Download ORAL SURGERY Third grade Lec. 7 Dr. Noor Sahban Tooth

ORAL SURGERY
Lec. 7
Third
grade
Dr. Noor Sahban
Tooth Extraction (Exodontia)
Definition:
Exodontia is a painless removal of the teeth from their bony alveolar socket with
relatively minimal amount of trauma to the investing or surrounding tissues, so
that the wound heals without postoperative problems.
Methods of extraction:
1. Intra-alveolar extraction (forceps + elevators extraction)
It consists of removing the tooth or root by the use of forceps or elevators or both
(which is enough for extraction in most of cases).
2. Trans-alveolar extraction (surgical extraction)
It consists of dissecting the tooth or root from its bony attachment by raising a flap
and removal of some of the bone surrounding the roots, which are then removed
by the use of elevators and/or forceps.
Indications for extraction:
Teeth are extracted for a variety of reasons. But you must remember that these
indications are guidelines and not absolute rules, they are:
1. Sever caries:
This is the most common reason to remove a tooth. Badly carious teeth that are
beyond restoration should be removed. Badly carious teeth resulted in bad oral
hygiene and bad smell in addition to that sharp edges of the carious teeth lead to
repeated ulceration to mucosa in addition to pain during eating and drinking.
Untreated teeth with caries may end with pulpitis, periapical pathology …etc.
2. Pulp pathology:
For example: acute or chronic pulpitis, non treatable pulp necrosis. If endodontic
treatment is not possible or if the tooth is not responsive to endodontic treatment
(root canal that is tortuous, calcified, and untreatable by standard endodontic
techniques) or a case in which endodontic treatment has been done but has failed
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to relieve pain or provide drainage and the patient does not desire retreatment,
extraction is indicated.
3. Apical pathology:
Periapical lesions like periapical abscess, periapical granuloma, and cyst. If the
teeth fail to respond to all conservative treatment to resolve apical pathology due
to technical reasons or other causes such teeth are indicated for extraction.
4. Sever periodontal disease:
Sever and extensive periodontal disease is a common reason for tooth removal. In
chronic periodontitis there is extensive bone loss and mobility in the tooth. As a
rough guide loss of about half of the normal alveolar bone or extension of pockets
to the bifurcation of the roots of posterior teeth and hyper mobility of the teeth
means the extraction of the involved tooth is necessary.
5. Roots and root fragments:
Retained roots may remain embedded in the bone without problem for a long
period, but some time removal of such roots maybe necessary; for example, root
may be at the submucosal level producing recurrent ulceration under the denture,
sometimes root fragments maybe involved in the initiation of bony pathology such
as osteomyelitis, cystic lesion or neoplasm. If such fragments are in close relation
to the neurovascular bundle (e.g. inferior alveolar nerve) the patient may complain
of facial pain or numbness in the area supplied by that nerve. As a general role, all
root fragments are indicated for extraction except for very small fragments maybe
left but the patient should kept under periodic observation.
6. Orthodontic reasons:
During the course of orthodontic treatment, tooth or teeth maybe extracted for:
a. Therapeutic extraction: e.g. extraction of upper premolar for treatment of
malposed upper canine. Extraction of teeth to provide space for tooth
alignment.
b. Malposed teeth: teeth which erupted out of line of arch difficult to clean and
not responsive to orthodontic treatment are indicated for extraction.
c. Preventive extraction: means that during mixed dentition period (permanent
and deciduous) dental surgeon may extract few deciduous teeth to prevent
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malocclusion and all these extractions should be done after proper
evaluation by an orthodontist.
7. Prosthetic considerations:
Extraction of teeth are indicated for:
a. Providing efficient dental prosthesis
b. Provide better design and success of partial denture
c. Enable the patient to have complete denture e.g. full mouth clearance.
8. Impacted teeth:
Retention of unerupted teeth beyond the normal time of eruption may sometimes
be responsible for:
a.
b.
c.
d.
e.
f.
Facial pain
Periodontal problems of the adjoining teeth
Temporomandibular joint problems
Bony pathology (e.g. cyst -dentigerous cyst-, tumor, pathological fracture)
May predispose to anterior teeth crowding.
Significant infection (pericoronitis) e.g. partially erupted third molar
9. Supernumerary teeth:
These teeth may be impacted or malposed and such teeth may predispose to
malocclusion, periodontal diseases, facial pain, bony pathology (cyst), esthetic
problems and preventing the eruption of teeth.
10. Tooth in line of fracture of the jaw:
This tooth may be extracted when:
a.
b.
c.
d.
It is a source of infection at the site of the fracture
The tooth itself is fractured
Interfere with fracture reduction
Interfere with healing of fracture
11.Teeth I relation to bony pathology:
They are indicated for extraction e.g. if they are involved in
a. Cyst formation
b. Neoplasm (tumor)
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c. Osteomyelitis (infection of bone)
And the tooth interfere with complete surgical removal of the lesion, the tooth
should be extracted.
12.Teeth prior to irradiation:
Irradiation is one of the methods for treating oral carcinomas and teeth which
cannot be kept in a sound condition should be removed before irradiation.
Extraction of the tooth after irradiation with the addition of infection will lead to
development of osteoradionecrosis of the jaw bone which is unpleasant
complication and difficult to be treated.
13.Focal sepsis:
Sometimes teeth or tooth may appear sound clinically but on radiographic
examination the tooth may appear to be considered as foci of infection (teeth
associated with periapical pathology or periodontal problems). These teeth or
tooth should be extracted in certain conditions e.g. heart surgery, heart valve
replacement, kidney transplant, eye surgery; to avoid the failure of these surgeries.
Contraindications for extraction:
Even if a given tooth meets one of the requirements for removal, in some
situations, the tooth should not be removed because of other factors or
contraindications to extraction. These factors are relative in their strength. In some
situations, the contraindication can be modified by the use of additional care or
treatment, and the indicated extraction can be performed. In other situations,
however, the contraindication may be so significant that the tooth should not be
removed. Generally, the contraindications are divided into two groups: 1) local
and 2) systemic.
Local contraindications:
1. Acute and uncontrolled infection:
Extraction in the presence of acute and uncontrolled infection may lead to spread
of infection locally or systemically leading to many complications some of them
are dangerous and life threatening (e.g. cavernous sinus thrombosis, mediastinitis,
Ludwig’s angina). Acute periapical abscess and facial abscess especially in
medically compromised patient contraindicates tooth extraction.
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2. Previous radiotherapy:
Previous therapeutic radiation in oral and maxillofacial region for treatment of
cancer leads to fibrosis and decreased vascularity of the tissue or area of extraction
and end with a condition in the bone called osteoradionecrosis.
3. Teeth located within areas of tumor:
Extraction of a tooth embedded in tumor especially malignant tumor lead to
dissemination of tumor thereby seeding metastases, unhealed socket and
postoperative complications (e.g. bleeding).
Systemic contraindications:
Systemic contraindications preclude extraction because of the patient’s systemic
health; in such cases the ability to withstand surgical work may be compromised.
So extraction should be postponed until the severity of the problem has been
resolved and may be arranged after consultation with physician to perform
extraction safely without complications so caution is advised in the following
conditions:
1. Sever uncontrolled metabolic disease: e.g. uncontrolled diabetes (high risk
of infection and unhealed extraction socket).
2. Sever uncontrolled cardiac disease: e.g. severe myocardial ischemia such as
unstable angina pectoris, recent significant myocardial infarction should not
have a tooth extracted except as an emergency in the hospital setting. Patients
who have severe, uncontrolled cardiac dysrhythmias should have their
extraction procedures deferred as well.
3. Sever uncontrolled hypertension: these cases should also have extractions
deferred because persistent bleeding, acute myocardial insufficiency, and
cerebro-vascular accidents are more likely to occur as a result of stress caused
by the extraction.
4. Bleeding disorder: e.g. hemophilia, platelet disorder, patient on
anticoagulant. These patients should not have teeth extracted until the
coagulopathy has been corrected. Most severe bleeding disorders can be
controlled by the administration of coagulation factors or platelet transfusions.
Close coordination with the patient’s physician can result in an uncomplicated
recovery from the extraction procedure in most situations.
5. Uncontrolled leukemia and lymphoma: these patients should not have teeth
extracted until the malignancy can be brought under control. The potential
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complications are infection as a result of non-functioning white cells and
excessive bleeding as a result of an inadequate number of platelets.
6. Pregnancy: is a relative contraindication to extractions; patients who are in
the first or third trimester should have their extractions deferred, if possible.
The latter part of the first trimester and the first month of the last trimester may
be as safe as the middle trimester for a routine uncomplicated extraction, but
more extensive surgical procedures requiring drugs other than local anesthetics
should be deferred until after delivery.
7. Patients who take or have taken a variety of medications e.g. systemic
corticosteroids, immunosuppressive agents and cancer chemotherapeutic agents
should have surgery performed with caution or after medical consultation.
8. Uncontrolled epilepsy.
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Preoperative evaluation of accused tooth:
In the preoperative assessment period, the tooth to be extracted should be
examined carefully to assess the difficulty of the extraction. This includes clinical
and radiographic examination.
Clinical examination of the accused tooth:
A variety of factors must be specifically examined to make the appropriate
assessment.
1. Access to the Tooth
a) Mouth opening of the patient: any limitation of opening may compromise the
ability of the surgeon to do a routine extraction. If the patient’s opening is
substantially compromised, the surgeon should consider a surgical approach to the
tooth instead of a routine elevator and forceps extraction. Additionally, the
surgeon should look for the cause of the reduction of opening. The most likely
causes are trismus associated with infection around the muscles of mastication,
temporomandibular joint (TMJ) dysfunction, and muscle fibrosis.
b) The location and position of the tooth: properly aligned tooth has a normal
access for placement of elevators and forceps. However, crowded or malposed
teeth may present difficulty in positioning the usually used forceps onto the tooth
for extraction. When access is a problem, a different forceps may be needed or a
surgical approach may be indicated.
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2. Mobility of the Tooth
The mobility of the tooth to be extracted should be assessed preoperatively.
 Greater-than-normal mobility is frequently seen with severe periodontal
disease. If the teeth are excessively mobile, an uncomplicated tooth
removal should be expected.
 Teeth that have less-than-normal mobility should be carefully assessed for
the presence of hypercementosis or ankylosis of the roots. Ankylosis is
often seen with primary molars that are retained and have become
submerged; in addition, ankylosis is seen occasionally in nonvital teeth that
have had endodontic therapy many years before the extraction. If the
clinician believes that the tooth is ankylosed, it is wise to plan for a surgical
removal of the tooth as opposed to a forceps extraction.
3. Condition of the Crown
The assessment of the crown of the tooth before the extraction should include:
a) The presence of large caries: if large portions of the crown have been
destroyed by caries, the likelihood of crushing the crown during the
extraction is increased, thus causing more difficulty in removing the tooth.
b) The presence of large restorations in the crown produces weakness in the
crown, and the restoration will probably fracture during the extraction
process.
c) Endodontically treated tooth becomes brittle and fractures easily when
force is applied.
d) If the tooth to be extracted has a large accumulation of calculus, the
gross accumulation should be removed with a scaler or ultrasonic cleaner
before extraction. The reasons for this are that calculus interferes with the
placement of the forceps in the appropriate fashion, and fractured calculus
may contaminate the empty tooth socket once the tooth is extracted.
e) The shape, position and size of the crown.
f) The condition of adjacent teeth: if adjacent teeth have large amalgams or
crowns, or have undergone endodontic therapy, it is important to keep this
in mind when elevators and forceps are used to mobilize and remove the
indicated tooth. If adjacent teeth have large restorations, the surgeon should
use elevators with extreme caution because fracture or displacement of the
restorations may occur.
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Radiographic evaluation of the accused tooth:
Preoperative clinical assessment may be supplemented sometimes by preoperative
radiographs. In general, periapical radiographs provide the most accurate and
detailed information concerning the tooth, its roots, and the surrounding tissue.
Panoramic radiographs are used frequently, but their greatest usefulness is for
impacted teeth. Radiographs are indicated in the following cases:
1. History of difficult extraction.
2. Teeth with extensive caries, large restoration or endodontically treated
tooth.
3. A tooth abnormally resistant to forceps extraction.
4. Impacted tooth or partially erupted tooth.
5. If after clinical examination you decided to remove the tooth surgically.
6. Any tooth in close relation to vital structures like neurovascular canal,
maxillary sinus, nasal cavity, mental foramen.
7. Any tooth has been subjected to trauma (fracture of root and/or alveolar
bone may be present).
8. An isolated maxillary molar especially if it is unopposed and overerupted. The bony support of such tooth is often weakened by the
presence of maxillary sinus.
9. Whenever underlying bony pathology is suspected e.g. cystic lesion,
tumors.
Radiographic findings essential for tooth extraction:
1. The relationship of the tooth to be extracted to adjacent erupted and
unerupted teeth should be noted. If the tooth is a primary tooth, the relationship
of its roots to the underlying permanent tooth should be carefully considered.
2. If surgical removal of a root or part of a root is necessary, the relationship of
the root structures of adjacent teeth must be known.
3. Relationship to Vital Structures:
a. When performing extractions of the maxillary molars, it is essential to be
aware of the proximity of the roots of the molars to the floor of the
maxillary sinus. If only a thin layer of bone exists between the sinus and the
roots of molar teeth, the potential for perforation of the maxillary sinus
during the extraction increases. Thus, the surgical treatment plan may be
altered to an open surgical technique, with division of maxillary molar roots
into individual roots before the extraction proceeds.
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b. The inferior alveolar canal may approximate the roots of mandibular
molars. Although the removal of an erupted tooth rarely impinges on the
inferior alveolar canal, if an impacted tooth is to be removed, it is important
that the relationship between molar roots and the canal be assessed. Such an
extraction may lead to injury of the canal and cause consequent damage to
the inferior alveolar nerve. Cone-beam computed tomography (CBCT)
images are often useful in these circumstances.
c. Radiographs taken before the removal of mandibular premolar teeth
should include the mental foramen. Should a surgical flap be required to
retrieve a premolar root, it is essential that the surgeon know where the
mental foramen is to avoid injuring the mental nerve during flap
development.
4. Configuration of Roots: radiographic assessment of the tooth to be extracted
probably contributes most to the determination of difficulty of the extraction.
a. The number of roots on the tooth to be extracted. Most teeth have the
typical number of roots, in which case the surgical plan can be carried out in
the usual fashion; but many teeth have an abnormal number of roots. If the
number of roots is known before the tooth is extracted, an alteration in the
plan can be made to prevent fracture of any additional roots.
b. The curvature of the roots and the degree of root divergence. Roots of the
usual number and of average size may still diverge substantially and thus
make the total root width so wide that it precludes extraction with forceps.
In situations of excess curvature with wide divergence, surgical extraction
may be required with planned division of the crown.
c. The shape of the individual root. Roots may have short, conical shapes
that make them easy to remove. However, long roots with severe and abrupt
curves or hooks at their apical end are more difficult to remove. The
surgeon must have knowledge of the shapes of the roots before surgery to
adequately plan the surgery.
d. The size of the root. Teeth with short roots are easier to remove compared
with teeth with long roots. A long root that is bulbous as a result of
hypercementosis is even more difficult to remove. The periapical
radiographs of older patients should be examined carefully for evidence of
hypercementosis because this process seems to be a result of aging.
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e. caries extending into the roots. Root caries may substantially weaken the
root and make it more liable to fracture when the force of the forceps is
applied.
f. Root resorption, internal or external. Root resorption weakens the root
structure and renders it more likely to be fractured. Surgical extraction may
be considered in situations of extensive root resorption.
g. previous endodontic therapy. If there was endodontic therapy many years
before the extraction process, there may be ankylosis or the tooth root may
be more brittle. In both situations, surgical extraction may be indicated.
5. Condition of Surrounding Bone:
a. Careful examination of the periapical radiograph indicates the density of
bone surrounding the tooth to be extracted. Bone that is more radiolucent is
likely to be less dense, which makes the extraction easier. However, if bone
appears to be radiographically opaque (indicating increased density), with
evidence of condensing osteitis or other sclerosis-like processes, it will be
more difficult to extract.
b. The surrounding bone should also be examined carefully for evidence of
an apical pathologic condition. Teeth that have non-vital pulps may have
periapical radiolucencies that represent granulomas or cysts. Awareness of
the presence of such lesions is important because these lesions should be
removed at the time of extraction.
Instruments used in simple uncomplicated teeth extraction:
1. Diagnostic instruments:
a) Dental mirror.
b) Dental probe.
c) Dental tweezers.
2. Dental forceps.
3. Dental elevators.
General assessment and considerations for extraction:
 Light:
Dentist work in a limited inaccessible area (extraction site), in addition to the
shadow of the hand and the instruments used. Good illumination of the
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operative field is very important and necessary to perform the extraction
efficiently and safely.
 Position of the dentist:
For right handed dentist: when extracting any tooth (except for the right
mandibular posterior teeth), the dentist should stand in front of the patient.
When extracting the right mandibular posterior teeth, the dentist should stand
behind the patient.
For left handed dentist: the positions reversed.
 Position of the dental chair and the patient’s head:
For a maxillary teeth extraction:
1. The back rest of the chair should be tipped backward so that the maxillary
occlusal plane is at an angle of about 60 degrees to the floor.
2. The height of the chair should be such that the patient’s mouth is at or
slightly below the operator’s elbow level.
3. The patient’s head:
a) During an operation on the maxillary right quadrant, the patient’s head
should be turned substantially toward the operator so that adequate access
and visualization can be achieved.
b) For extraction of teeth in the maxillary anterior portion of the arch, the
patient should be looking straight ahead.
c) For the maxillary left portion of the arch, the patient’s head is turned
slightly toward the operator.
For the extraction of mandibular teeth:
1. The back rest of the chair should be positioned in a more upright position so
that when the mouth is opened wide, the occlusal plane is parallel to the floor.
2. The height of the chair should be lower than for extraction of maxillary
teeth, and the surgeon’s arm should be inclined downward. This provides a
comfortable and stable position that is more controllable compared with the
higher position.
3. The patient’s head:
a) During removal of mandibular right posterior teeth, the patient’s head
should be turned toward the surgeon to allow adequate access to the jaw,
and the surgeon should maintain the proper arm and hand positions.
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b) When removing teeth in the anterior region of the mandible, the surgeon
should rotate around to the side of the patient.
c) When operating on the left posterior mandibular region, the surgeon
should stand in front of the patient, but the patient’s head should not turn
toward the surgeon.
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