Complicated Extraction and Odontectomy

1. COMPLICATED
EXTRACTION
& ODONTECTOMY
Presenter: R1 鄭瑋之
Instructor: VS 陳靜容醫師
Date: 2012/2/17

2. Outlines

3. Indications for Surgical Extraction
•Erupted teeth
–Excessive forced may cause a fracture of bone/tooth
–Heavy or dense bone (aging, bruxism)
–Root condition: hyper-cementosis (aging), divergent
(maxillary 1
st
molars)
–Maxillary sinus
–Extensive caries or large restorations
–Retained roots

4. •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

5. •Impacted teeth
1)Prevention of odontogenic cysts/tumors
•Follicular sac  crown/cyst/odontogenic tumor (1~2%)
•Neoplastic change: about 3% (decrease with age)
2)Teeth under dental prostheses
•Ridge where an impacted tooth is covered by only soft tissue
or 1 or 2 mm of bone
3)Prevention of jaw fracture
4)Management of unexplained jaw pain (1~2%)
Indications for Surgical Extraction

6. 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

7. 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

8. Multiple Extraction
•Summary
–Upper posterior teeth, leaving the 1
st
molar
–Upper anterior teeth, leaving the canine
–Upper 1
st
molar
–Upper canine
–Lower posterior teeth, leaving the 1
st
molar
–Lower anterior teeth, leaving the canine
–Lower 1
st
molar
–Lower canine

9. Classification of Impacted Teeth

10. Mesioangular
impaction
43%
Least difficult
Horizontal
impaction
3%
More difficult than
mesioangular ones
Vertical
impaction
38%
Third in difficulty
Distoangular
impaction
6%
Most difficult

11. 63% 25% 12%

14. Surgical Procedure

15. Envelope incision
Posteriorlaterally
to avoid lingual n.
Three-cornered flap
Release incision:
M of the 2
nd
molar.
1. Gain adequate access through a
properly designed soft tissue flap

16. 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

17. Mesioangular impaction
B.B and D bone are removed
C.D of the crown is sectioned. Occasionally the entire tooth.
D.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

18. Horizontal impaction
B.B and D bone are
removed
C.Crown is sectioned
from the roots.
D.Roots are
delivered together
or independently
with a Cryer.
E.M root is elevated
in similar fashion
3. Divide tooth into sections and
delivered with elevators

19. Vertical impaction
•Bone on O, B, D of crown is removed, and the tooth is sectioned into
M and D. If fused single rootD of the crown is sectioned off.
•The posterior aspect of the crown is elevated first with a Cryer.
•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

20. Distoangular impaction
•O,B,D bone is removed with more D bone.
•Crown is sectioned off.
•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

21. Impacted maxillary third molar
B.B bone is removed with a bur or a hand chisel.
C.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

22. •Debride the wound of all debris after
with periapical curettes
•Smooth the sharp, rough edges of bone
with bone files.
•Remove remnants of dental follicle with
mosquitos and hemostats.
•Final irrigation with saline and thorough
inspection
•Check for adequate hemostasis
•Closure of the wound
4. Debridement, irrigation and
closure of wound

23. 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.

24. •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

25. •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 3
rd
and 4
th
days with pain and
malodor
–Irrigation, placement of an obtundent dressing,
changed daily
•Nerve injury (3%)
Post-OP Complications