COMPLICATEDEXTRACTION

& ODONTECTOMY

Presenter: R1 鄭瑋之Instructor: VS 陳靜容醫師Date: 2012/2/17

Outlines

Indications for Surgical Extraction

• Erupted teeth1) Excessive forced may cause a fracture of bone/tooth2) Heavy or dense bone (aging, bruxism)3) Root condition: hyper-cementosis (aging), divergent

(maxillary 1st molars)4) Maxillary sinus5) Extensive caries or large restorations6) Retained roots

• Impacted teeth1) Pericoronitis prevention/treatment (25~30%)2) Prevention of dental disease

• Caries (15%)• Periodontal disease (5%)

3) Orthodontic Considerations• Crowding of mandibular Incisors (controversial)• Interference of orthodontic treatment/orthognathic surgery

4) Root resorption of adjacent teeth: about 7%

Indications for Surgical Extraction

• Impacted teeth5) Prevention of odontogenic cysts/tumors

• Follicular sac crown/cyst/odontogenic tumor (1~2%)• Neoplastic change: about 3% (decrease with age)

6) Teeth under dental prostheses• Ridge where an impacted tooth is covered by only soft tissue

or 1 or 2 mm of bone

7) Prevention of jaw fracture8) Management of unexplained jaw pain (1~2%)

Indications for Surgical Extraction

Contraindications for Surgical Extraction

• Extremes of age– Removal of tooth bud at early stage is unnecessary– Healing response ↓ with ageImpacted teeth– fully impacted, no communication with oral

cavity, no signs of pathology, > age 40• Compromised medical status– work closely with the patient’s physician

• Surgical damage to adjacent structures

Multiple Extraction

1. Preextraction treatment planning– Dentures, soft tissue surgery, implants

2. Extraction Sequencing:– Maxillary teeth first

Infiltration anesthetic: more rapid Debris may fall into the empty sockets With mainly buccal force

– The most posterior teeth first more effective use of dental elevators

– The most difficult (molar and canine) last

Multiple Extraction

• Summary1) Upper posterior teeth, leaving the 1st molar2) Upper anterior teeth, leaving the canine3) Upper 1st molar4) Upper canine5) Lower posterior teeth, leaving the 1st molar6) Lower anterior teeth, leaving the canine7) Lower 1st molar8) Lower canine

Classification of Impacted Teeth

Mesioangularimpaction

43%Least difficult

Horizontal impaction

3%More difficult than mesioangular ones

Vertical impaction

38%Third in difficulty

Distoangularimpaction

6%Most difficult

63% 25% 12%

Surgical Procedure

Envelope incisionPosteriorlaterallyto avoid lingual n.

Three-cornered flapRelease incision:M of the 2nd molar.

1. Gain adequate access through a properly designed soft tissue flap

A. The bone overlying the O surface of tooth is removed with a fissure bur.

B. Bone on the B and D sides of impacted tooth is then removed.

2. Remove bone as little as possible

Mesioangular impactionA. B and D bone are removedB. D of the crown is sectioned. Occasionally the entire tooth.C. Small straight elevator into M side, and the tooth is delivered

with a rotational and level motion of elevator.

3. Divide tooth into sections and delivered with elevators

Horizontal impactionA. B and D bone are

removedB. Crown is sectioned

from the roots.C. Roots are

delivered together or independently with a Cryer.

D. M root is elevated in similar fashion

3. Divide tooth into sections and delivered with elevators

Vertical impactionA. Bone on O, B, D of crown is removed, and the tooth is sectioned into

M and D. If fused single rootD of the crown is sectioned off.B. The posterior aspect of the crown is elevated first with a Cryer.C. Small straight no. 301 elevator ito lift M of the tooth with a rotary

and levering motion.

3. Divide tooth into sections and delivered with elevators

Distoangular impactionA. O,B,D bone is removed with more D bone.B. Crown is sectioned off.C. Roots are delivered by a Cryer with a wheel-and-axle motion. If

the roots diverge, it may be necessary in some cases to split them into independent portions.

3. Divide tooth into sections and delivered with elevators

Impacted maxillary third molar A. B bone is removed with a bur or a hand chisel.B. Tooth is then delivered by a small straight elevator with

rotational and lever types of motion in DB and O direction.

3. Divide tooth into sections and delivered with elevators

1) Debride the wound of all debris after with periapical curettes

2) Smooth the sharp, rough edges of bone with bone files.

3) Remove remnants of dental follicle with mosquitos and hemostats.

4) Final irrigation with saline and thorough inspection

5) Check for adequate hemostasis6) Closure of the wound

4. Debridement, irrigation and closure of wound

Postoperative Management

• Analgesics– During the first 24 hours, analgesics are prescribed

routinely; after this time, they are used only when required. Combination of codeine and aspirin/acetaminophen or NSAID might be suggested.

• Antibiotics– Preexisting pericoronitis antibiotics for a few days– No preexisting infection antibiotics is not indicated

• Anti-inflammatory medication– Steroid or aspirin might be considered.

• Trismus– Reaches its peak on the second day and

resolves by the end of the first week.

• Bleeding– Moist gauze pack ing with pressure– Socket packed with oxidized cellulose

• Swelling/edema– Corticosteroids– Ice packing has no effect on edema– Reaches its peak by the end of the second day

• Infection (1.7~2.7%)– Debris left under the mucoperiosteal flap

Post-OP Complications

• Fracture– Broken root displaced into submandibular

space, IAN canal, or maxillary sinus– Radiographic follow-up

• Alveolar osteitis/Dry socket (3%-25%)– Lysis of a blood clot before replaced with

granulation tissue– Occurs during the 3rd and 4th days with pain and

malodor– Irrigation, placement of an obtundent dressing,

changed daily

• Nerve injury (3%)

Post-OP Complications