Exodontia.Info
Operculectomy
If the flap / hood of gum (operculum) overlying a (wisdom) tooth becomes infected / inflamed,
this elicits an
operculitis, which is a form of pericoronitis.

Operculectomy is the removal of the flap of gum overlying a tooth

Often, wisdom teeth are only partly erupted into the mouth.  There is often a flap of gum (
operculum) overlying
the tooth.  It is difficult to keep the area clean because of this flap.  The flap can also be traumatised by the upper
wisdom tooth biting onto it.  If this is the case, the upper wisdom tooth may need to be removed as well.

Once the
operculum has been removed, it should be easier to clean the area, lessening the risk of decay in the
wisdom tooth (and the adjacent tooth) and of infection in and around the crown of the tooth.

The removal of the
operculum can be achieved by a number of means (‘cold steel’, glacial acetic acid, radio-
surgical
means, laser or cautery).
Problems with the procedure:

  • It may not help at all.

  • It possible that the operculum may grow back and the operculectomy may need to be repeated.

  • The Lingual Nerve (supplies sensation to the tongue) may be effected.  This can result in a numb tongue as
    well as loss of taste on that side of the tongue; the numbness can last up several months.

  • If the wisdom teeth flare-ups have been quite episodic, then it may be hard to know if the operculectomy has
    in itself, been successful.

  • The op site may become infected afterwards.  This can happen in fit and healthy people with "clean mouths"
    and even if the patient is on antibiotics.  Very occasionally, the infection may be such that the patient may
    need to be admitted to hospital for drainage of the abscess under a general anaesthetic.


An
operculectomy is sometimes considered if the upper, opposing wisdom tooth is traumatising the operculum.  
The
SIGN Guidelines suggest pain associated with the lower wisdom tooth is commonly exacerbated by the
upper wisdom tooth biting on the gum flap (
operculum), causing pain and discomfort.

Alternatively, if the upper
wisdom tooth is easy to remove and is non-functional, then immediate removal of that
tooth will often dramatically relieve the pain from the area.  This is particularly useful where there is likely to be
delay in the removal of the lower wisdom tooth and can be regarded as an interim measure (after referral but
prior to surgery).
Last Updated 5th January 2020
Useful Articles:

Int J Laser Dent 2014.  Case Report.  Minimally Invasive Management of Pericoronal Abscess using a 810 nm
Diode Laser

Researchgate 2014.  Operculectomy as a conservative approach to third molar extraction

Compend Cont Ed Dent 2015.  Laser-Assisted Operculectomy

Int J Current Research 2016.  Comparison of Healing Process of Operculectomy with Laser & Surgical Knife - A
Clinical Study


Useful Website:

DocDoc
Photo of Pericoronits / Operculitis effecting Lower Jaw Wisdom Teeth
This list of warnings might seem excessive to some however the legal ruling in the case of Chester vs Afshar
(2004)
would suggest that it is quite prudent / necessary to list them.  Others might say that there isn't enough
information but where do you stop?  

The following list of warnings regarding
operculectomy is neither exhaustive nor is it predictive.  The most
pertinent warnings have been included here
.


Operculectomy Specific Warnings:

Failure of Procedure.  Even though an operculectomy may have been successfully carried out, there may still be
problems of infection / inflammation around the crown of the tooth. That is, the
operculectomy may not have
worked.

Repeated Operation due to Regrowth of Operculum.  The operculum can always grow back.  If this is the case
and the
operculum is symptomatic, the operculum can be removed again.  It is always possible that at this stage,
the patient may just want to have the wisdom tooth removed.

Numbness of tongue ± loss of taste.  The Lingual Nerve may be damaged during the procedure resulting in
numbness (the “numbness” can range from “blunted sensation” to a burning sensation) affecting the tongue ± loss
of taste to that side of the tongue.  The numbness of the tongue ± loss of taste can last from weeks to months
though it does have a low incidence.

Need to remove the upper wisdom tooth.  The upper wisdom tooth may be biting on the operculum, traumatising
it and exacerbating the painful symptoms.  The patient may benefit from having this tooth removed as well.

Initial Appearance.  Initially, the operculectomy site may look somewhat disconcerting.  It can appear raw,
charred, deep, swollen and may bleed easily.  The op site heals quite quickly (becoming noticeable after the 1st
week or so).  For the 1st week of healing, it is worth using an
antiseptic mouthwash (such as Corsodyl or Peroxyl
mouthwashes), a
local anæsthetic mouthwash if painful (such as Difflam or Bongela) and hyaluronic acid gel /
mouthwash (such as Gengigel).


General Surgical Warnings:

Pain.  As it is a surgical procedure, there will be soreness after the operculectomy.  This can last for several
days.  Painkillers such as
ibuprofen, paracetamol, Solpadeine or Nurofen Plus are very effective.  Obviously, the
painkiller you use is dependent on your medical history & the ease of the operation.

Swelling.  There will be swelling afterwards.  This can last up to a week and peaks at around 2 - 3 days.  Use of
an icepack or a bag of frozen peas pressed against the cheek adjacent to the operation site will help to decrease
the swelling.  Avoidance in the first few hours post-operatively of alcohol, exercise or hot foods / drinks will
decrease the degree of swelling that will develop.

Bruising & Bleeding into Cheeks.  Some people are prone to bruise.  Older people, people on aspirin or steroids
will also bruise that much more easily.  The bruising can look quite florid; this will eventually resolve but can take
several weeks (in the worst cases).

Swelling that does not resolve within a few days may be due to bleeding into the cheek.  The cheek swelling will
feel quite firm.  Coupled with this, there may be limitation to mouth opening and bruising.  Both the swelling,
bruising and mouth opening will resolve with time.

Stitches.  Where the operculum has been removed, it is often cauterised using electro-cautery, lasers, radio-
frequency cautery
or chemical cautery.  These may need to be augmented with stitches.  The stitches dissolve
and ‘fall out’ within 10 – 14 days.

Limited Mouth Opening.  Often the chewing muscles and the jaw joints are sore after the procedure so that
mouth opening can be limited for the next few days.  If you are unlucky enough to develop an infection afterwards
in the operation site, this can make the limited mouth opening worse and last for longer.  There may also be
scarring around the operation site - this scar can contribute to limited mouth opening.

Post-op Infection.  You may develop an infection in the operation site after the procedure.  This though is rare.  
There may be swelling, limited mouth opening, pain, bad breath and an unpleasant taste in the mouth. If this
happens, you need to contact your surgeon or dentist of A&E as soon as possible.

Occasionally, there may be a collection of pus from the infection that may need draining.  This may be done under
a general anæsthetic - if so, the wisdom tooth associated with the
operculum may be removed at the same time.
The medico-legal landscape of consent has been shaped by a number of cases, such as Chester v Afshar
[2004], Montgomery v Lanarkshire Health Board [2015], Duce v Worcestershire Acute Hospitals NHS Trust
[2018]
amongst others, so that it is more patient-centred.

Many of the legal claims in surgical (& medical) cases occur as a result of “failure to warn”, i.e. lack of
adequately documented and appropriate consent.

A pre-requisite for obtaining consent for a surgical (medical / dental) procedure from a patient, is a full
exchange of information regarding any risks, drawbacks and limitations of the proposed treatment and any
alternatives to it (even non-treatment).

The clinicians should provide the patient with as much information as is appropriate and relevant, that it should
be in terms the patient understands & the risks should be personalised for that individual patient.  Also, there
should be enough time for the patient to understand the information given and get a second opinion if needs be.