesial handle as much as possible. [Jaz]
Okay, so proximity to the second molar, any others? [Nekky]
Yeah, my last one here. And this is what I call the depth of application. So since we’re keeping the mesial portion of the tooth, we’re usually gonna be elevating on that mesial crown there at the CEJ. And so what I like to do is I like to separate the second molar roots into thirds. So we section it like the most top third here is easy, the middle third is medium difficulty and the lower third of the second molar root is difficult. And if we match the third molar up to the second molar roots and see where the mesial CEJ is of that third molar, we can almost have a guesstimate of how difficult this tooth is going to be to access. So if that depth of application is deep, and it’s you know, very apical in relation to that second molar, that’s often going to be a very difficult tooth to get to and it’s going to be a difficult tooth to remove. And so a quick and dirty way of looking at a difficult case real quick is just look at the depth of application in relation to that second molar root and you almost have a telltale sign of you know How easy it’s going to be to get to this tooth. [Jaz]
Okay, brilliant. And yes, I can certainly visualize that trying to kind of put your instrument your luxator or elevator at that point, and how much less visibility you have, the deeper it is. So that’s covered nicely. The thing that really concerns most of us, when we’re starting out with wisdom teeth, as well as assessing the difficulty is the nerve right? Like we, like I want I am personally, like, I have got a phobia of being responsible, being that dentist who cause that nerve damage on a patient. So I remember in that same job role I told you about that DCT position at Guys hospital starting to get patients referred to the hospital for wisdom teeth being on the consultant clinics, and any tooth that had roots, even like close, let alone superimposed, I was like, freaking out, oh my god, oh my god, you know, the risk, the risk, but my consultant would come by and be like, you know, calm down, okay? It’s just super imposition. So what are the actual three or four things that we’re looking for, that will determine a high risk of inferior alveolar nerve damage? [Nekky]
Absolutely. And really, this goes back, I think, to both of our dental education. And, you know, we see this paper by, you know, Rood and Shehab in 1990, the landmark paper of radiographical features, and you see them in dental school, the seven pictures of the tooth, and the nerve, and the pictures were almost blurry, you know what I mean, like, and that’s almost an indication of what you see in real life. Because on the panoramic X ray, the tooth looks blurry anyway. So you can even see where the nerve is in relation to the tooth. So we just weren’t educated properly. So there’s, you know, there’s four, you know, relationships between the tooth and the nerve that’s related to the tooth and three that are related to the canal. But, you know, let’s just wash our hands on all that, I want to share with you the three signs that I look at. Okay, so the first one is darkening of the roots. Okay, when I see a darkened root in relation to the mandibular canal, or the inferior alveolar canal, I know that there could be a close relationship going on. And it doesn’t mean that if you take out that tooth, they’re going to have a nerve injury or paraesthesia. But it just means that there’s a higher risk of it. And so we have to talk to our patients about that. But we’ll talk about that in a sec. The other two signs is diversion of the canal in relation to that third molar. So if that third molar like is in position, and then the canal literally goes around it, I call that diversion of the canal. And that’s a sign of a high risk association between the tooth and the nerve. And then the last one is loss of the white line of the canal. So if you see your third molar, but you can’t, you can’t really see the white line of the canal in relation to that third molar, that’s another indication that that’s a high risk tooth to come out. But what I found is, you know, we have our signs, it doesn’t mean that you know, we’re going to have, you know, nerve injury, but it’s important to talk to your patients about this. And so see, you know, you talk to your patient, and you tell them that there’s a high risk of nerve injury, and you always give it back to them and you’re like, Are you okay, with taking out this tooth? These are the reasons why I think you should take it out. These are the reasons what could happen if you don’t take it out. Okay, but it’s up to you, what do you want to do. And if you do that, and if you take your time to explain to your patients, you know, the pros and cons, risks and benefits of taking out that tooth in relation to that, you know, possible nerve injury, and they get a nerve injury, they’re more likely to work with you than against you. And so patients always do much better with explanations than with excuses after the fact. So you have to take your time to educate your patients show them you know, why this is a high risk tooth and what would happen with a possible nerve injury. [Jaz]
Amazing. So darkening of the root, deviation of the canal and loss of the continuity of the cortical lines of the inferior alveolar nerve. Those are three main signs as you taught me as well. And that’s really useful to go by. Now, as I told you my fear of being that dentist who’s ultimately responsible, so my threshold for a CB CT is quite low, like if I see if definitely if I see any of those three signs, I’m thinking, Okay, CB CT, but sometimes if I don’t see those three signs, but you know, the root is superimposed with the canal, I sometimes will be like, okay, maybe we should get a CBCT because I’m a chicken. I’m practicing defensive dentistry in a way. What do you think is your threshold for CBCT? And does the CBCT change your management in any way or when you actually go to remove the tooth? [Nekky]
You know, that’s a great question. First of all, I don’t think you’re a chicken I think you care about your patients. And so I think that’s a huge factor right there. If we want to be cowboys and cowgirls and just go after every single third molar we wouldn’t really care about taking a CB CT. So my threshold is quite low just like you. Why wouldn’t we want more information when we have the ability to get more information if you were gonna get your third molar out, you know, you’re 35 years old, you’ve had you know, chronic pericoronitis, but there’s a one of the close relationships like we were discussing, wouldn’t you want your dentist to have all the information possible? So we have to think about it from the patient point of view. So my threshold is quite low as well. Definitely, if I see those three indications, I’m always taking a CB CT. And what I’m looking for on the CB CT that maybe not everyone understands is if we lose cortication of the mandibular canal in relationship with that tooth. So if the tooth root and the canal are touching, and there’s no more cortication of that canal, that’s when we’re like, Okay, this is a high risk extraction, that doesn’t mean that they’re going to get a nerve injury, but there’s a higher chance of that. So I always like to take a CB CT. And the other thing that I’m looking for on a CB CT is the tooth in relation to the cortical plate. So in cases where we see darkening of the root that may indicate that we have the actual tooth roots embedded in that lingual cortical plates are actually extending beyond it. And so what if you break a root tip, you know, which may happen, and then you go fishing for that root tip. And you can push that root tip into an anatomical space because it’s already beyond the lingual plate. But if you didn’t have that CBCT you may not know that so I think the CBCT provides you invaluable information and I encourage you to take them whenever you’re unsure. [Jaz]
Amazing. You’ve covered that really well now one question I also had when I told everyone on the telegram group that hey, you know when we’re talking wisdom teeth with Nekky, it’s Kameran Ali, he had this question about coronectomy, Okay? When would you and obviously you covered it in the course. But when would you consider a coronectomy which leads on quite nicely to talk about risk and CB CTs? [Nekky]
Absolutely, I think coronectomy is a great option when you do have a high risk scenario. So say you have an older patient who is more likely to get a you know postoperative nerve injury in comparison to a younger patient you know with a similar relationship. Why not do a coronectomy but you have to do the coronectomy properly, you can’t just cut off the crown and then expect you know everything to be okay there’s a couple tips and tricks that maybe I can share with you here. If you’re going to do a coronectomy in a high risk, you know, nerve, possible of nerve injury situation, you want to make sure you remove all the enamel of that crown. So what I like to do is I like to cut off that tooth root or that tooth crown three millimeters below the CEJ and that way we ensure that you know all that enamel is gone because the thought of a coronectomy is if we can bury the roots we want bone to grow over time, but we know bone doesn’t grow to enamel so you have to make sure you get rid of all the enamel. So I like to make sure that my bone level is three millimeters above my actual root. Okay, so there’s a three millimeter gap there. And second you you want to make sure in my experience when I do coronectomy, I always try to get primary closure. If I don’t get primary closure I find you know it doesn’t always close up the way I want it to. And you know that could be okay but try to get primary closure. And the cool part about coronectomy is one of two things are going to happen. Either the tooth is going to you know continue to erupt away from the mandibular canal where you can take it out if the patient is having an issue or bone grows right over. I think those are two great scenarios that you can either take out the tooth without a you know risk of a mandibular nerve injury or bone grows right over and you let it be so I think your coronectomy is a phenomenal option. [Jaz]
I used to work with a consultant or surgical at Guy’s hospital. And he was really like well known for coronectomies and really pioneering and championing coronectomies in London and in the UK. So I learned a lot from him. I remember being on his clinic. And you know, just as you said, that I didn’t know I didn’t realize at the time that is so important to make sure you don’t even have a single prism of enamel, you just won’t get the healing. So you’ve echoed that already. And one more thing is that, if you’re going to try this at home or in the office is just as you told me as well, make sure that if the roots do mobilize ie you’re trying to, you’re aiming to do coronectomy, but by accident, you know the roots start moving, then and you got to take it out, right? Explain a little bit more about that. [Nekky]
Yeah, totally like you can’t, you can’t leave mobile roots in there because they’re not going to heal but also infected roots. You don’t want to leave an infected root. If it is in close proximity to that mandibular canal, you can’t leave infected roots in there, those aren’t going to heal over, that’s just going to continue to get infected. So you have to take those out. You know, will a coronectomy work 100% of the time? No, but I think it’s a great option to try especially in very high risk scenarios. And I think it’s a great option I do coronectomies when I have to but not every indication is a chance to do coronectomy. [Jaz]
Absolutely. Now the next question I want to asked you is about flaps, right? Because I’ve been in a situation where, unfortunately, my, you know, periosteum is tearing a little bit. I have haven’t done as clean as of a flap as I’d like to. So it’s something that for me, once you get a decent flap, as you’ve shown so many times in the videos that you share, it’s so so critical to see that nice clean bone. And I love the videos of you just moving away the flaps so nicely. I wish every one of my flaps look like yours. But I learned so much from you, which is the main thing I learned from flaps was that previously, when I’ve done my incisions, I have failed to go over my incisions again and again and again and again and again, like four or five times, just like you teach. And that is the main lesson I want to pass on to the Protruserati listening today is that don’t just make the incision once and that’s it got over it, especially in that distal area of your tooth where you have a dense connective tissue as you taught it. So just expand on that, and what other tips and tricks and I know there’s one that you love about the Hydraulic. Tell us about that as well just get really cleaned up, because that is a real game changer. [Nekky]
Yeah, so I think a huge part of third molar extractions is respect for the periosteum. And I’m sure you’ll agree with me there. Because if we have messy flaps, your patient comes back, you know, weeks later, they’re still in pain, there’s a ton of swelling, the gingiva just doesn’t look good. And really, we feel really bad as clinicians when our surgeries aren’t clean, when our patients aren’t healing. So number one, you have to respect the periosteum. And how we respect the periosteum is by making clean flaps. So when you’re making your flap, I want you to think of you making your flap with intention and confidence. Okay? It’s not just ‘Okay, I think I’ll make an incision here. Oh, no, I don’t like that incision. Let’s make it over here now.’ And then you just tear up the periosteum, there’s bleeding and swelling. So we don’t want that. So a trick that I use over and over again, is I make my incisions with intention and confidence. But then I go over my incision, at least four times, okay? And if I go over it twice, it’s not good enough, sometimes there’s dense connective tissue, especially in cases of a partially erupted third molar with, you know, chronic pericoronitis, that tissues kind of attached on that tooth pretty good. So you have to go over your incision, at least four times, okay? And then another tip that I use is a lot of us in school were taught to use the Molt 9 periosteal elevator, it’s huge, it doesn’t allow us to get to where we need to. And that’s how I was ripping a lot of flaps, as well earlier. So I use a smaller periosteal elevator, it’s called a P24G. And it’s a great little tool for reflecting a nice clean flap, as I’m sure you’ve seen there, Jaz, but I want to share with you another tip, and you can use this tip anywhere in the mouth, okay? and it’s called the hydraulic flap. And what we need to do and the goal of whenever we reflect a full thickness flap, is we want to get that periosteum right off the bone, and it’s just so clean when it comes off the bone, we don’t want to tear the periosteum. So a little trick that I do is I’ll use a short needle, like for anesthesia. And I’ll just inject my lidocaine all the way to bone all along my flap, and I almost bubble up the tissue a little bit, and you know exactly what I’m talking about when you just hit bone. And then that tissue bubbles off. And that’s that hydraulic flap I’m talking about. So then when you make your incision, that flap literally peels right off the bone, because we’ve already got that periosteum off the bone. And that’s a tip you could use anywhere in the mouth. And it just works great. [Jaz]
That’s a massive tip. And it’s funny, you know, you wait for these gems, and then they come along at the same time. So George talked about hot pokes and fail ID blocks. And he mentioned it to me about eight weeks ago, and then I saw it again on your course. And he actually had the clinical demonstration of it. And I thought, Wow, this is so so good. So I just want to just ask you a little bit more about that when you are injecting, Are you in the attached gingiva? Or are you more in the mucogingival, beyond the mucogingival line in the free tissues when you’re doing that? [Nekky]
Yeah, that’s a great point actually go right at the mucogingival junction. And so it’s easy to do, so you get a little bit of both. I find if you go in the mucosal area, the flap usually reflects quite easy off that anyway, it’s usually around the mucogingival junction and the attached tissue that you have to start reflecting your tissue. And I always start, you know, at the papilla and I go, you know distally from there. So that’s what I found works really well for me is just injecting along the mucogingival junction and you just want to bubble that tissue it takes not even two seconds. So it’s a great tip to do. [Jaz]
I mean that’s a top tip. So I’m itching to go for my next wisdom tooth case. So I can try obviously we have the mentoring session which you gave me and we talked about this case that’s upcoming for me so I’ll let you know how that goes. And armamentarium like when I was in Singapore, and I keep referring back to Singapore, but that was a big part of my journey with wisdom teeth, because I was just doing a lot more of them. I knew I hated using the straight hand piece. I used it once in hospital. I just hated the access. I know you use both and you’re very proficient on both but I needed something that was super GDP friendly and so I bought the 45 degree NSK handpiece while I was in Singapore because the exchange rate was good and it was on offer so I was like yes this is great. I also bought myself a normal red ring electric handpiece for my preps and stuff, absolutely fantastic. Love these hand pieces, but the 45 degree one it’s like purpose built for wisdom teeth and for sectioning. And then when I saw on your course that you were recommending that handpiece, I was like ‘Oh my god, I’m so lucky that I actually have this exact same one that Nekky uses.’ So tell us about armamentarium maybe just give us a few tips for you know if I eventually need to use a straight handpiece and do tell us when you might think we’d use that surgical handpiece rather than the 45 degree IE what might be a potential disadvantage of that 45 degree handpiece? [Nekky]
Oh totally. Okay, so first of all, I’d use a 45 degree angled handpiece 98% of the time. I love my 45 angled handpiece and I know we have the exact same one and I just think that they’re the best hand pieces out there. And I think as GDPs, we like using things that are familiar. So if the 45 degree angled handpiece not too different from our regular handpieces that we use for you know, operative dentistry, so I love the 45 degree angle handpiece. It feels great and it gives you good visibility. Now the problem with a 45 degree angle handpiece is you’re always gonna wish your bur was just a little bit longer especially if you have a more impacted tooth you’re gonna wish you just could get a little bit deeper and unfortunately you can’t always do that. So that’s when the straight hand piece comes into play. But even for me I feel a straight hand pieces is not, I don’t get the same tactile ability as I do with a straight hand piece. straight hand piece is always just feel a little foreign to me as well. Where straight hand piece shines is for horizontally impacted third molars when that furcation is just a little bit deeper because your 45 degree angle the handpiece may not be able to get all the way to the furcation to section the roots just because of the position of it. So that’s where a straight handpiece works well but for you know a vast majority of the cases 45 degree angle handpieces are the way to go. They’re easy, they’re reliable and they feel normal in our hands as GDP so I highly highly recommend them. [Jaz]
Absolutely I love the 45 degree on but with a straight hand piece I found that access to there is just probably unfamiliar the way you hold it in your hand and also the patient’s lip you have to move in to get access to air you have to really move that cheek out the way a lot more but you know it’s also one of the things that the more if I was to use the surgical handpiece more straight one then I would become better at it. So it’s one of those things that you know the more effort you put in, the more time you put in, the more proficient you become using that particular armamentarium. [Nekky]
For sure but for GDPs like we’re using not everyone is going to be doing third molars all day so is it you know worth the investment to spend a ton of money getting a straight surgical handpiece or can you use that 45 degree angled handpiece and you can use it you know it’s a section in upper first molar and you can section a lower third molar so i think you know in terms of you know armamentarium that we can use everywhere as GPS I would go with the 45 degree angled, myself. [Jaz]
That was one of the best investments I’ve made in equipment that 45 degree handpiece because I took out loads of wisdom teeth in Singapore and it was all thanks to that handpiece because it just gave me the confidence and the access that I really needed so I’m just, again, like I said I’m so glad that that’s the one you recommended as well. Which takes me to my last question Nekky before we just do the outro is your big three tips, okay? To dentists everywhere who maybe have taken a few wisdom teeth out for and they just need a few nuggets, a few gems. Can you just share with us your three magic Nekky tips. [Nekky]
No problem. Okay, so my first tip right off the bat, clean incisions, respect the periosteum clean flaps, the cleaner your flap is the the more you’ll be able to see, the less stress you’ll have because you’re not constantly pulling on your flap, and the faster that patients can heal. So right off the bat, you have to get good at flaps, no more messy flaps. And Jaz, just like I showed you, flaps do not have to be messy. You just go over your incision numerous times, you use the right instruments and you know where to make your incisions to just literally open that area up so easily and so quickly to make a messy flap takes longer than it does to make a clean flap. So right off the bat you have to get proficient at flaps and it’s not difficult. Two, is the key to third molars in my opinion is hitting the furcations in sectioning teeth. If you want to get faster at taking out third molars hit your furcations and I made stickers and my stickers all say I give them to all my people and I’m like ‘Man, hit your furcations’ and that’s what third molars is all about. If you get good at hitting your furcation, you’re taking out third molars. Okay, and lastly, after you’ve taken out the tooth, it’s all about rinsing your flap, I’m not rinsing the socket, I’m rinsing my flap, if we can get all the little shards of bone and tooth and all the gunk that comes along with extractions off of our periosteum before we close it up, you’re gonna find patients heal so much faster and they don’t come back with a lot of post operative concerns. I feel a lot of post operative concerns comes from having messy surgical sites. So if we can have clean flaps, we rinsed the area, smooth bone, we use a bone file after we take out third molars, we don’t want jagged bone around there, everything’s smooth, everything’s clean, we’ve rinsed our flat and we close it up your gold. [Jaz]
Amazing. Nekky, you’ve honestly covered so much in the last I don’t know like 35, 40 minutes then that was really a gem pack because I like to call it I mean the way I found you was, my colleague John I know you listen to this, Hello John. Baby number two coming for you soon, John. So I’m very excited for you john. So John works with me. He’s actually my boss and he referred me these wisdom teeth and I looked at him and it was just just a tiny bit beyond my comfort level, right? And I shied away and it was really bugging me and it was really bugging me that okay I wish I had someone to mentor me, hold my hand through this and so that you know obviously I saw your course on course karma, you know, splint course also was on course karma so was RBB masterclass so then started speaking. I’ve been doing a course now you had that one to one mentorship with me as well to discuss exactly those cases so if anyone want to see how to take out this wisdom tooth, this mesio-angular wisdom tooth which did actually concern me and worry me and then also the same patient upper right third molar mesio-angular quite less common obviously for an upper wisdom tooth and you just completely alleviated all my concerns, you talk me through exactly how to do it, you show me some clinical videos so now I’m totally ready to target that but your entire course, the third molar experience was just phenomenal. Now, I was telling my Protruserati on the Protrusive Dental community Facebook group, so guys if you’re not on this group already, please do a search on Facebook, join us and I was telling these guys ‘Okay, I’m doing this wisdom tooth course, it’s okay so far 200 lessons Oh my god.’ Okay, that’s I mean that’s amazing 200 lessons but I was like, I was like desperate to get through it, get through it, get through it because just you did the same thing that I do on my splint course which is you don’t rush to the juicy bits that that dentists really want, right? The dentist wants the clinical videos, right? I always desperate for these YouTube videos in 2017 whereas you saved them all like I don’t know 50, 60 of them of all these surgical extractions that you do which is absolute gold, but I respect the fact that you really covered the theory, the flaps, the everything we talked about, the when to get a CBCT, how to manage preoperative complications, post operative pain before you then literally throw all this gold of clinical videos which you know, massive kudos to you how you organize that so that’s been absolutely brilliant. And I think we’ve been emailing and it’d be really kind of Nekky to offer anyone who’s listening, who wants to learn wisdom tooth surgery from the third molar experience 15% discount using the code “protrusive”. Is that right? [Nekky]
Yep. “protrusive” Yeah, for your group man. I think this course, I created this course because so many people have fear in frustration of third molars and it doesn’t need to be that way. Why don’t we have people teaching this out there because we all have to take out the third molars and we don’t do it correctly so why not teach us all how to do it but it’s not taught easily in dental schools and so I wanted to fill that gap and be the mentor that you know I didn’t have when I was going through it so I’m really proud of this course, it took me years to make and [Jaz]
It’s like a lot of hard work I mean even just to get the clinical views and some videos you actually on purpose made it to like it felt as though I was there, I was extracting it the way you angle it and you made a point so I’ve made the record this video so you feel as though you are, you know, lower right molar tooth, you are using the blade to make the decision and what I learned on there not only has helped me to take on these courses also with your mentorship which I’m so grateful for that specific case I know you’re there to support and I remember that you actually sent me this personalized Whatsapp Video was like ‘Hey, Jaz. Great to have you on the course. Look forward to doing that.” That was a real surprise. But I was also proud that I was a first ever delegate to send the video back to you. [Nekky]
Yes, ever. Half the people don’t even text me back. But it’s, I think it’s cool. I like to meet the people in my course I don’t want you to take the course and then I never get to talk to you. So I like to, you know, carve out time and talk to everyone individually see what they’re having problems with because if we’re not here for each other, what are we doing this for? I’m literally here to help you and I’ve dedicated my evenings after you know taking out third molars in the day I want to help my fellow dentist because we all need to get better together. [Jaz]
You really do live and breathe third molars and honestly it really shone through in the course. Absolutely fantastic. But like I said, I had my reservations Nekky, that okay, Can you learn third molar online and what you showed with the videos and the number, the quantity and the quality of the videos made me feel so much more confident plus the mentorship that you offer was amazing. So guys, if you’re looking for a third molar course, Nekky’s is the one to do. Do use the code, he’s generously offered 15% off, it’s “protrusive” and you know it’s just shows how much hard work you put in. So Nekky, thank you for that course. Thank you for mentoring me. I mean obviously send you some photos of these roots that when I hit that furcation, and I get those roots out I’m gonna send them, I’m gonna WhatsApp them straight to you, brother. [Nekky]
That’s right. I’m gonna send you out some stickers now too, because you got to hit those furcations every day. You need to remind yourself it’s gonna be great. [Jaz]
That’s such a cool tagline, man. Nekky, thanks so much for tackling all those. Kameran thanks for the question that you sent in on our telegram group. By the way if you’re not in our telegram group is protrusive.co.uk/telegram there’s so many great dentists I think over over like almost 400 dentists on that telegram group and it’s just, it’d be great to have you guys on if you’re listening. Nekky join that, Are you on telegram, Nekky? [Nekky] No I’m gonna have to though. [Jaz] Okay, you will be now. Download telegram on your phone. [Nekky] I will be now. [Jaz] Join our telegram, it’s like WhatsApp on steroids. Okay, so join our telegram and you will be our resident third molar mentor. Thank you. I really appreciate you coming on, Nekky. Thank you so much. Have a awesome weekend. What are you up to? [Nekky]
Man, this is a huge honor for me. You know just hidden to the office, we’re expanding our office right now after all this COVID stuff it’s hard to find workers so everything’s behind so you know I’m just trying to play catch up and having fun doing it. So it’s good. [Jaz]
Well, thanks for carving out time for this but also I just remembered when we had that mentoring session, okay? It was like, I don’t know 10:30 here. It was 4:30am and you look so fresh and so good and so pumped. I was absolutely amazed, blown away by the service. So I shall have to mention that. Nekky, thank you so much for your time, really appreciate it. Thanks for all those gems. [Nekky]
Absolute honor. This is a dream come true for me. So you’re a dental legend, Jaz. So it’s great for me to be on here with you. [Jaz]
Thank you so much Nekky.
Jaz’s Outro: My goodness isn’t Nekky such a charismatic man. I mean, I love his style of teaching. I love his deep voice. I love his AV setup. He’s like been one of the best guests I’ve ever had in terms of good audio and video equipment. So kudos to you buddy. Like I said if you want to join the course, if you want to find out more about the course is a thirdmolarsonline.com that’s thirdmolarsonline.com I’ve done it, it was sensational. And with the one to one mentoring that he gave me. I just feel really confident to tackle that case that really sparked my desire to learn more about tackling more complex wisdom teeth. So the code to use is “protrusive” Nekky, thank you so much for giving 15% off to all the Protruserati. I hope you guys make use of it and hopefully Nekky will also join us on our telegram group to be our resident third molar expert. Nekky, you did a fantastic job on this episode. Thanks so much. I’ll catch you same time. Same place. Next week. Guys, thank you so much for listening all the way to the end.