COMPLICATED EXTRACTION & ODONTECTOMY

Presenter: R1 Instructor: VS Date: 2012/2/17

Outlines
1 2 3 4 Indications for Surgical Extraction Contraindication for Surgical Extraction Multiple Extractions Classification of Impacted Teeth

5
6

Surgical Procedure
Postoperative Management

Indications for Surgical Extraction

Erupted teeth
1) Excessive forced may cause a fracture of bone/tooth 2) Heavy or dense bone (aging, bruxism) 3) Root condition: hyper-cementosis (aging), divergent (maxillary 1st molars) 4) Maxillary sinus 5) Extensive caries or large restorations 6) Retained roots

Indications for Surgical Extraction

Impacted teeth
1) 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 teeth
5) 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 fracture 8) Management of unexplained jaw pain (1~2%)

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 patients 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 more effective use of dental elevators

The most posterior teeth first

The most difficult (molar and canine) last

Multiple Extraction
Summary
1) 2) 3) 4) 5) 6) 7) 8) Upper posterior teeth, leaving the 1st molar Upper anterior teeth, leaving the canine Upper 1st molar Upper canine Lower posterior teeth, leaving the 1st molar Lower anterior teeth, leaving the canine Lower 1st molar Lower canine

Classification of Impacted Teeth

Angulation

2
3

Relationship to anterior border of ramus

Relation to occlusal plane of 2nd molar

Angulation Lower
43% Least difficult 3% More difficult than mesioangular ones 38% Third in difficulty 6% Most difficult

Mesioangular impaction Horizontal impaction Vertical impaction Distoangular impaction

Angulation Upper

63%

25%

12%

Relationship to anterior border of ramus

Pell and Gregory class 1 impaction

Pell and Gregory class 2 impaction

Pell and Gregory class 3 impaction

Relation to occlusal plane of 2nd molar

Pell and Gregory class A impaction

Pell and Gregory class B impaction

Pell and Gregory class C impaction

Surgical Procedure
1. Gain adequate access through a properly designed soft tissue flap 2. Remove bone as little as possible

3. Divide tooth into sections and delivered with elevators

4. Debridement, irrigation and closure of wound

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

Envelope incision Posteriorlaterally to avoid lingual n.

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

2. Remove bone as little as possible

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.

3. Divide tooth into sections and delivered with elevators

Mesioangular impaction A. B and D bone are removed B. 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 impaction A. B and D bone are removed B. 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 impaction
A. 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 impaction A. 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.

4. Debridement, irrigation and closure of wound

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 hemostasis 6) Closure of the 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.

Post-OP Complications
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%)