MINOR ORAL SURGICAL PROCEDURES.

Minor oral surgery includes removal of retained or burried roots, broken teeth, wisdom teeth and cysts of the upper and lower jaw. It also includes apical surgery and removal of small soft tissue lesions like mucocele, ranula, high labial or lingual frenum etc in the mouth. These procedures are carried out under local anesthesia with or without iv sedation and have relatively short recovery period.


Technique (Figure 2)
In case of paralleling technique two paralleling incisions are made on the side of ridge of the frenum this will reduce the removal of excess mucosal tissue. After that deep dissection for the muscle fibers are done to remove the attachment. This will decrease the chances of recurrence. Then the thin incised tissue is removed by making sharp cut above and below frenum. Primary closure is possible in this case throughout the length of frenum because of close approximation of margin produced by thin paralleling incision. Primary closure and less removal of gingival and mucosal tissues could be the reason for less postoperative pain and speech discomfort3.

Miller's Technique
The Miller"s technique was advocated by Miller PD in 1985.The ideal time for performing this surgery is after the orthodontic movement is complete and about 6 weeks before the appliances are removed to allow healing and tissue maturation.

Technique (Figure 3)
The area is anaesthetized with a local infiltration by using 2% lignocaine with 1:80000 adrenaline. Excision of the frenulum and exposure of the labial alveolar bone in the midline. A horizontal incision is made to separate the frenulum from the interdental papilla. A laterally positioned pedicle graft (split thickness) is obtained and it is sutured across the midline. A periodontal dressing is placed. a) Frenum excised c)Lateral pedicle graft obtained d) Graft sutured Figure 3:-Miller"s technique. Z plasty Armamentarium Scalpel blade no.15, gauze sponges, tissue forceps, 5-0 vicryl sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

Technique (Figure 4)
The area is anaesthetized with a local infiltration by using 2 % lignocaine with 1:80000 adrenaline. The length of the frenum is incised with the scalpel and at each end, limbs at between 60º and 90º angulation, incisions are made in equal length to that of the band. By using fine tissue forceps, with care not to damage the apices of the flaps, the submucosal tissues are dissected beyond the base of each flap, into the loose nonattached tissue planes. Thus, double rotation flaps which are at least 1 cm long are obtained. The resultant flaps which are created are mobilized and transposed through 90º to close the vertical incisions horizontally Absorbable 5-0 vicryl sutures are placed, first through the apices of the flaps, to ascertain the adequacy of the flap repositioning and then they are evenly spaced along the edges of the flaps, to close the wound along the cut edges of the attached mucoperiosteum and the labial mucosa. A periodontal dressing is placed. After 1 week, the dressing is removed, while the remnants of the sutures are left, as resorbable sutures are used. a)Incision placed b)Two triangular flaps obtained. c)Flaps sutured Figure 4:-Z-plasty technique. V-y plasty Armamentarium Hemostat, scalpel blade no.15, gauze sponges, 4-0 black silk sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

Technique (Figure 5)
The area is anaesthetized with a local infiltration by using 2 % lignocaine with 1:80000 adrenaline, the frenum is held with the hemostat and an incision is made in the form of V on the undersurface of the frenal attachment. The frenum is relocated at an apical position and the V shaped incision is converted into a Y, while it is sutured with 4-0 silk sutures. A periodontal pack is placed. The periodontal pack and the sutures were removed at 1 week of followup. a) Frenum held with hemostat b) Frenum incised c) V-shaped incision sutured Figure 5:-V-Yplasty technique.
Advantage Of Conventional Frenectomy 1. Cost effective 2. Decreased chances of recurrence.
Disadvantage Of Conventional Frenectomy 1. Requires sutures 2. Postoperative bleeding, pain or swelling. Electrosurgery Electrosurgery is the use of a high frequency electrical energy in the radio transmission frequency band applied directly to tissue to induce histological effects. It is a surgical technique performed on soft tissue using controlled, high-frequency electrical (radio) currents in the range of 1.5 to 7.5 million cycles per second, or megahertz. In 1928 William Cameron developed the first dental electrosurgical unit4.

Types Of Electrodes
There are 3 classes of electrodes: 1. Single-wire electrodes for incising or excising; 2. Loop electrodes for planning tissue; and 3. Heavy, bulkier electrodes for coagulation procedures.

Precautions/ Guidelines
Following factors should be considered while using electrosurgery for better result; Select smallest possible electrode.
The thicker the electrode, the greater the amount of lateral heat hence large electrodes cause more tissue damage than small ones.
Incision should be made at the rate of 7mm/s, The quicker the active electrode is passed over the tissue, the lesser the lateral heat. The active electrode must not remain in contact with tissue for more than 1 to 2 seconds at a time to prevent overheating of the tissue surface.

Allow cooling period of 8 s between successive incisions
A cooling period of at least 8 seconds between subsequent incisions in the same area is necessary to assure that lateral heat production capable of initiating adverse tissue responses does not occur.

Avoid contact of metallic restorations
Contact of an active electrode with metallic restorations should be limited to periods less than 0.4 seconds. Longer periods of contact may result in pulpal necrosis.

Use appropriate electric power.
A higher frequency unit tuned to optimal power output is used to set, to generate a fully rectified filtered waveform.

Armamentarium
An electrocautery unit with the loop electrode and a hemostat.

Technique (figure 6)
The area is anaesthetized with local infiltration by using 2% lignocaine with 1:80000 adrenaline. Frenum is held with hemostat at the depth of the vestibule and two incisions are placed using needle electrode. Muscle fibers are then separated using loop electrode. Coagulation is achieved by using ball electrode. Immediate post-operative views showed arrest of bleeding and no requisite for sutures. One week post-operative view showed presence of slough in the operated site indicating healing process. One month post-operative view showed complete healing of tissues.

Partial ankyloglossia
Partial ankyloglossia is the presence of a sublingual frenulum which changes the appearance and/or function of the infant"s tongue because of its decreased length, lack of elasticity or attachment too distal beneath the tongue or too close to or onto the gingival ridge.

Complete ankyloglossia
Complete ankyloglossia is a condition in which there is extensive fusion of the tongue to the floor of the mouth which is extremely rare.

Morphological Classification
Morphological classification is based on the distance from the tip of the tongue to the attachment of the frenum, has been suggested by Kotlow [1999]7.
Clinically acceptable normal range of free tongue: greater than 16 mm 1.

Diagnosis
Diagnostic criteria for tongue tie is based on the length of the lingual frenulum, amplitude of tongue movement, heart-shaped look when the tongue is protruded and thickness of the fibrous membrane. The examination of lingual frenulum should consider the morphological and functional aspects of the tongue. (Table 1) For a correct diagnosis the function deserves more consideration than the appearance. In children or adults we have to evaluate the possibility of the tongue to touch with its tip the retro-incisal papilla on the palate, the heart shape during the lingual protrusion, reduction of sublingual space, difficulty during the lingual movements, space between central inferior incisors due to the tensile force exerted by the lingual frenum during speech and deglutition. Furthermore, the affected children cannot lick their lips or an ice cream or cannot play a musical instrument. Hazelbakers assessment tool for appearance and function of the tongue.

Speech Articulation Test
A simple speech articulation test has been suggested in which if the elevation of the tongue tip is restricted, the articulation of 1 or more of the tongue sounds-such as "t", "d", "l", "th" and "s" will not be accurate.

Treatment
Several conservative, as well as surgical options, exist for the management of tongue tie. It includes speech therapy, otolaryngotherapy, frenotomy, frenectomy, frenuloplasty and laser frenectomy.

Speech Therapy
A functional assessment of the lingual frenum is essential to decide the need for speech therapy or surgical intervention. A speech therapy may be indicated for children who have not an excessive brevity of frenum, because they highlight difficulties in articulatory features, sometimes associated with a pathological swallowing and postural changes, but in history there are no important problems during breastfeeding.

otolaryngotherapy
Patient is advised to an otolaryngotherapist for the assessment of tongue related problems due to ankyloglossia.If the intervention of a speech therapist and otolaryngotherapist fails to resolve speech and tongue related problems, then it may be necessary to consider surgical protocol.

Surgical Techniques Historical background
During the 18th century, midwives used to divide the lingual frenulum with their sharp fingernails. For over a century, a grooved tablespoon was created specifically to release the tongue-ties. Pediatricians used similar devices over decades but recurrence was common.
Traditional frenectomy technique is performed using local anaesthesia, scalpels for incisions according to the technique and sutures. All this requires surgical dexterity as well as the capacity to work with small patients. Laser technique is an excellent alternative to traditional surgery. It is simple and rapid to perform, well accepted and tolerated by patients, requires a minimal anaesthesia, with an asymptomatic postoperative period, without relapse.

Techniques
Surgical techniques include frenotomy and frenectomy.

Frenotomy
Frenotomy is a simple cutting of the frenulum without excision of the tissue.

Armamentarium
Gauze piece, sterile blade or Goldman Fox scissors.

Procedure (Figure 8)
It is the procedure where frenum is cut or divided. It is accompanied without anaesthesia and with minimal discomfort in infants. The parent or assistant holds the head and stabilizes. The infant is made to sit supine to prevent tongue from falling back. The tongue is held with gauze and lifted gently, and then two gloved fingers of clinician"s left hand are held under the tongue to lift and support tongue. The frenum is then divided/cut using small sterile blade/ Goldman Fox scissors, in a single motion, at the thinnest portion through the white, fascia-like tissue along a line parallel with the tongue. Occasionally complete release may be accomplished with a single cut.
However when the frenum is quiet tight 2-3 sequential cuts are required for retraction.Since the frenum is poorly vascularized and innervated it is at the clinician"s advantage to use this simple procedure without any complication. a)Tongue being held up b) Frenulum was cut. Figure8:-Frenotomy.

Advantages
1. Conservative, simple and quick procedure that may be performed in the dental office settings during initial consultation. 2. Minimal discomfort. 3. After the procedure, feeding may be resumed immediately and is without apparent discomfort. 4. No specific follow up care is required. Disadvantage 1. There are chances of recurrence, 2. At times there is need to perform complementary procedures to release the tongue satisfactorily.

Postoperative Instrucions For Frenotomy
Parents should be advised that post-operative white fibrin clot might be seen to form at the incision site during the first couple of days, and they should be reassured that it is part of healing process and not to mistake for an infection. Follow up in 1-2 weeks should be made.

Frenectomy
Frenectomy is defined as complete excision, i.e., removal of the whole frenulum.The technique is same as that of labial frenectomy but in lingual frenectomy hemostat, grooved director are used as additional armamentarium8.

Frenectomy With The Use Of One Hemostat Advantage
The hemostats are used to delimit the area to be excised as well as to guide the incisions.

Disadvantage
Two incisions has to be placed.

Frenectomy With The Use Of Two Hemostats Advantage
When two hemostats are used, the risk of inadvertent soft tissue laceration is decreased.

Disadvantage
When the frenulum is too short, the use of two hemostats may not be feasible due to space limitation.

Frenectomy with the use of a grooved director Advantage
Grooved director allows firm control of the tongue during anesthesia and serves as a guide for the incision at the upper aspect of the frenulum.

Disadvantage
1. Grooved director does not eliminate the need for tongue traction.
2. Tongue retraction with a silk suture in order to stabilize the tongue during dissection and suture of the wound is still required.

Frenectomy Using Electrocautery
Same as that in labial frenectomy.

Recentadvances in the treatment of ankyloglossia Laser for treatment of ankyloglossia
Laser have been found to be very effective and minimally invasive procedure with immediate improvement in speech. Many lasers are available including Er:YAG,CO2 and Nd:YAG.Each of these Lasers exhibits specific properties depending on their position in the electromagnetic spectrum.
Same as that in recent advances of labial frenectomy.
Postoperativeinstructions For Lingual Frenectomy 1. Sucking of ice chips during first 24 hours, 2. Avoidance of any hot, hard or spicy food stuff. 3. Performance of postoperative tongue exercises after first 24 hours(postoperatively tongue exercise included touching of tongue to the palatine rugae while keeping mouth opened, rolling tongue side to side touching corner of the mouth, stretching of the tongue with a protrusive action). 4. Patients were instructed to continue this exercise 3-4 times daily for 2 min until the incision healed and 5. Sutures were removed carefully 1-week after surgery Gingivectomy Gingivectomy was first introduced by Robicsek in 1883 and the gingivectomy technique has been defined by Grant et al(1979) as the excision of the soft-tissue wall of the pocket9.It provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots. This creates a favorable environment for gingival healing and restoration of a physiologic gingival contour.

Indications
1. Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm. 2. Elimination of gingival enlargements 3. Elimination of suprabony periodontal abscesses.

Contraindications
1. The need for bone surgery or examination of the bone shape and morphology. 2. Situations in which the bottom of the pocket is apical to the mucogingival junction In these situations initial incisions would be made in the alveolar mucosa, so pocket elimination will result in complete elimination of the attached tissue. 3. Esthetic considerations, particularly in the anterior maxilla in which osseous 4. recontouring is unnecessary. (Table 4) 1. Ramon Syndrome 2. Juvenile hyaline fibromatosis (Murray-Peretic-Drescher syndrome) 3. Zimmerman-Laband syndrome 4. Rutherford syndrome 5. Jones syndrome 6. Borronedermato-cardio-skeletal syndrome (Autosomal recessive/X-linked recessive)

Surgical Techniques
Gingivectomy technique may be performed by means of scalpels, electrodes, lasers or chemicals.

Surgical Gingivectomy
Surgical gingivectomy is a conventional technique performed using scalpel. Procedure 1. STEP 1: The pockets on each surface are explored with a periodontal probe and marked with a pocket marker.
Each pocket is marked in several areas to outline its course on each surface. 2. STEP2: Periodontal knives (e.g. Kirkland knives) are used for incisions on the facial and lingual surfaces and those distal to the terminal tooth in the arch.Orban periodontal knives are used for interdental incisions. Bardparker blades #12 and #15 as well as scissors are used as auxiliary instruments. 3. The incision is started apical to the points marking the course of the pockets and is directed coronally to a point between the base of the pocket and the crest of the bone. It should be as close as possible to the bone without exposing it, to remove the soft tissue coronal to the bone. 4. Either interrupted or continuous incisions may be used. The incision should be beveled at approximately 45 degrees to the tooth surface and recreate the normal festooned pattern of the gingiva. Failure to bevel the incision will leave a broad, fibrous plateau, which will take a longer time to develop a physiologic contour. 5. STEP 3: Remove the excised pocket wasll, clean the area and closely examine the root surface. 6. STEP 4: Carefully curette the granulation tissue and remove any remaining calculus and necrotic cementum to leave a smooth and clean surface. 7. STEP 5: Cover the area with a surgical pack. a) Gum surface marked b) Incision made Kirkland knife c) Incision with orban knife Figure 9:-Conventional gingivectomy technique. Advantages 1. Ease of use, 2. Precise incision with well-defined margins, 3. Relatively fast and uneventful healing, 4. No unwanted lateral tissue damage can be used to bone proximity and economic.

Gingivectomy By Electrosurgery
Electrosurgery has been used since 1928 in dentistry for soft tissue procedures like gingivectomy, gingivoplasty, soft tissue growth excision, crown lengthening etc.

Procedure
The removal of gingival enlargements is performed with the needle electrode, supplemented by the small ovoid loop or the diamond-shaped electrodes for festooning. A blended cutting and coagulating current is used in all reshaping procedures, the electrode is activated and moved in a concise shaving motion.
In the treatment of acute periodontal abscess, the incision to establish drainage can be made with the needle electrode without exerting pressure. The incision remains open because the edges are sealed by the current. After the acute symptoms subside, the regular procedure for the treatment of the periodontal abscess is followed.
For hemostasis, the ball electrode is used. Hemorrhage must be controlled by direct pressure first then the surface is lightly touched with a coagulating current. Electrosurgery is helpful for the control of isolated bleeding points. Bleeding areas located interproximally are reached with a thin, bar-shaped electrode (figure 10).

Gingivectomy By Chemosurgery
Technique to remove the gingiva using chemicals, such as 5% paraformaldehyde or potassium hydroxide. Advantages 1. Less armamentarium 2. Less chair side time Disadvantages 1. The depth of action cannot be controlled, therefore, healthy attached tissue underlying the pocket may be injured. 2. Gingival remodeling cannot be accomplished effectively.

Laser Gingivectomy
The lasers most often used in dentistry are the carbon dioxide and the neodymium: yttrium-aluminium-garnet (Nd: YAG), which have wavelengths of 10,600 nm and 1064 nm, respectively, both in the infrared range.

Procedure
Patient is advised diode laser gingivectomy (810 nm) as an adjunct to nonsurgical periodontal treatment on sites with gingival enlargement. The diode laser gingivectomy is performed under topical lignocaine anaesthetic gel, applied for 3 minutes prior to operation. The gingivectomy is performed with gentle, sweeping brush strokes with a power output of 1.2 W, continuous wave (CW) using the laser fibre tip (400 µm in diameter).gingivectomy and gingivoplasty of upper and lower anterior teeth is carried out. Ablation is performed using light brushing strokes and the tip is kept in continuous motion. Remnants of the abladed tissue are removed using sterile gauze dampened with saline. Gingivoplasty is done in the interdental papilla and marginal gingival to create a normal physiological contour by changing the tip angulations. This procedure is done until the desired architecture of marginal gingival is achieved. High-volume suction is used to evacuate the laser plume and charred odour. Hemostasis is checked. Safety glasses are worn by the operator; patient and assistant. Any instrument with mirrored surface is avoided to avoid reflection of the laser beam to other (figure 11). a)Intraoperative b) Immediate after the procedure Figure11:-Laser assisted gingivectomy.

Advantage
1. Minimal or no anesthetic is required, 2. No harm to dental hard tissues. Their judicious use does not injure the dental pulp, because of low or no heat production. 3. They are compact and portable in design with efficient and reliable benefits for use in soft tissue oral surgical procedures. 4. Laser assisted surgeries are easy to perform with less discomfort, minimal or no bleeding due to sealing of capillaries by protein denaturation and stimulation of clotting factor VII production, 5. Shorten healing time with reduced postoperative bleeding and edema. Disadvantages 1. Eye damage by laser light, so protective glasses are required. 2. Cutting is slower than that with electrosurgery with burning flesh odor. 3. Working area should free of combustible gases. During laser use, laser plume requires use of a high-filtration face mask.

Success Rate
According to Mavrogiannis et al (2006)10there was significantly less recurrence of drug-induced gingival overgrowth in patients treated with laser excision, compared with those treated by conventional gingivectomy.
Postoperative Instructions After Gingivectomy 1. Do not rinse vigorously in the first 2 hours. 2. While lips and tongue are numb, be careful not to bite them or push on any protective dressing.
3. The day after surgery, use warm salt water to lightly rinse after each meal and before bedtime. 4. The day after surgery, floss and brush areas not operated. 5. On the fourth day after surgery, floss and brush operated areas not covered with a dressing. 6. Do not use water spray devices.

Mucocele
Mucoceles, one of the most common nonmalignant masses of the oral cavity, are probably the most common disease of the accessory (minor) salivary glands. It affect both genders in all age groups, with the peak age of incidence between 10 and 29 years. The lesions are more common in the inner portion of the lower lip, although they can also be found in the buccal mucosa, tongue and on the floor of the mouth. . The size of oral mucoceles varies from 1 mm to several centimeters in diameter and their duration may range from days to years.

Prevalence International
According to Martins et al (2011)11 the prevalence of all oral mucoceles is 2.5 lesions/1000 population with no gender predilection.

National
According to Chandramani et al(2014)12 oral mucoceles were highly prevalent in the age group of 15-24 years, were seen in 51.72% of males and 48.28% of females, with a ratio of 1.07:1.

Classification
Based on the underlying etiopathogenesis, these lesions classically have been divided into retention mucoceles and extravasation mucoceles13.

Retention Mucocele
Retention mucoceles consist of a well-defined cystic cavity presenting an epithelial wall lined with cuboid or squamous cells are less frequent and are seen particularly in elderly patients. They are uniformly distributed throughout all the territories that contain minor salivary glands (frequently on upper lip, hard palate, floor of mouth and maxillary sinus). According to Chandramani et al (2014)12 the retention type accounts for about 15.52%.

Etiology
Obstruction of salivary gland duct.
The retention mucocele is caused by obstruction of a minor salivary gland duct by calculus or possibly by the contraction of scar tissue around an injured minor salivary gland duct. The blockage of salivary flow causes the accumulation of saliva and dilation of the duct. Eventually, an aneurysm-like lesion forms, which can be lined by the epithelium of the dilated duct.

Pathogenesis
The pathogenesis of the retention mucocele is still uncertain. It is believed that with the increase in age, there is a natural reduction in salivary secretion, promoting the formation of a mucous plug that causes partial or total obstruction of the salivary gland system duct, resulting in dilation of the duct and increase in intraluminal pressure.

Extravasation Mucocele
Extravasation mucoceles are in fact pseudocysts lacking a well-defined wall, and are composed of compressed elements of the surrounding connective tissue, and inflammatory components. They account for over 80% of all mucoceles, and are more common in individuals under 30 years of age. They are fundamentally located in the lower lip (80%, Girish et al, 2016).

Etiology Trauma
The formation of an extravasation mucocele is believed to be the result of trauma to a minor salivary gland excretory duct. Laceration of the duct results in the pooling of saliva in the adjacent submucosal tissue and consequent swelling.

Pathogenesis
1. The extravasation type will undergo three evolutionary phases. In the first phase there will be spillage of mucus from salivary duct into the surrounding tissue in which some leucocytes and histiocytes are seen. 2. In second phase, granulomas will appear due to the presence of histiocytes, macrophages, and giant multinucleated cells associated with foreign body reaction. This second phase is called as resorption phase. 3. Later in the third phase there will be a formation of pseudo capsule without epithelium around the mucosa due to connective cells.

Diagnosis
The appearance of mucocele is pathognomonic, and so the data about the lesion location, history of trauma, rapid appearance, variations in size, bluish color and the consistency.

Ranula
Ranula was first reported during the period of Hippocrates and Celsius. The word ranula has been derived from the Latin word "Rana" which means the frog ( figure 24). This is because it resembles the translucent belly of a frog. Ranula is formed by rupture of excretory duct of the salivary gland, which is followed by rupture of saliva into the surrounding tissues.Salivary secretions from sublingual gland is also rich in protein and amylase and hence it has been suggested that ranulas are commonly caused by ruptured sublingual excretory ducts. The high protein content of the fluid in the ranula stimulates inflammatory reaction causing pseudocyst formation.

Prevalence
According to Saraniya Packiri et al (2017)14the prevalence of pediatric ranula was 1.15:1 (F:M) with a slight predilection towards the female population.

Etiology
The etiology is unknown, but it has been associated with congenital anomalies trauma and diseases of the sublingual gland.

Congenital ranula
Congenitally, ranula occurs following imperforate salivary gland duct and ostial stenosis leading to cyst formation. The prevalence of congenital ranula is 0.74%. Trauma Trauma or surgery to the floor of the mouth, neck region which may rupture the sublingual gland acini.

Classification
There are two different types of ranulas based on pathogenesis.

True cyst
This type of ranula has an epithelial lining. This type of ranula is usually caused due to obstruction of ducts of sublingual gland or ducts of one of the minor salivary glands.

Pseudocyst
This type of ranula does not have an epithelial lining. This is caused due to ductal injury of commonly the sublingual salivary gland, extravasation of saliva and accumulation into the submucous tissue. Sometimes this type of ranula is surrounded by granulation tissue or condensed connective tissue.
According to the variations of its extension, ranula has been classified into three clinical types 1. Sublingual type 2. Sublingual-submandibular type and 3. Submandibular type.
The sublingual type is a simple ranula, while the sublingual-submandibular type and submandibular type are plunging ranula.
Clinically ranula has been classified into two types (figure 16)

Intra oral (simple) ranula
This type of ranula is confined to the floor of the mouth. It is known to slowly enlarge in size into painless fluctuant swelling.

Plunging (cervical) type ranula
Plunging ranulas commonly arise from sublingual salivary gland.It is seen as a painless swelling in the neck that gradually increases in size.

Pathogenesis Intraoral ranula
There are two different concepts for the pathogenesis of ranula. One is true cyst due to ductal obstruction with an epithelial lining, and the other is a pseudocyst due to obstruction of ductal injury and extravasation of mucus without an epithelial lining.

Plunging ranula
Plunging and sublingual plunging ranulas cause swelling in the neck by one of the four mechanisms: 1. Sublingual gland may project through the myolohyoid muscle, or alternatively an ectopic salivary gland may present on the cervical side of the mylohyoid.Mucus secretion from these ectopic glands may drain into neck mass. 2. A hiatus or dehiscence in the mylohyoid muscle may occur. This defect is observed along the lateral aspect of the anterior two third of the muscle. Mucus from sublingual gland may pass through this defect and reach the submandibular space. 3. Plunging ranulas occur iatrogenically as a result of removal of oral ranulas. It may develop secondarily after surgical procedures such as implant placement, removal of sialolith and duct transposition. 4. A duct from the sublingual gland may join the submandibular gland or its duct, allowing the ranula to form in continuity with the submandibular gland. Therefore, ranula my reach the neck from behind the mylohyoid muscle. This abnormal communication may cause stasis of salivary flow in the duct leading to extravasation of the saliva into the neck in the submandibular region.

Neonate ranula
The cause of ranula in neonates is not known. When the duct orifice is not patent this may end up with congenital sialocele which is a true cyst with epithelial lining. This is thought to result from a congenital failure of canalization of the terminal end of the duct.

Clinical Presentation
1. Is a smooth cystic swelling under the tongue, usually to one side. 2. It is often transparent or bluish in appearance with overlying small blood vessels. 3. In a deeper ranula there will be a greater thickness of tissue separating the lesion from the oral cavity and the blue translucent appearance may not be a feature. 4. Asymptomatic in presentation. 5. Large swellings may push the tongue backwards and affect speech, mastication, respiration, and swallowing due to the upward and medial displacement of the tongue.

Treatment Of Mucocele And Ranula
Size of the lesion is the most important factor to determine the approach for the treatment of mucocele and ranula. Conventional surgical removal like marsupialization, excision of the submandibular gland or combined excision of both the ranula and sublingual gland, is the most common method used to treat these lesions. Other treatment options includeCO2 laser ablation, cryosurgery, intralesional corticosteroid injectionandmicromarsupialization.

Conventional techniques Drainage
Conventionally the only treatment employed was drainage. With the patient under local anaesthesia, saliva was aspirated using a wide-bore needle to completely decompress the ranula, or the oral floor was incised using a size 11 scalpel.

Marsupialization
Marsupialization (the opening of a cyst to the surface) has been used frequently in the treatment of ranula/mucocele. It is the oldest and most widely reported treatment method.

Indication
For ranula/mucocele less than 2 cm in diameter.

Enucleation
Surgical enucleation is the most widely used form of treatment and consists in complete removal of the lesion during the surgical procedure.

Procedure (Figure 18)
A topical anesthetic is applied around the lesions for 3 min followed by an infiltrative local anesthesia at 4 equidistant points around the lesions, using short needles mounted in an aspirating Carpule syringe. The base of the lesions is clamped with Halstead tweezers, incised with a scalpel blade #15, and the lesions are removed and sent to histopathological analysis. The soft tissues are sutured with a silk thread. Postoperative care recommendation and prescription of pain relievers are done and the patients returned to the dental clinic 7 days later for removal of sutures and clinical follow-up of the healing process.

Electrocautery
Electrocautery is a technique in which low voltage and relatively high amperage are used to heat a metal instrument tip. This can be produced either with commercial alternating current with a step-down transformer or by a battery, such as in a small Concept cautery.

Procedure (Figure 19)
A local infiltrative anesthesia is infiltrated around the lesion. Before infiltration, a topical anesthetic gel for 2 minutes is applied. The lip is then everted with digital pressure to increase the lesion"s prominence. A thick silk thread is passed through the lesion at its largest diameter and a surgical knot was made followed by excisional biopsy using electrocautery. Analgesic was prescribed on the first post operatory day to prevent any possible pain.

Cryosurgery
Cryosurgery is another effective method. The procedure uses a gas expansion cryoprobe with a 10-mm-diameter round tip. Bodner and Tal (1991) performed three applications at the same site in a single session without the need of local anesthesia. The selected cryodose for each application was a 30-s freeze at -81°C followed by an approximately 1-min thaw.

Indication
To treat various soft tissue pathologies like ranula/mucocele in oral and maxillofacial surgery.

Procedure (Figure 20)
Local anesthesia is given to anesthetize the surrounding structures. A closed system consisting of a cryoprobe and nitrous oxide gas is used. Nitrous oxide is released from a high pressure inside the cryotip which is placed directly on the lesion. The lesion is exposed directly to three consecutive "freeze-thaw cycles" and each cycle lasted for 5-10 s. The cryoprobe is moved from the center of the lesion to the borders until the lesion appeared white and frozen, resembling an ice ball. a) Application of cryoprobe b) Immediate after treatment.   Kurozu (1983)16reported the recurrence rate of 15% after cryosurgery.

Recent advannces in the treatment of mucocele/ranula micro-marsupialization
Micro-marsupialization is a procedure carried out to drain the accumulated saliva by passing a suture thread along the largest diameter of the lesion. The introduction of a suture also permits the formation of an epithelial tract to form between the surface and the underlying salivary glandular tissues. The technique was first described by Morton and Bartley.

Procedure (Figure 21)
Micro-marsupialization procedure is performed after the application of topical anesthetic (2% lignocaine gel) for approximately 3 min or surgical site is infiltrated with 2% lignocaine hydrochloride injection. A 3-0 silk suture is passed through the lesion along its widest diameter taking care not to reach the underlying tissue, and a surgical knot is made. Mucoceles are then compressed slightly to extravasate as much accumulated saliva as possible around the suture. Patients are advised to apply 0.5% chlorhexidine gel postoperatively to prevent secondary infection. Sutures are then removed after 7 days. a) Intraoperative view, b) Immediate postoperative Figure 21:-Micromarsupilization technique.

Advantages
1. Rapid and simple to perform, 2. Less invasive, 3. Well tolerated by the patients, 4. Least traumatic technique, 5. Effective alternative especially in uncooperative, mentally retarded, pediatric age group patients, and all patients not fit for surgical procedure.

Disadvantages
Need multiple visits.

Laser
In 1985, Frame JW introduced laser for the treatment of ranula/mucocele. Ranula has a high water content, which is vaporized by carbon dioxide laser. The heat generated causes coagulation of blood vessels resulting in haemostasis.Carbon dioxide laser is effective in management of pediatric ranula/mucocele, with limited side effects.
In case of recurrence of ranula/mucocele, surgical approach with the removal of associated salivary gland is the best treatment option.

Intralesional Injection Of Ok 432 (Picibanil)
The use of OK-432 in ranula treatment was first reported by Ikarashi et al(1987) in the treatment of a plunging ranula in an adult patient. OK-432 is a lyophilized state human-driven group A streptococcus pyogenes strain which is produced by processing with heat and benzylpenicilline.

Mechanism Of Action
Effect mechanism of OK-432 has been explained with inflammatory response produced. Inflammatory cells coming into cyst postinjection and stimulate the immune response. Endothelium permeability increases, with the release of various cytokines such as interleukin-6, tumor necrosis factor, interferon gama. And this caused the contraction of cyst by increasing the drainage of lesion to lymph ducts. Other than this, increasing the number of OK-432 natural killer and T-lymphocyte increases the contraction of cyst.

Procedure
In patients who undergo OK-432 treatment, a history of penicillin allergy should be elucidated as the OK-432 formulation contains benzyl penicillin.The application was performed with 0.1 mg of OK-432 (defined as 1 Klinische Einheit (KE) unit) mixed with 10 ml of saline.The ranula content, often described as a yellowish mucoid fluid, was aspired as much as possible. Then the OK-432 mixture was added to the cyst in the same volume as the aspirated liquid. This procedure was often performed without the need for local anesthetic. Syringes used were Contraindications 1. Grossly decayed tooth 2. Severe periodontal condition 3. Non cooperating patient 4. Medical conditions like immunosuppression, uncontrolled diabetes etc.

Avulsion
Avulsion of teeth results in total displacement of tooth out of its socket. Modern clinical practice offers a wide variety of treatment to replace the missing teeth like replantation, removable prosthesis, fixed partial denture and implant. Fixed partial denture and implants are generally not indicated in children until the skeletal growth is completed. Thus replantation of teeth is considered to be the best optimal treatment option following avulsion.

Treatment Factors Maturity of the root
The immature teeth showed better prognosis than mature teeth as the immature tooth has the potential to establish revascularization.

Extralveolar dry time
Complete healing can be guaranted if the tooth is replanted in the first 5 minutes.Every effort should be made to replant the tooth within the first 15-20 minutes.Replantation within 45 minutes of avulsion is considered immediate replantation.

Medium of storage
Storage media in order of preference and availability are;milk,saliva9either in the vestibule of the mouth or in a container into which the patient spits),physiologic saline or water.Water is the least desirable storage medium because of the hypotonic environment which causes rapid cell lysis and increased inflammation on replantation.Cell culture media such as Hank"s Balanced Salt Solution in specialized transport containers; have shown superior ability in maintaining the viability of the periodontal fibres for extended periods.

Preoperative Assessment Preparation Of The Socket
The socket should be undisturbed before replantation.Emphasis is placed on the removal of obstacles within the socket to facilitate the replacement of the tooth into the socket.It should be lightly aspirated if blood clot is seen.If the alveolar bone has collapsed a blunt instrument should be inserted carefully into the socket in an attempt to reposition the wall(figure 23).  The periodontal ligament cells are most likely to be viable.Thus immediate replantation can be performed in these cases.

Extra oral time
15-20 minutes extra oral dry storage Procedure 1. When the avulsed tooth has an immature apex,the condition of the PDL as well as the potential for pulpal revascularization must be considered. 2. The avulsed tooth that is extra oral for less than 15 minutes has a fairly viable PDL but we need to consider the possibility of contamination by bacteria especially in such cases of open apex. 3. The tooth should not be replanted immediately but should be soaked in 1 mg of doxycycline in 20 ml physiologic saline for 5 minutes before replantation because of its antibacterial efficacy ( figure 25). 4. After soaking in 1mg doxycycline in 20 ml of physiologic saline, the tooth can be replanted assuming that the pulpal tissue is vital and revascularization would be stimulated by the process of disinfection followed by replantation. Moreover there are chances of physiologic closure of open apex due to revascularization. 5. Thus the tooth should be radiographically examined during periodic follow up visits to evaluate the closure of apex. When an avulsed tooth has been extra oral and dry stored for this length of time, there is usually complete PDL cell necrosis.It is not possible to reconstitute the PDL cells and soaking in the pH-balanced solution is unnecessary. In addition,there is little likelihood of the pulp revascularizing.
The avulsed tooth, however can still have a significant incidence of success if treated as follows.

Procedure
1. The necrotic PDL should be removed carefully for example with gauze or the tooth might be soaked in a saturated citric acid for 3 minutes and rinsed off with a physiologic solution.Citric acid expose the collagen fibres on root cementum and promote a contact surface for reattachment of periodontal ligament collagen fibres. 2. It is then soaked in a 2% sodium fluoride for 20 minutes, then soaked in a 1 mg/20 ml doxycycline solution for 5 minutes.Treatment of root surface with sodium fluoride will prevent the inflammatory resorption and ankylosis in short-term. 3. As the chances of pulp revascularization is not possible, in these casesthe endodontic cleaning and shaping of the canal is performed extraorally with the tooth in the hand. 4. Then apexification procedure can be initiated with calcium hydroxide. 5. Following this tooth is replanted and tooth should be radiographically examined during periodic follow up visits to evaluate the formation of calcific barrier.
6. Once the calcific barrier is formed or if there are no signs of resorption, then obturation with gutta percha is done.

Follow Up
1. Splint removal done after 4 weeks. 2. Clinical and radiographic evaluation should be done after 4 weeks, 3 months,6 months and then yearly thereafter.

Transplantation
Transplantation is the insertion of a tooth from one place to another place in the mouth (autotransplantation) or from mouth of one individual to the mouth of the other individual (allotransplantation).

Types Of Transplantation
Tooth transplantation is mainly divided into two types:

Allotransplantation
Allotransplantation (homogenous), where a tooth is transferred from one individual to a different individual of the same species.

Drawbacks
1. Histocompatibility between donor and recipient, which often leads to a rapid destruction and loss of the grafted tooth. 2. The potential for infection from the hepatitis B visrus or human immunodeficiency virus is increased.

Success rate
Yang et al (1990)21 reported a successful case of homologous tooth transplantation. A maxillary second premolar obtained from a tooth bank was implanted into a fresh central incisor extraction site. A 3-yr follow-up radiograph indicated satisfactory apical healing and minimal replacement resorption. Clinically, the transplantation site was free of symptoms and there was no evidence of periodontal disease or tooth mobility.

Autotransplantation
Autotransplantation (autogenous), where a tooth is transferred from one site to another in the same individual.Autotransplantation of teeth has been done for many years but with varying degrees of success.It has been used to replace missing teeth and teeth of poor prognosis.

Definition
Autotransplantation is defined as the transplantation of embedded, impacted or erupted teeth from one site into extraction sites or surgically prepared sockets in the same person.

Indications
1. When a tooth from the dental arch has to be extracted for any reasons and a non-functional tooth is available in the jaws. 2. When the recipient site is free from inflammation or other bony pathology. 3. A developing mandibular third molar is an ideal donor for the first molar area.Maxillary molars, canine and mandibular premolars are also used for autotransplantation.

Contraindications
1. Lack of proper oral hygiene 2. The impossibility of ensuring a regular follow-up. 3. Inadequate width of the alveolar bone at the recipient site.
splinted in place with the help of wires.It is recommended that in autotransplantation, the donor tooth should be directly shifted to recipient site from donor site for obtaining better results.
Follow Up 1. The splint was removed at 6 weeks postoperative. 2. Clinical and radiographic evaluation was done at 2 weeks, 1month, 3 months and 6 month follow-up.

Success Rates
In recent metaanalysis,the survival rates of autotransplantation at 5 years was 98% for teeth with incomplete root formation(Atala et al 2017)22and 90% for teeth with complete root formation(Czouchrowska et al 2002) 23.

Recent Advances In Autotransplantation Technique
More recently,computer aided surgical stimulation (CASS) has been used in the field of oral and maxillofacial surgery including autotransplantation of teeth(Cross et al,2013; Jang,Lee and Kim,2013).Rapid prototyping replicas based on cone beam computed tomography(CBCT)have been used as alternatives to donor teeth for preparation of new sockets,which have proven useful in reducing extraalveolar time and injury to periodontal ligament cells.In order to precisely transfer desired positions of the donor teeth to the clinic and simplify the surgical procedure,clinicians tend to design certain types of individual surgical guides besides replicas.In addition,after transplantation of donor tooth to recipient sites,various position maintaining methods have been used across different studies,including sutures,resin wire splints and titanium screws.

Computer aided surgery
The patients was scanned by CBCT.The mesiodistal diameter as well as shape and length of the roots canals of the donor tooth were observed and recorded.A plaster cast of the mandibular dentition was fabricated for the patient,and subsequently,CBCT scans of the plaster cast were taken(CBCT).

Virtual design of surgical guides
The local surgical splint was generated between occlusal surfaces of the autotransplanted tooth and the opposite tooth. The splint was used to locate position of the replica of the donor tooth, hence it was attached to the digital donor tooth.

Fabrication of surgical guides
Conventional polishing and sterilization process were performed before their application in clinical surgery.

Surgical procedure
The tooth at the recipient socket was extracted beforethe autotransplantation surgery, in order to avoid any consequent infection due to apical inflammation.After the guide template and arch were fabricated ,the patient was called back for surgery under local anesthesia.During surgery,the new socket at the recipient position was prepared using round bur.The replica with the local surgical splint was used as a guide before extraction of the donor tooth.Subsequently,the donor tooth was gently extracted and placed into the new socket, and the surgical template aws used to check and confirm the desired position of the autotransplanted tooth.After the desired position of the donor tooth was achieved,the arch bar was ligated to the teeth with bifilar,a 0.25mm diameter steel wires to fix the autotransplanted tooth.

Conical(occurrence 70-8-%)
Conical-shaped supernumerary teeth are the most common. They present with conical or triangular-shaped crowns and complete root formation. They are found most often as isolated single cases and are usually located between the maxillary central incisors (mesiodens).However, they can also occur as bilateral structures in the premaxilla (figure 31).

Tuberculate (occurrence rate of 10-12%)
The tuberculate supernumerary has a barrel-shaped appearance and a crown consisting of multiple tubercles. It may be invaginated.Unlike conical supernumerary teeth, which have complete root formation, tuberculate types have either incomplete or absent root formation.They are larger than conical supernumerary teeth and are usually found in a palatal position relative to the maxillary incisors. They are often paired and bilateral supernumerary cases have a predominance of tuberculate shaped teeth. It has been suggested that tuberculate supernumeraries may represent a third dentition(figure 31).

Figure 31:-Tuberculate tooth
Supplemental (occurrence rate of 6-8%) Supplemental supernumerary teeth resemble their respective normal teeth. They usually form at the end of a tooth series. The most common supplemental tooth is the permanent maxillary lateral incisor, although supplemental premolars and molars also occur.The majority of supernumerary teeth in the primary dentition are supplemental and rarely remain unerupted(figure 32).

Odontome (occurrence rate of 3-4%)
Odontome are hamartomas (benign, disordered overgrowths of mature tissue) comprising all dental tissues and appearing radiographically well-demarcated, mostly radio-opaque lesions in tooth-bearing areas. There are two different types of odontome like compound and complex. Compound odontomes comprise many separate, small tooth-like structures. A complex odontome is a single, irregular mass of dental tissue that has no morphological resemblance to a tooth(figure 33).

Diagnosis
Occasionally, supernumerary teeth are asymptomatic and may be detected as a chance finding during radiographic examination. Detailed history, clinical examination, thorough investigation, early diagnosis and appropriate treatment of supernumerary teeth are taken into consideration.. In most cases, erupted supernumerary teeth could be diagnosed by general oral examination, and imaging methods could be helped in diagnosis of unerupted extra teeth. An anterior occlusal or periapical radiograph using paralleling technique and panaromic view(Orthopantomograph) are the most useful radiographic investigations to visualize supernumerary teeth.

Radiographic investigations Intraoral periapical radiographs (iopar)
The unerupted ones are best diagnosed by radiographs like IOPA.

Panoramic radiographs
It helps in the diagnosis of impacted supernumerary teeth.