Simple Tooth Extraction dental extraction

Simple tooth ext

1. Simple Tooth Extraction
Abed Yakan
DDS, PGDip, MS, PhD -OMFS
Division of Clinical Dentistry -Oral & Maxillofacial Surgery
University of Detroit Mercy
UDM -AY -Simple Tooth Extraction

2. UDM -AY -Simple Tooth Extraction
Contents:
❑Patient and Surgeon Preparation.
❑Chair Position for Extractions.
❑Mechanical Principles Involved In Tooth Extraction.
❑Principles of Elevator and Forceps Use.
❑Procedure for Closed (Simple) Extraction.
❑Specific Techniques for The Removal of Each Tooth.

3. UDM -AY -Simple Tooth Extraction
❑PATIENT AND SURGEON PREPARATION
➢Surgeons must prevent transmission of infection.
➢All patients must be viewed as having bloodborne diseases.
➢Long-sleeved gowns, surgical gloves, surgical mask, and eyewear
with side-shields are required.

4. UDM -AY -Simple Tooth Extraction
➢A sterile waterproof drape should be put across the patient’s chest to
decrease the risk of contamination.
➢Patient should rinse their mouths vigorously with an antiseptic.
➢Placeapartiallyunfolded4×4inchgauzelooselyintothebackofthe
mouthtoserveasabarriertocatchthetoothorfragmentsrather
thanbeswallowedoraspirated..

5. UDM -AY -Simple Tooth Extraction
❑CHAIRPOSITIONFOREXTRACTIONS
➢Comfortableforthepatientandsurgeon.
➢Allowsthesurgeontohavemaximalcontroloftheforcethatis
beingdeliveredtothepatient’stooth.
➢Allowsthesurgeontokeepthearmsclosetothebodyand
providesstabilityandsupport.
➢Alsoallowsthesurgeontokeepthewristsstraightenoughto
delivertheforcewiththearmandshoulder,andnotwiththe
fingersorhand.
➢Cancontrolthesuddenlossofresistancefromatooth.
➢Dentistsusuallystandduringextractions..

6. UDM -AY -Simple Tooth Extraction
➢Position of dental chair during extraction.
a. Maxilla: angle between dental chair and the horizontal (floor) is 120°.
b. Mandible: angle between dental chair and the horizontal (floor) is 110°..

7. UDM -AY -Simple Tooth Extraction
❖Themostcommonerrordentistsmakeinpositioningthedental
chairforextractionsistohavethechairtoohigh.
➢Thisforcesthesurgeonstooperatewiththeirshouldersraised.
➢Makingitdifficulttodeliverthecorrectamountofforcetothe
toothbeingextractedinthepropermanner.
➢Itisalsotiringtothesurgeon.
❖Anotherfrequentpositioningproblemisforthedentisttolean
overthepatientandputhisorherfaceclosetothepatient’s
mouth.
➢Thisinterfereswithsurgicallighting.
➢Ishardonthedentist’sbackandneck.
➢Andalsointerfereswithproperpositioningoftherestofthe
dentist’sbody..

8. UDM -AY -Simple Tooth Extraction
Extractionofmaxillaryteeth
➢thechairshouldbetipped
backwardsothatthe
maxillaryocclusalplaneis
atanangleofabout60
degreestothefloor.
➢Raisingthepatient’slegs
atthesametimehelps
improvethepatient’s
comfort.
➢Theheightofthechair
shouldbesuchthatthe
patient’smouthisatthe
operator’selbowlevel..

9. UDM -AY -Simple Tooth Extraction
➢Duringanoperationonthemaxillaryrightquadrant,thepatient’s
headshouldbeturnedsubstantiallytowardtheoperatorsothat
adequateaccessandvisualizationcanbeachieved..

10. UDM -AY -Simple Tooth Extraction
➢Forextractionofteethinthemaxillaryanteriorportionofthe
arch,thepatientshouldbelookingstraightahead..

11. UDM -AY -Simple Tooth Extraction
➢Thepositionforthemaxillaryleftportionofthearchissimilar,
exceptthatthepatient’sheadisturnedslightlytowardthe
operator..

12. UDM -AY -Simple Tooth Extraction
Extractionofmandibularteeth
➢Thepatientshouldbe
positionedinamoreupright
position.
➢whenthemouthisopened
wide,theocclusalplaneis
paralleltothefloor.
➢ThesurgeonShouldsupport
thejaw.
➢Thechairshouldbelowerfor
extractionofmaxillaryteeth.
➢Theheightofthechair
shouldbesuchthatthe
patient’smouthisslightly
belowtheoperator’selbow
level..

13. UDM -AY -Simple Tooth Extraction
➢Aproperlysizedbiteblockshouldbeusedtostabilizethe
mandiblewhenextractionforcepsareused.
➢Eventhoughthesurgeonwillsupportthejaw,theadditional
supportprovidedbythebiteblockwillresultinlessstressbeing
transmittedtothejaws.
➢Careshouldbetakentoavoidusingtoolargeabiteblock
becauselargeonescanoverstretchtheTMJligamentsandcause
patientdiscomfort.Typically,pediatricbiteblocksarethebestto
use,eveninadults..

14. UDM -AY -Simple Tooth Extraction
➢Duringremovalofmandibularrightposteriorteeth,thepatient’s
headshouldbeturnedacutelytowardthesurgeontoallowadequate
accesstothejaw,andthesurgeonshouldmaintaintheproperarm
andhandpositions.
Infrontofthepatientapproach Sideofthepatientapproach..

15. UDM -AY -Simple Tooth Extraction
➢Whenremovingteethintheanteriorregionofthemandible,the
surgeonstandsatthesideofthepatient,wholooksstraightahead.
American-StyleForceps English-StyleForceps..

16. UDM -AY -Simple Tooth Extraction
➢Duringremovalofmandibularleftposteriorteeth,thepatient’s
headshouldnotturnsoacutelytowardthesurgeon,andthe
surgeonshouldmaintaintheproperarmandhandpositions.
Infrontofthepatientapproach Sideofthepatientapproach..

17. If the surgeon chooses to sit while performing extractions, several
modifications must be made.
For maxillary extractions:
➢The patient is positioned in a semi-reclining position.
➢The patient should be lowered as far as possible so that the level of
the patient’s mouth is as near as possible to the surgeon’s elbow..

18. For Mandibular Extraction:
➢The patient is slightly more upright than for extraction of
maxillary teeth.
➢The surgeon can work from the side of the patient or from
behind the patient..

19. UDM -AY -Simple Tooth Extraction
❑MECHANICAL PRINCIPLES INVOLVED IN TOOTH EXTRACTION
The removal of teeth from the alveolar process requires the use of
the following mechanical principles and simple machines:
•The lever,
•The wedge,
•And the wheel and axle..

20. UDM -AY -Simple Tooth Extraction
❖Thelever
➢Isamechanismfortransmittingamodestforce(withthe
mechanicaladvantagesofalongleverarmandashorteffector
arm)intoasmallmovementagainstgreatresistance.
The first-class lever
transforms small force and large movement to small movement and large force..

21. UDM -AY -Simple Tooth Extraction
➢AnexampleoftheuseofaleveriswhenaCranepickisinsertedinto
apurchasepointofatoothandthenisusedtoelevatethetooth.
A -The purchase point creates a first-class lever situation.
B -The tooth is elevated with buccoalveolarbone used as the fulcrum..

22. UDM -AY -Simple Tooth Extraction
❖The wedge
➢Awedgecanbeusedtoexpand,split,
anddisplaceportionsofthesubstance
thatreceivesit.
➢Whenforcepsareused,Thebeaksof
theforcepsactaswedgestoexpand
alveolarboneanddisplacethetoothin
theocclusaldirection(outofthe
socket)..

23. UDM -AY -Simple Tooth Extraction
➢Whenastraightelevatorisusedto
luxateatoothfromitssocket.Asmall
elevatoriswedgedintothe
periodontalligamentspace,which
displacestheroottowardthe
occlusion(outofthesocket)..

24. UDM -AY -Simple Tooth Extraction
❖Thewheelandaxle
➢Whichismostcloselyidentifiedwiththetriangular,orpennant-
shaped,elevator(Cryer).
➢Thehandlethenservesastheaxle,andthetipofthetriangular
elevatoractsasawheelandengagesandelevatesthetooth
rootfromthesocket.
Triangularelevatorintheroleof
awheel-and-axlemachineusedto
retrievetherootfromthesocket..

25. UDM -AY -Simple Tooth Extraction
❑PRINCIPLESOFELEVATORANDFORCEPSUSE
➢Elevatorshelpintheluxationofatooth.
➢Thegoalofforcepsuseistwofold:
(1)Expansionofthebonysocketbyuseofthewedge-shaped
beaks.
(2)Removalofthetoothfromthesocket..

26. ForcepscanapplyFIVEmajormotionstoexpandthebonysocketand
luxatetheteeth:
1.TheFirstIsApicalPressure;
➢Theforcepsshouldbeseatedwithstrongapicalpressuretoexpand
crestalboneandtodisplacethecenterofrotationasfarapicallyas
possible..

27. ➢Ifthebeaksoftheforcepsareforcedintotheperiodontalligament
space,thecenterofrotationismovedapically,whichresultsin
greatermovementoftheexpansionforcesatthecrestoftheridge
andlessforcemovingtheapexanddecreasesthechanceforapical
rootfracture.
If the forceps are apically seated, the center of rotation (*)
is displaced apically, and smaller apical pressures are generated.
This results in greater expansion of the buccal cortex, less movement of the
apex of the tooth, and, therefore, less chance of fracture of the root..

28. UDM -AY -Simple Tooth Extraction
2.TheSecondIsTheBuccalPressure;
➢Resultinexpansionofthebuccalplateatthecrestoftheridge.
➢Excessiveforcecanfracturebuccalboneorcauseafractureofthe
apicalportionoftheroot..

29. UDM -AY -Simple Tooth Extraction
3.TheThirdIsTheLingualOrPalatalPressure;
➢Resultinexpansionofthelinguocrestalboneatthecrestofthe
ridgeandslightlyexpandbuccalboneattheapicalarea..
➢Excessiveforcecanfracturetheboneorcauseafractureofthe
apicalportionoftheroot..

30. UDM -AY -Simple Tooth Extraction
4.TheFourthIsTheRotationalPressure;
➢Rotatesthetoothwhichcausessomeinternalexpansionofthe
toothsocketandtearingofperiodontalligaments.
➢Usefulfortheteethwithsingle,conicalroots(suchascentral
maxillaryincisorsandmandibularpremolars)..

31. UDM -AY -Simple Tooth Extraction
5.Finally,TheTractionalForces;
➢Usefulfordeliveringthetoothfromthesocketonceadequate
bonyexpansionisachieved.
➢Theseshouldalwaysbesmallforcesbecauseteetharenotpulled..

32. UDM -AY -Simple Tooth Extraction
❑PROCEDURE FOR CLOSED (SIMPLE) EXTRACTION
➢Thecorrecttechnique=atraumaticextraction.
Thewrongtechnique=excessivelytraumaticextraction.
➢The three fundamental requirements for a good extraction are:
1)Adequate access and visualization of the field of surgery.
1)An unimpeded pathwayfor the removal of the tooth.
2)The use of controlled force to luxate and remove the tooth.

33. UDM -AY -Simple Tooth Extraction
➢For the tooth to be removed, it is usually necessary to:
1.Expandthealveolarbonywallstoallowthetoothrootan
unimpededpathway,
2.Teartheperiodontalligamentfibersthatholdthetoothinthe
bonysocket.
The use of elevators and forceps as levers and wedges with steadily
increasing force can accomplish these two objectives.

34. UDM -AY -Simple Tooth Extraction
GeneralStepsMakeUpTheClosedExtractionProcedure:
Step1:loosenthesofttissuefromaroundthetooth(gingival
attachmentandtheinterdentalpapilla)withthesharpendofthe
periostealelevator.
•Ensurethatprofoundanesthesiahasbeenachieved.
•Allowtheelevatorandforcepstobepositionedmoreapically..

35. Step2:involvesluxationofthetoothwithadentalelevator.
❖Theinitialstepintheelevationprocess:
➢ThestraightelevatorisinsertedFROMTHEBUCCALSIDE
perpendiculartothetoothintotheinterdentalspace.
➢Theelevator’sbladeisturnedtowardthetoothbeingextractedWITH
CAUTION.
➢Strong,slow,forcefulturningofthehandlemovesthetooth.
➢LeadtoexpansiontheboneandtearingofthePDL..

36. UDM -AY -Simple Tooth Extraction
➢Duringluxation,acottonrollorgauzeshouldbeplacedbetween
thefingerandpalatalorlingualside,toavoidinjuryofthe
fingerortongueincasetheelevatorslips..

37. UDM -AY -Simple Tooth Extraction
➢Incertainsituations(Noadjacenttooth-Extractionofbothteeth-
Extractionofwisdomteeth)theelevatorcanbeturnedinthe
oppositedirectionandmoreverticaldisplacementofthetoothwill
beachieved,whichcanpossiblyresultincompleteremovalofthe
tooth.

38. UDM -AY -Simple Tooth Extraction
❖The next step in the elevationprocess:
➢Thesmall,straightelevatorisinsertedintotheperiodontal
ligamentspaceatthemesial–buccallineangleandthedistal–
buccallineangle.
➢Beingrotatedbackandforth,helpingluxatethetoothwithits
wedgeactionasitisadvancedapically.
➢Whenasmall,straightelevatorbecomestooeasytotwist,a
larger-sizedelevatorisusedtodothesameapical
advancement.
➢Oftenthetoothwillloosensufficientlytoberemovedeasily
withforceps..

39. UDM -AY -Simple Tooth Extraction
Step 3: involves adaptation of the forceps to the tooth.
➢The proper forceps are now chosen for the tooth to be extracted.
➢The forceps are then seated onto the tooth so that the tips of the
forceps beaks grasp the root underneath loosened soft tissue as
apically as possible.
➢The lingual beak is usually seated first and then the buccal beak..

40. UDM -AY -Simple Tooth Extraction
➢Thesurgeon’shandshouldbegraspingtheforcepsfirmly.
HoldingmandibularextractionforcepsHoldingmaxillaryextractionforceps
➢Thesurgeonshouldbepreparedtoapplyforcewiththeshoulderand
upperarmwithoutanywristpressure.
➢Thesurgeonshouldbestandingupright,withfeetcomfortably
apart..

41. Step4:involvesluxationofthetoothwithforceps.
➢Themajorportionoftheforceisdirectedtowardthethinnestand,
therefore,weakestbone.
➢Themajormovementislabialandbuccalforallteethinthemaxilla
andallbutmolarteethinthemandible.
➢Thesurgeonusesslow,steadyforcetodisplacethetoothbuccally.
➢Thetoothisthenmovedagaintowardtheoppositedirectionwith
slow,deliberate,strongpressure.
➢Asthealveolarbonebeginstoexpand,theforcepsarereseated
apicallywhichcausesadditionalexpansionofalveolarboneand
furtherdisplacesthecenteroftherotationapically.
➢Buccalandlingualpressurescontinuetoexpandthealveolarsocket..

42. UDM -AY -Simple Tooth Extraction
Thefollowingthreefactorsmustbere-emphasized:
(1)Theforcepsmustbeapicallyseatedasfaraspossibleand
reseatedperiodicallyduringtheextraction;
(2)Theforcesappliedinthebuccalandlingualdirectionsshouldbe
slow,deliberatepressuresandnotjerkywiggles;
(3)Theforceshouldbeheldforseveralsecondstoallowthebone
timetoexpand.
**********

43. UDM -AY -Simple Tooth Extraction
Step5:involvesremovalofthetoothfromthesocket.
➢Oncethetoothhasbeenluxated,aslighttractionalforce
towardthebuccallyorlabiallysidecanbeused.
➢Tractionalforcesshouldbeminimizedbecausethisisthelast
motionthatisusedoncethealveolarprocessissufficiently
expandedandtheperiodontalligamentiscompletelysevered.
******************

44. UDM -AY -Simple Tooth Extraction
It must be remembered that teeth
Are Not Pulled, rather, They Are Gently Lifted
from the socket once the alveolar process has been expanded..
The surgeon should realize that the major role of forceps
IS NOT TO REMOVE THE TOOTH,
but rather to expand the bone so that the tooth can be removed.

45. UDM -AY -Simple Tooth Extraction
Role of the Opposite Hand during Extraction
➢Reflectingthesofttissuesofthecheeks,lips,andtongueto
provideadequatevisualizationoftheareaofsurgery.
➢Protectingotherteethfromtheforceps.
➢Stabilizingthepatient’sheadduringtheextractionprocess.
➢Supportingandstabilizingthejawwhenmandibularteethare
beingextracted.
➢Supportingthealveolarprocess.
➢Providingtactileinformationtotheoperatorconcerningthe
expansionofthealveolarprocessduringtheluxationperiod..

46. UDM -AY -Simple Tooth Extraction
RoleoftheAssistantduringExtraction:
➢Reflectingthesofttissueofthecheeksandtonguesothatthe
surgeoncanhaveanunobstructedviewofthesurgicalfield.
➢Suctioningawayblood,saliva,andtheirrigatingsolutionsused
duringthesurgicalprocedure.
➢Protectingtheteethoftheoppositearch.
➢Supportingthemandibleduringtheapplicationoftheextraction
forcestopreventTMJdiscomfort.
➢Providingpsychologicalandemotionalsupportforthepatient..

47. ❑SPECIFIC TECHNIQUES FOR THE REMOVAL OF EACH TOOTH
❖Maxillary Teeth
➢Maxillary left or anterior teeth:
The left index finger should reflect the lip and cheek tissues;
the left thumb should rest on the palatal alveolar process.
➢Maxillary right teeth:
The left index finger is positioned on the palate, with the left thumb on
the buccal aspect..

48. Themaxillaryincisors:
➢Upperuniversalforceps(No.150)-forceps(No.1).
➢centralincisorsgenerallyhaveconicroots.
➢lateralincisorsslightlylonger,slendererandhaveadistal
curvatureontheapicalonethirdoftheroot.
➢Alveolarboneisthinonthelabialsideandheavieronthe
palatalside.
➢Rotationalmovementshouldbeminimizedforthelateralincisor..

49. UDM -AY -Simple Tooth Extraction
TheMaxillaryCanines:
➢Upperuniversalforceps(No.150)-forceps(No.1).
➢Thelongesttoothinthemouth.
➢Rootisoblongandproduceabulge(canineeminence)
➢Theboneoverthelabialaspectofthemaxillarycanineisusually
thin.
➢Canbedifficulttoextractsimplybecauseofitslongroot..

50. UDM -AY -Simple Tooth Extraction
The Maxillary First Premolar:
➢Upper universal forceps (No. 150) -forceps (No. 150A) and (No. 7).
➢Root bifurcationusually occurring in the apical one third to one half.
➢These roots may be extremely thin and are subject to fracture.
➢The tooth should be luxated as much as possible.
➢Palatal movements are made with small amounts of force to
prevent fracture of the palatal root tip, which is harder to retrieve.
➢Any rotational force should be avoided..

51. UDM -AY -Simple Tooth Extraction
The Maxillary Second premolar:
➢Upper universal forceps (No. 150) -forceps (No. 150A) and (No. 7).
➢Is a singlerootedtooth .
➢The root is thick and has a blunt end.

52. UDM -AY -Simple Tooth Extraction
The Maxillary Molars:
➢The maxillary first and second molar has three roots.
➢Forceps No. (53 R & L ) –(17R & 18L) –(88 R&L).
➢The maxillary third molar frequently has conic roots.
➢Forceps (No. 210).
➢The third molar is also extracted using elevators alone.
Should look carefully at the relationship with the maxillary sinus..

53. ❖MandibularTeeth
➢Mandibularleftandanteriorteeth:
Theleftindexfingershouldreflectthelipandcheektissues;
Theleftmiddlefingershouldrestonthelingualalveolarprocess;
Theleftthumbisplacedbelowthechin.
MandibularRightteeth:Surgeon’slocation(FrontORSideofthepatient)
I.Theleftindexfingershouldrestonthelingualalveolarprocess;
Theleftmiddlefingershouldreflectthelipandcheektissues;
Theleftthumbisplacedbelowthechin.
OR
II.Theleftthumbispositionedonthelingualaspect,withtheleftindex
onthebuccalaspect,therestfingersareplacedbelowthechin..

54. UDM -AY -Simple Tooth Extraction
The Mandibular Anterior teeth:
➢Theloweruniversal(No.151)forceps-(No.151A)-EnglishstyleAshe
forceps(No.74).
➢Mandibularincisorsandcaninesaresimilarinshape,
➢Thecaninerootsbeinglongerandheavier.
➢Theincisorrootsaremorelikelytobefracturedbecausetheyarethin.
➢shouldberemovedonlyafteradequatepre-extractionluxation.
➢Afterluxation,rotationalmovementmaybeusedtoexpandthe
bone..

55. UDM -AY -Simple Tooth Extraction
The Mandibular Premolars:
➢The lower universal (No. 151) forceps -(No. 151A) -English style
Ashe forceps (No. 13).
➢Are among the easiest teeth to remove.
➢The roots tend to be straight and conic.
➢Rotational movement is used more when extracting these teeth
except with root curvature..

56. UDM -AY -Simple Tooth Extraction
The Mandibular molars:
➢Forceps (No. 17) –(cowhornNo. 23 & No. 87) –(No.22) and
(No.222) for the third molars.
➢Usually have two roots.
➢Linguoalveolarbone is thinner than the buccal plate..

57. UDM -AY -Simple Tooth Extraction
➢If the tooth roots are bifurcated, Cowhornforceps, can be used.
A, Forceps are positioned to engage the bifurcation area of the lower molar.
B, The handles of the forceps are squeezed, which forces the beaks to be in the bifurcation,
and creates force against the crest of the alveolar ridge.
C, Strong buccal forces are then used to expand the socket.
D, Strong lingual forces are used to luxate the tooth further.
E, The tooth is delivered in the bucco-occlusal direction with buccal and tractional forces..

58. UDM -AY -Simple Tooth Extraction
If root fracture does occur,
a mobile root tip can be removed
More Easily Than
one that has not been well luxated.

59. Thank You For
Your Kind Attention
[email protected]
UDM -AY -Simple Tooth Extraction

60. Surgical Tooth Extraction
Abed Yakan
DDS, PGDip, MS, PhD -OMFS
Division of Clinical Dentistry -Oral & Maxillofacial Surgery
University of Detroit Mercy
UDM -AY -Surgical Tooth Extraction

61. UDM -AY -Surgical Tooth Extraction
Contents:
❑Definition.
❑Introduction.
❑Indications for surgical extraction.
❑Techniques for surgical extraction.
❑Justification for leaving root fragments.
❑Multiple extractions.

62. UDM -AY -Surgical Tooth Extraction
Definitions:
❖Surgical(Open)extractionistheremovalofatooththat
presentsclinicallywithaconditionthatdoesnotsafelyor
adequatelyallowaccessusinganon-surgicalapproach.
❖SurgicalExtractionofanEruptedTooth:Atoothrequiring
removalofboneand/orsectioningoftooth,andincluding
elevationofmucoperiostealflapifindicated.Includesrelated
cuttingofgingivaandbone,removaloftoothstructure,minor
smoothingofsocketboneandclosure.(ADA,2017)
❖SurgicalRemovalofResidualToothRoots:(cuttingprocedure)
includescuttingofsofttissueandbone,removaloftooth
structureandclosure.(ADA,2017)..

63. UDM -AY -Surgical Tooth Extraction
Introduction:
➢Thesurgical(Open)extractionofaneruptedtoothisatechnique
thatshouldnotbereservedfortheextremesituation.
➢Surgicalextractionmaybemoreconservativeandcauseless
operativemorbiditycomparedwithaclosedextraction.
➢Greatforcesmayresultinremovaloflargeamountsofbone.
➢Thebonelossmaybeless:
•Ifasofttissueflapisreflected,andaproperamountofboneis
removed.
•Ifthetoothissectioned..

64. UDM -AY -Surgical Tooth Extraction
The surgeon should seriously consider performing a surgical
extraction after initial attempts at forceps extraction have failed.
Instead of applying greater amounts
of force that may not be controlled!
The surgeon should simply reflect a soft tissue flap,
section the tooth, remove some bone, if needed,
and extract the tooth in sections.
In these situations, the philosophy of “divide and conquer” results
in the most efficient and least traumatic extraction..

65. UDM -AY -Surgical Tooth Extraction
Indications for Surgical Extraction:
When we anticipate the difficulty or possible need for
Excessive force to extract a tooth.
➢Ifthepatienthasthickorespeciallydensebone,particularlyof
thebuccocorticalplate.
➢Ifteetharesurroundedbydense,thickbonewithstrong
periodontalligamentattachments.
An open technique usually results in a quicker, more straightforward extraction..

66. UDM -AY -Surgical Tooth Extraction
➢Ifthepatienthashypercementosis:cementumhascontinuedto
bedepositedonthetoothandhasformedalargebulbousroot
thatisdifficulttoremovethroughtheavailabletoothsocket
opening.
If Great force used to expand the bone
may result in fracture of the root or the buccocorticalbone..

67. UDM -AY -Surgical Tooth Extraction
➢Rootsthatarewidelydivergent,orhaveseveredilaceration,or
rootcanaltreatedwithlargerestoration.
Difficult to remove without fracturing one or more of the roots..

68. Techniques for Surgical
Extraction
UDM -AY -Surgical Tooth Extraction

69. Techniques for Surgical Extraction of Single-Rooted Tooth:
Provideadequatevisualizationandaccessbyreflectingasufficiently
largemucoperiostealflap.
Methodsofremoval:
1-Attempttoreseattheextractionforcepsandremovethetooth.
2-Graspabitofbuccalboneunderthebeakoftheforcepstoobtaina
bettermechanicaladvantageandgraspofthetoothroot.
3-Pushthestraightelevatordowntheperiodontalligamentspacelike
ashoehornandapplytoandfromotiontoluxatethebrokenroot..

70. UDM -AY -Surgical Tooth Extraction
4-Useaburwithirrigationtoremovetheboneandreducethe
amountofforcenecessarytodisplacetheroot.
•Thewidthofbuccalbonethatisremovedisessentiallythesame
widthasthetoothinamesiodistaldirection.
•Boneshouldberemovedapproximatelyonehalftotwothirdsthe
lengthofthetoothroot.
•Aforcepsorsmallstraightelevatorcanbeusedtoremovethe
tooth..

71. UDM -AY -Surgical Tooth Extraction
5-Ifthetoothisstilldifficulttoextractaftertheremovalofbone,a
purchasepointcanbemadeintherootwiththeburatthemostapical
portionoftheareaofboneremoval.
•Thepurchasepointholeshouldbeabout3mmindiameterand
deepenoughtoallowtheinsertionofaninstrument.
•Aheavyelevatorcanbeusedtoelevateorleverthetoothfromits
socket.
•Softtissueisrepositionedandsutured..

72. UDM -AY -Surgical Tooth Extraction
TechniquesforSurgicalExtractionofMultirootedTeeth:
➢Thetooth(Crown&RootsoronlyRoots)maybedividedwith
aburtoconvertamultirootedtoothintotwoorthreesingle-
rootedteeth.
➢Thegoalistoseparatetherootstomakethemeasierto
elevate..

73. UDM -AY -Surgical Tooth Extraction
❖Removalofthelowerfirstmolar:
Isusuallydoneby2methods:
I-Sectioningthetoothbuccolinguallyto(2halvesoftherootandthe
crown).
➢Oncethetoothissectioned,itisluxatedwithstraightelevatorsto
beginthemobilizationprocess.
➢Thesectionedtoothistreatedasalowerpremolartooth..

74. UDM -AY -Surgical Tooth Extraction
A,Thislowermolarhasrootsthatmakeitnecessarytosectionthetooth.
B,Flapraisedtoexposeboneandallowsectioning.
C,SurgicalhandpiecewithfissureburusedtosectiontoothintoM&Dparts.
D,Straightelevatorinsertedintoburcuttocompletedivisionofthecrown.
E,Eachrootcannowbeelevatedandremoved.
F,Completedprocedurewithsutureclosingdistalrelease..

75. II-Analternativemethodistosectionthemesialrootfromthetooth
andconvertthemolarintotwosingle-rootedteeth.
➢Thecrownwiththedistalrootisextractedwithlowermolar
forceps.
➢ThemesialrootiselevatedwithCryerelevator(insertedintothe
emptytoothsocketandrotated,thesharptipengagesthe
cementum).
➢Iftheinterradicularboneisheavy,thefirstrotationortwoofthe
Cryerelevatorremovesbone,whichallowstheelevatortoengage
thecementumofthetoothonthesecondorthirdrotation..

76. UDM -AY -Surgical Tooth Extraction
Ifthecrownofthemandibularmolarismissing:
A,Aburisusedtosectionthetoothintotwoindividualroots.
B,Thesmallstraightelevatorhasbeenusedtomobilizetheroots,andtheCryer
elevatorisusedtoelevatethedistalroot.
C,TheoppositememberofthepairedCryerelevatorsisthenusedtodeliverthe
remainingtoothrootwiththesametypeofrotationalmovement..

77. UDM -AY -Surgical Tooth Extraction
❖Removalofmaxillarymolars:
➢Thisthree-rootedtoothmustbedividedinapatterndifferentfrom
thatofthetworootedmandibularmolar.
A,Theburisusedtosectionthebuccalrootsfromthecrownportionofthetooth.
B,Uppermolarforcepsarethenusedtoremovethecrownwiththepalatalroot.
C,Thestraightelevatoristhenusedtomobilizeordeliveroneorbothofbuccalroots.
D,TheCryerelevatorcanbeusedintheusualfashionbyplacingthetipofthe
elevatorintotheemptysocketandrotatingittodelivertheremainingroot..

78. UDM -AY -Surgical Tooth Extraction
Ifthecrownofthemaxillarymolarismissing:
A,Theburisusedtosectionthethreerootsintoindependentportions.
B,Therootshavebeenluxatedwiththesmallstraightelevatorandthemesiobuccal
rootisdeliveredwiththeCryerelevatorplacedintotheslotpreparedbythebur.
C,TheCryerelevatorisagainusedtodeliverthedistalbuccalroot.
D,Maxillaryrootforcepscanbeusedtograspanddelivertheremainingroot.
E,Thesmallstraightelevatorcanbeusedtoelevateanddisplacetheremainingroot
ofthemaxillarymolarinthebucco-occlusaldirection..

79. UDM -AY -Surgical Tooth Extraction
Techniques for Removal of Root Fragments and Tips:
❖Simple technique:
Most useful when:
➢The tooth was well luxated and mobile before the root tip fractured.
❖Surgical technique:
Most useful when:
➢The tooth was NOT luxated or mobile before the root tip fractured.
➢The root is bulbous hypercementosedwith bony interferences.
➢There is severe dilaceration of the root end.
The surgeon should begin a surgical technique
if the simple technique is not immediately successful..

80. UDM -AY -Surgical Tooth Extraction
Requirements for removal of a small root tip fragment:
The surgeon SHOULD CLEARLY SEE the roottip,
so, it is critically important to have:
(1)Properlight.
(2)Irrigation.
(3)Excellentsuction..

81. UDM -AY -Surgical Tooth Extraction
❖SimpletechniqueforRemovalofRootFragmentsandTips:
➢Examinetheextractedtoothtoseehowmuchofarootremains.
➢Repositionthepatientsothatadequatevisualizationis
achieved.
➢Irrigatedandsuctionthesocketbecausetheloosetooth
fragmentoccasionallycanbeirrigatedfromthesocket.
➢Inspectthetoothsocketcarefullytoassesswhethertheroothas
beenremovedfromthesocket.
➢Removetherootapexfromthesocketwitharoottippick..

82. UDM -AY -Surgical Tooth Extraction
Root apex removal with root tip pick:
A,Small(2to4mm)portionoftherootapexisfractured.
B,Theroottippickisteasedintotheperiodontalligamentspaceandusedto
gentlyluxatetheroottipfromitssocket.
Neither excessive apical force, norexcessive lateral force
should be applied to the root tip pick..

83. UDM -AY -Surgical Tooth Extraction
Root tip removal with the small straight elevator:
➢Indicatedforremovallargerrootfragments.
A,Thesmallstraightelevatoriswedgedintothe
periodontalligamentspacetodisplacethetoothinthe
occlusaldirection,thepressureappliedshouldbeingentle
to-and-fromotions.
B,Excessivepressureintheapicaldirectionresultsin
displacementofthetoothrootintoundesirableplacessuch
asthemaxillarysinus..

84. UDM -AY -Surgical Tooth Extraction
❖SurgicaltechniqueforRemovalofRootFragmentsandTips.
Twomainsurgicaltechniquesareusedtoremoveroottips.
I-Assurgicalremovalofsingle-rootedteeth:
➢Boneisremovedwithaburtoexposethebuccalsurfaceofthe
toothroot.
➢Therootisbuccallydeliveredthroughtheopeningwithasmall
straightelevator..

85. UDM -AY -Surgical Tooth Extraction
II-The open-window technique:
A,Theopen-windowapproachforretrievingtherootisindicatedwhen
buccocrestalbonemustbemaintained.
B,Aburisusedtouncovertheapexoftherootandtoallowsufficientaccessfor
theinsertionofthestraightelevator.
C,Thesmallstraightelevatoristhenusedtodisplacetherootoutofthetooth
socket..

86. UDM -AY -Surgical Tooth Extraction
General Steps of Surgical Extractions
➢Reflect the suitable flap.
➢Remove a small portion of crestal bone to expose the edge or the
furcation of the root.
➢Remove the tooth or the root with the suitable technique.
➢Check the bone edges; if sharp, smooth it with a bone file.
➢Irrigate the entire surgical field with sterile saline.
➢Set the flap in its original position and sutured into place with 3-0
black silk or chromic gut sutures..

87. JUSTIFICATION FOR LEAVING ROOT FRAGMENTS
The surgeon may consider leaving the root fragments if:
➢Closed (simple) approaches of removal have been unsuccessful.
➢Open (Surgical) approach may be excessively traumatic.
➢The risks of removing a small root tip may outweigh the benefits:
•Cause excessive destruction of surrounding tissue.
•If excessive amounts of bone must be removed to retrieve the root.
•Risk of displacing the root into tissue spaces or into maxillary sinus.
➢Three conditions should exist for a tooth root to be left:
•The root fragment should be no more than 4 to 5 mm in length.
•The root must be deeply embeddedin bone and not superficial.
•The tooth involved must NOTbe infected.
Consider the record in Pt’s chart, radiographic documentation,
inform the patient and follow-up..

88. UDM -AY -Surgical Tooth Extraction
MULTIPLE EXTRACTIONS
❖Treatment Planning:
➢Pre-extractionplanningwithregardtothereplacementofthe
teethtoberemoved.
➢Theneedforanyothertypeofsoftorhardtissuesurgerysuch
astuberosityreductionortheremovalofundercutsorexostoses
incriticalareas.
➢Ifdentalimplantsaretobeplacedimmediatelyoratalater
time..

89. UDM -AY -Surgical Tooth Extraction
❖ExtractionSequencing:
➢Maxillaryteethshouldusuallyberemovedfirst:WHY?
•Aninfiltrationanesthetichasamorerapidonsetandalso
disappearsmorerapidly.
•Duringtheextractionprocess,debrismayfallintotheempty
socketsofthelowerteeth.
•Maxillaryteethareremovedmainlybybuccalnotverticalforce.
Disadvantage of extracting maxillary teeth first, the hemorrhage may
interfere with visualization during mandibular surgery.
➢Posteriorfirst.
➢Themostdifficultlast.
Removal of the teeth on either side weakens the bony socket on the
mesial and distal sides of these teeth,
and their subsequent extraction is made more straightforward..

90. UDM -AY -Surgical Tooth Extraction
❖Technique for Multiple Extractions:
A, This patient’s remaining mandibular teeth are to be extracted.
B, The soft tissue attachment to teeth is incised with the No. 15 blade.
C, The periosteal elevator is used to reflect labial soft tissue justto
the crest of labioalveolarbone..

91. UDM -AY -Surgical Tooth Extraction
D,Theteethinthequadrantareluxatedwiththestraightelevator
andthendeliveredwithforcepsintheusualfashion.
E,Rongeurforcepsareusedtoremoveonlybonethatissharpand
protrudesabovereapproximatedsofttissue.
F,Thebuccolingualplatesarepressedintotheirpre-existing
positionwithfirmpressureunlessimplantsareplanned..

92. UDM -AY -Surgical Tooth Extraction
G,Tissueisclosedwithinterruptedblacksilksuturesacrossthe
papilla.
H,Thepatientreturnsforsutureremoval1weeklater.
I,Normalhealinghasoccurred,andsuturesarereadyforremoval..

93. Thank You For
Your Kind Attention
[email protected]
UDM -AY -Surgical Tooth Extraction

94. Principles of Wound and Bone Healing
Abed Yakan
DDS, PGDip, MS, PhD -OMFS
Division of Clinical Dentistry -Oral & Maxillofacial Surgery
University of Detroit Mercy
UDM -AY -Principles of wound and bone healing

95. UDM -AY -Principles of wound and bone healing
Contents
❑CausesofTissueDamage.
❑WoundRepair.
❑HealingofExtractionSockets.
❑BoneHealing.

96. UDM -AY -Principles of wound and bone healing
❑CausesofTissueDamage
TraumaticInjuries(PhysicalorChemical).
Physical:
•Compromisedbloodflow.
•Crushing.
•Desiccation.
•Incision.
•Irradiation.
•Overcooling.
•Overheating..

97. UDM -AY -Principles of wound and bone healing
Chemical:
•AgentswithunphysiologicPH.
•Agentswithunphysiologictonicity.
•Proteases.
•Vasoconstrictors.
•Thrombogenicagents..

98. UDM -AY -Principles of wound and bone healing
❑WoundRepair
Epithelialization
➢TheInjuredepitheliumhasageneticallyprogrammedregenerativeabilitythatallowsit
tore-establishitsintegritythroughproliferation,migration,andaprocessknownas
contactinhibition.(Contactinhibitionisaregulatorymechanismthatfunctionstokeepcellsgrowingintoalayer
onecellthick“amonolayer”.Ifacellhasplentyofavailablesubstratespace,itreplicatesrapidlyandmovesfreely.This
processcontinuesuntilthecellsoccupytheentiresubstratum).
➢Woundsinwhichonlythesurfaceepitheliumisinjured(i.e.,abrasions)healbythe
proliferationofepitheliumacrossthewoundbed.
➢Woundsinwhichthesubepithelialtissueisalsodamagedproliferatesacrosswhatever
vascularizedtissuebedisavailableandstaysundertheportionofthesuperficialblood
clotthatdesiccates(i.e.,formsascab)untilitreachesanotherepithelialmargin..

99. UDM -AY -Principles of wound and bone healing
StagesofWoundHealing
Thesethreebasicstagesare:
I.Inflammatory.
II.Fibroblastic.
III.Remodeling..

100. UDM -AY -Principles of wound and bone healing
I.Inflammatorystage(LagPhase):
➢Beginsthemomenttissueinjuryoccursandlasts3to5days.
➢Ithastwophases:(1)vascularand(2)cellular.
(1)ThevascularPhase:A.VasoconstrictionB.Vasodilation.

101. (2)Thecellularphase:
TissuetraumaactivatecomplementfactorsC3aandC5a.
C3aandC5aactaschemotacticfactorscausingneutrophilmarginationandmigration.
Theneutrophilsreleasethecontentsoftheirlysosomes.
Thelysosomalenzymesworktodestroybacteriaanddigestnecrotictissue.
Inflammatorystageofwoundrepair:
✓Woundfillswithclottedblood,inflammatorycells,andplasma.
✓Adjacentepitheliumbeginstomigrateintowound.
✓Undifferentiatedmesenchymalcellstransformintofibroblasts..
UDM -AY -Principles of wound and bone healing

102. UDM -AY -Principles of wound and bone healing
▪Thecardinalsignsofinflammation:Redness(i.e.,Erythema).
Swelling(i.e.,Edema).
Warmth.
Pain.
Lossoffunction.
▪Theinflammatorystageissometimesreferredtoasthelagphase,becausethe
principalmaterialholdingawoundtogetherisfibrin,whichpossesseslittletensile
strength..

103. UDM -AY -Principles of wound and bone healing
II.Fibroblasticstage:
➢Thestrandsoffibrinformingalatticework.
➢fibroblastsbeginlayingdowngroundsubstance
andtropocollagen.
•Thegroundsubstancecementscollagenfibers.
•Fibroblastsalsosecretefibronectin.
✓Helpsstabilizefibrin.
✓Actsasachemotacticfactorforfibroblasts.
•Existingvesselsformsnewcapillariesbuds.
•Fibroblastsdeposittropocollagentoproduce
collagentostrengthenthehealingwound.
•Collagenislaiddownrandomly.
•Woundwillbeabletowithstand70%to80%as
muchtensionasuninjuredtissue.
➢Fibroblasticstagenormallylasts2to3weeks..

104. UDM -AY -Principles of wound and bone healing
III.Remodelingstage:
➢Manyofrandomlylaidcollagenfibersare
replacedbyneworientedcollagenfibers.
➢Theexcesscollagenfibersareremoved,
whichallowsthescartosoften.
➢Woundstrengthincreasesnotmorethan
80%to85%ofthestrengthofuninjured
tissue.
➢Woundmetabolismlessens,vascularityis
decreased,whichdiminisheswound
erythema..

105. UDM -AY -Principles of wound and bone healing
FactorsThatImpairWoundHealing
LocalFactors:
(1)Foreignmaterial inflammatory-infection.
(2)Necrotictissue prolongedinflammatorystage-nutrientsourceforbacteria.
(3)Ischemia increasesthechancesofwoundinfection.
(4)Woundtension reopenthewoundandhealwithexcessivescarformation..

106. UDM -AY -Principles of wound and bone healing
SystemicFactors:

107. UDM -AY -Principles of wound and bone healing
MethodsofWoundHealing
Primary,Secondary,andTertiaryIntention.
➢Healingbyprimaryintention:
•Notissueloss.
•Stabilizedinthesameanatomicpositiontheyheldbeforeinjuryandareallowedtoheal.
•Healingoccursmorerapidly.
•lowerriskofinfection.
•lessscarformation..

108. UDM -AY -Principles of wound and bone healing
➢Healingbysecondaryintension:
•Agapisleftbetweentheedgesofanincision.
•Tissuelosshasoccurredinawoundthatpreventsapproximationofwoundedges.
•Requirealargeamountofepithelialmigration,collagendeposition,contraction,and
remodelingduringhealing.
•Healingisslower.
•Producesmorescartissue.
Extraction sockets are examples of wounds that heal by secondary intention..

109. UDM -AY -Principles of wound and bone healing
Healingbytertiaryintention:
•Delayclosingawound,suchaswhenthereispoorcirculationinthewoundareaor
infection.
•Healingisslower.
•Producesscartissue.
•Somesurgeonsusethetermtertiaryintentiontorefertothehealingofwoundsthrough
theuseoftissuegraftstocoverlargewoundsandbridgethegapbetweenwoundedges..

110. UDM -AY -Principles of wound and bone healing
❑HealingofExtractionSockets
➢Socketshealbysecondaryintention.
➢Whenatoothisremoved,theremainingemptysocketconsistsofcorticalbonecoveredby
tornperiodontalligaments,witharimoforalepithelium(gingiva)leftatthecoronal
portion.
➢Healingofextractionsocketsstartsimmediatelyafterextractionandlastsseveralmonths..

111. UDM -AY -Principles of wound and bone healing
1
st
WeekOfHealing
•Thesocketfillswithblood,whichcoagulatesandsealsthesocketfromtheoral
environment.
•Whitebloodcellsenterthesockettoremovebacteriaanddebris.
•Ingrowthoffibroblastsandimmaturecapillaries.
•Re-epithelializationandgranulationtissueformations.
•Osteoclastsaccumulatealongthecrestalbone..

112. UDM -AY -Principles of wound and bone healing
2
nd
–4
th
WeekOfHealing:
•largeamountofgranulationtissuefillsthesocket.
•Osteoiddepositionhasbegunalongthealveolarboneliningthesocket.
•Epithelializationofmostsocketscompleteatthistime.
•Thecorticalbonecontinuestoberesorbedfromthecrestandwallsofthesocket.
•Newtrabecularboneislaiddownacrossthesocket..

113. UDM -AY -Principles of wound and bone healing
4
th
–6
th
MonthOfHealing:
•Thecorticalboneliningasocketusuallyfullyresorbed(thisisrecognizedradiographically
byalossofadistinctlaminadura).
•Thebonefillsthesocket.
•Theepitheliummovestowardthecrestandbecomesatthelevelofadjacentcrestal
gingiva.
•Theonlyvisibleremnantofthesocketafter1yearistherimoffibrous(scar)tissuethat
remainsontheedentulousalveolarridge..

114. ❑BoneHealing
➢3stages:inflammation,fibroblasticand
remodeling,withprimaryorsecondaryintention.
➢Osteoblasts and osteoclasts are involved.
I.EarlyPhaseoffibroblasticstageofbonerepair:
•Osteogeniccellsfromperiosteumandmarrow
proliferateanddifferentiateintoosteoblasts,
osteoclasts,andchondroblasts,andcapillary
buddingbegins.
•Osteogeniccellsresorbnecroticboneandbone
thatneedstoberemodeled.
•Osteoblaststhenlaydownosteoid,which,if
immobileduringhealing,usuallygoesonto
calcify..
Early phase of fibroblastic stage of bone repair.
UDM -AY -Principles of wound and bone healing

115. II.Latephaseoffibroblasticstageofbonerepair:
•Largeamountofcollagenmustbelaiddown
tobridgethebonygap.
•Thefibroblastsproducesomuchfibrous
matrixandformwhatiscalledacallus.
•Osteoclastsresorbnecroticbone.
•Chondroblastlaydowncartilage.
•Osteoblastlaydownbone.
•Capillaryingrowthcontinues.
•Internalandexternalcallusesform..
Late phase of fibroblastic stage of bone repair.
UDM -AY -Principles of wound and bone healing

116. Remodelingstageofbonerepair:
•Osteoclastsremoveunnecessarybone.
•Osteoblastslaynewbonetissue.
•NewHaversiansystemsdevelop.
•Callusesgraduallydecreaseinsize..
Remodeling stage of bone repair
UDM -AY -Principles of wound and bone healing

117. UDM -AY -Principles of wound and bone healing
Healingofbonebyprimaryintention:
➢Boneisincompletelyfracturedorin“greenstickfracture”.
➢Anatomicreductionofthefracture.
Littlefibroustissueisproduced,andreossificationoccursquickly..

118. UDM -AY -Principles of wound and bone healing
Twofactorsareimportanttoproperbonehealing:
(1)Vascularity.
(2)Immobility.
❖Ifvascularityoroxygensuppliesare:
•Sufficient bonewillform.
•Sufficientlycompromised cartilagewillform.
•Poor thefibroustissuedoesnotchondrifyorossify.
❖Mobilityatthesite:
•Compromisevascularityofthewound.
•Formationofcartilageorfibroustissue,ratherthanbonealongthefractureline..

119. Thank You For
Your Kind Attention
[email protected]
Office Hours by Appointment -Room 358
UDM -AY -Principles of wound and bone healing

120. Perioperative Complications of Tooth Extraction
Abed Yakan
DDS, PGDip, MS, PhD -OMFS
Division of Clinical Dentistry -Oral & Maxillofacial Surgery
University of Detroit Mercy
UDM -AY -Perioperative Comp. of Tooth Ex.

121. UDM -AY -Perioperative Comp. of Tooth Ex.
Contents
❑PreventionOfComplications.
❑SoftTissueInjuries.
❑ProblemsWithAToothBeingExtracted.
❑InjuriesToAdjacentTeeth.
❑InjuriesToOsseousStructures.
❑InjuryToRegionalNerves..

122. UDM -AY -Perioperative Comp. of Tooth Ex.
❑PreventionofComplications
1.Thebestandeasiestwaytomanageasurgicalcomplicationistopreventitfromever
happening;
•Thoroughpreoperativeassessment.
•Comprehensivetreatmentplan.
•Carefulexecutionofthesurgicalprocedure.
•Thecomplicationisoftenpredictableandcanbemanagedroutinely.

123. UDM -AY -Perioperative Comp. of Tooth Ex.
2.Dentistsmustperformsurgerythatiswithinthelimitsoftheircapabilities;
•Evaluatetheirtrainingandabilitiesbeforedecidingtoperformaspecificsurgicaltask.
•Becautiousofunwarrantedoptimism.
•Keepinmindthatreferraltoaspecialist..

124. UDM -AY -Perioperative Comp. of Tooth Ex.
3.Thoroughreviewofthepatient’smedicalhistory.
4.Obtainadequateimagesandcarefullyreviewingthem.
5.Followbasicsurgicalprinciples.
6.Thoroughpreoperativeinstructionsandexplanationsforthepatient
7. Follow the principles of asepsis, atraumatic handling of tissues, hemostasis, and
thorough débridementof the wound after the surgical procedure.
➢Controlled Force Is of Paramount Importance; This Means “Finesse,” Not “Force”..

125. UDM -AY -Perioperative Comp. of Tooth Ex.
❑SoftTissueInjuries
The surgeon must continue to pay careful attention to soft tissue
while working on bone and tooth structures..
Almostalwaystheresultofthe:
➢Surgeon’slackofadequateattentiontothedelicatenatureofthemucosa.
➢Attemptstodosurgerywithinadequateaccess.
➢Rushingduringsurgery.
➢Useofexcessiveanduncontrolledforce.

126. UDM -AY -Perioperative Comp. of Tooth Ex.
❖TearofaMucosalFlap
➢Inadequateenvelopeflap,whichisthenforciblyretractedbeyondtheabilityofthetissue
tostretchasthesurgeontriestogainneededsurgicalaccess.
➢Inadequatecareduringitsreflection.
➢Preventionofthiscomplicationisthreefold:
(1)Creatingadequatelysizedflapstopreventexcesstensionontheflap.
(2)Usingcontrolledamountsofretractionforceontheflap.
(3)Creatingreleasingincisions,whenindicated.
➢Treatment:
•Carefulsuturingofthetearresultsinadequate,butsomewhatdelayed,healing.
•Excisingtheedgesofthetornflaptocreateasmoothflapmarginbeforeclosure.
•Avoidexcisionofexcessiveamountsoftissuewhichleadstoclosureundertension!..

127. UDM -AY -Perioperative Comp. of Tooth Ex.
❖PunctureWound
➢Instrumentsmayslipandpunctureortearintoadjacentsofttissue.
➢Preventionofthiscomplicationisthreefold:
•Useofcontrolledforce.
•Usingfingersupportfromtheoppositehandifslippageisanticipated.
➢Treatment:
•Controlbleedingbydirectpressureappliedtothewound.
•Thewoundisusuallyleftopenun-sutured(adequatepathwayfordrainage)..

128. ❖StretchorAbrasionorBurn
➢Abrasionsorburnstolips,cornersofthemouth,orflapsusuallyresultfromametal
retractororfromthehandpieces(acombinationoffrictionandheatdamage).
➢Preventionofthiscomplication:
•Theassistantandthesurgeonshouldbeawareofthelocationoftheshankofthebur.
➢Treatment:
•Ifanareaoforalmucosaisabradedorburned regularoralrinsing.
•Ifanareaofskinisabradedorburned keepitcoveredwithanantibioticointment..
UDM -AY -Perioperative Comp. of Tooth Ex.

129. UDM -AY -Perioperative Comp. of Tooth Ex.
❑ProblemsWithAToothBeingExtracted
❖RootFracture:
➢Themostcommonproblemassociatedwiththetoothbeingextracted.
➢Preventionofthiscomplication:
•Performanopenextractiontechniqueandremovebonetodecreasetheamountofforce
necessarytoremovethetooth.

130. ❖RootDisplacement
I.DisplacementintotheMaxillarySinus(Oro-antralcommunication).
➢Maxillarymolarorrootcanbedisplaced,Ifthisoccurs;thesurgeonmust:
•Apply(Valsalvamaneuver)afterextraction;
Observebubblingfromsocketwhenpatienttriestoexhale
gentlythroughtheirnosewhilenostrilsarepinched.
•Identifythesizeoftherootlostintothesinus.
•Assesswhethertherehasbeenanyinfectionofthetoothorperiapicaltissues.
•Assessthepreoperativeconditionofthemaxillarysinus.
UDM -AY -Perioperative Comp. of Tooth Ex.

131. ➢Preventionofthiscomplication:
•Preoperativeradiographsevaluation:
✓Maxillarysinuspneumatization.
✓Thebonebetweentheteethandthesinus.
•Becarefulduringtheluxationofaroottip.
UDM -AY -Perioperative Comp. of Tooth Ex.

132. UDM -AY -Perioperative Comp. of Tooth Ex.
➢Treatment(OAC):
1.Ifthecommunicationanddisplacedfragmentisa2-3mm,nopre-existinginfection:
•Aradiographshouldbetakentodocumentitspositionandsize.
•Makeabriefattemptatremovingtheroot(Irrigationandsuction).
•Ifthistechniqueisnotsuccessful,leaveitinthesinus(willfibroseontothesinusmembrane).
•Thepatientmustbeinformedandgivenproperfollow-upinstructions.
•The oroantral communication should be managed with:
✓Gelfoamsponge and a “figure-of-eight” suture over the socket.
✓Sinus precautions (Avoid blowing the nose, sneezing, sucking on straws and smoking).
✓Antibiotics.
✓And a nasal spray to lessen the chance of infection by keeping the ostium open..

133. UDM -AY -Perioperative Comp. of Tooth Ex.
2.Ifthetoothrootisinfectedorthepatienthaschronicsinusitis.
Ifalargerootfragmentortheentiretoothisdisplacedintothemaxillarysinus.
IfImpactedmaxillarythirdmolarsaredisplacedintothemaxillarysinus.
The patient should be referred to an oral-maxillofacial surgeon for removal of the root tip
via a Caldwell-Luc or endoscopic approach..

134. UDM -AY -Perioperative Comp. of Tooth Ex.
II.Displacementintotheinfratemporalspace.
➢DuringelevationoftheImpactedmaxillarythirdmolars,theelevatormayforcethetooth
posteriorlythroughtheperiosteumintotheinfratemporalfossa.
➢Thetoothisusuallylateraltothelateralpterygoidplateandinferiortothelateral
pterygoidmuscle.
➢Thedentistshouldmakeasinglecautiousefforttoretrievethetoothwithahemostat.
➢Ifthetoothisnotvisible,don’tattempt..

135. UDM -AY -Perioperative Comp. of Tooth Ex.
➢Ifthetoothisnotretrievedafterasingleeffort,theincisionshouldbeclosed,andthe
operationstopped.
➢Thepatientshouldbeinformedthatthetoothhasbeendisplacedandwillberemovedlater.
➢Antibioticsshouldbegiventohelpdecreasethepossibilityofaninfection.
➢Duringtheinitialhealingtime,fibrosisoccursandstabilizesthetoothinafirmposition.
➢Thetoothisremovedlaterbyanoral-maxillofacialsurgeonafterradiographiclocalization..

136. UDM -AY -Perioperative Comp. of Tooth Ex.
III.Displacementintothesubmandibularspace.
➢Ifthelingualcorticalbonewasthin;evensmallamountsofapicalpressureduring
extractionofmandibularteethorrootscanresultindisplacementitintothatspace.
➢Thedentistshouldmakeasingleefforttoremoveit.
➢Theindexfingerisinsertedontothelingualaspectinanattempttoplacepressureagainst
thelingualaspectofthemandibleandforcetherootbackintothesocket.
➢Ifthiseffortisnotsuccessfulattheinitialattempt,thedentistshouldabandonthe
procedureandreferthepatienttoanoral-maxillofacialsurgeon.
➢Iftherootfragmentissmallandwasnotinfectedpreoperatively,thesurgeonmayelect
toleavetherootinitspositionbecausesurgicalretrievaloftherootmaybeanextensive
procedureorriskseriousinjurytothelingualnerve..

137. UDM -AY -Perioperative Comp. of Tooth Ex.
III.ToothLostIntoThePharynx
➢Thecrownofatoothoranentiretoothmightbelostintothepharynx:
▪Thepatientshouldbeplacedintoapositionwiththemouthfacingthefloor.
▪Thepatientshouldbeencouragedtocoughandspitthetoothoutontothefloor.
▪Thesuctiondevicecansometimesbeusedtohelpremovethetooth.
▪Inspiteoftheseefforts,thetoothmaybeswallowedoraspirated..

138. UDM -AY -Perioperative Comp. of Tooth Ex.
➢Ifthetoothhasbeenswallowed:
•Itwillpassthroughthegastrointestinaltractwithin2to4days.
•Becauseteetharenotusuallysharp,unimpededpassageoccursinalmostallsituations.
•Itmaybeprudenttohavethepatientgotoanemergencyroomandhavearadiographof
theabdomentakentoconfirmthatthetoothis,indeed,inthegastrointestinaltractand
notintherespiratorytract.
•Follow-upradiographsareprobablynotnecessarybecauseswallowedteethare
ultimatelypassedoutalongwithfeces..

139. UDM -AY -Perioperative Comp. of Tooth Ex.
➢Ifthepatienthasaviolentepisodeofcoughingorshortnessofbreath:
•Thetoothmayhavebeenaspiratedthroughthevocalcords.
•Thepatientshouldbetransportedtoanemergencyroom.
•Chestandabdominalradiographsshouldbetakentodeterminethelocationofthetooth.
•Theurgentmanagementofaspirationistomaintainthepatient’sairwayandbreathing.
•Supplementaloxygenmaybeappropriateifsignsofrespiratorydistressareobserved..

140. UDM -AY -Perioperative Comp. of Tooth Ex.
❑InjuriesToAdjacentTeeth
I.FractureorDislodgmentofanAdjacentRestoration:
➢Ifalargerestorationexists,thedentistshouldwarnthepatientpreoperativelyaboutthe
possibilityoffracturingordisplacingitduringtheextraction.
➢Preventionofsuchafractureordisplacement:
•Avoidingapplicationofinstrumentationandforceontherestoration.
•Straightelevatorshouldbeinsertedentirelyintotheperiodontalligamentspace,ornot
usedatalltoluxatethetoothbeforeextraction.
•Thepatientshouldbeinformedifafractureofatoothorrestorationhasoccurredand
thatareplacementrestorationisneeded..

141. UDM -AY -Perioperative Comp. of Tooth Ex.
II.ChippingorFracturingACuspofTheOppositeTooth:
➢Ifexcessivetractionalforcesareused,theforcepsstrikestheteethoftheoppositearch,
chippingorfracturingacusp.
➢Thisismorelikelytooccurwithextractionoflowerteethbecausetheseteethmay
requiremoreverticaltractionalforcesfortheirdelivery.
➢Preventionofthistypeofinjurycanbeaccomplishedby:
▪Avoidtheuseofexcessivetractionalforces.
▪Adequatelyluxatethetoothwithapical,buccolingual,androtationalforcestominimize
theneedfortractionalforces.
▪Thedentistorassistantshouldprotecttheteethoftheoppositearch.
▪Ifsuchaninjuryoccurs,thetoothshouldbesmoothedorrestored..

142. UDM -AY -Perioperative Comp. of Tooth Ex.
III.LuxationofanAdjacentTooth
➢Inappropriateuseoftheextractioninstrumentsmayluxateanadjacenttooth.
➢Forcepswithbroaderbeaksshouldbeavoidedbecausetheywillcauseinjuryandluxation
ofadjacentteeth.
➢Ifanadjacenttoothissignificantlyluxated:
•Repositionthetoothintoitsappropriatepositionandstabilizeit.
•Avoidhyperocclusionandtraumaticocclusion.
•Theluxatedtoothshouldbestabilizedwithsemirigidfixation:
✓Asimplesilksuturethatcrossesthetoothisusuallysufficient.
✓Avoidrigidfixationwithwires;itmayresultinexternalrootresorptionandankylosis..

143. UDM -AY -Perioperative Comp. of Tooth Ex.
IV.ExtractionoftheWrongTooth
➢Extractionofthewrongtoothshouldneveroccur.
➢Thisisusuallythemostcommoncauseofmalpracticelawsuitsagainstdentists.
➢Acommonreasonisthatadentistremovesatoothforanotherdentist:
✓Theuseofdifferingtoothnumberingsystemsor
✓Differencesinthemountingofradiographs.
✓Whenthedentistisaskedtoremoveteethfororthodonticpurposes.
An attentive clinical assessment of the tooth to be removed
before the elevator and forceps are applied
are the main methods of preventing this complication.

144. UDM -AY -Perioperative Comp. of Tooth Ex.
➢Ifthesurgeonrealizesthiserrorimmediately:
•Thetoothshouldbereplacedquicklyintothetoothsocket.
•Thetoothshouldbestabilizedwithsemirigidfixation.
•Thecorrectextractionshouldbedeferredfor4or5weeksuntilthefateofthereplanted
toothcanbeassessed.
•Ifthewrongfullyextractedtoothhasregaineditsattachmenttothealveolarprocess,then
theoriginallyplannedextractionmayproceed.
➢Ifthesurgeondoesnotrealizethiserrorimmediately:
•Littlecanbedonetocorrecttheproblem.
•Replantationoftheextractedtoothafterithasdriedcannotbesuccessfullyaccomplished.
➢Whenthewrongtoothisextracted:
•Informthepatientandanyotherdentistinvolvedwiththepatient’scare.
•Theorthodontistmaybeabletoadjustthetreatmentplan.
•adentalimplant–supportedrestorationmaytotallyrestorethepatient’sdentalstatusas
itwasbeforetheinadvertentextraction..

145. UDM -AY -Perioperative Comp. of Tooth Ex.
❑InjuriesToOsseousStructures
I.FractureoftheAlveolarProcess
➢Insteadofexpanding,thebonefracturesandisremovedwiththetooth.
➢Theseboneinjuriesarecausedbyexcessiveforcefromtheforceps.
➢Themostlikelyplacesforbonefracturesare:
•Thebuccalcorticalplateoverthemaxillarycanine.
•Thebuccalcorticalplateovermaxillaryfirstmolars.
•Theportionsofthefloorofthemaxillarysinusthatareassociatedwithmaxillarymolars.
•Themaxillarytuberosity.
•Thelabialboneovermandibularincisors..

146. UDM -AY -Perioperative Comp. of Tooth Ex.
➢Management:
•Ifthebonehasbeencompletelyremoved:
✓Itshouldnotbereplaced.
✓Anysharpedgesshouldbesmoothed.
✓Softtissueshouldberepositionedovertheremainingbonetopreventdelayedhealing.
•Iftheboneremainsattachedtotheperiosteum:
✓Usuallyhealsifitcanbeseparatedfromthetoothandisleftattachedtothesofttissue.
✓Itisworththespecialefforttodissectthebonefromthetooth.
✓Theboneandthesofttissueflaparereapproximatedandsecuredwithsutures..

147. UDM -AY -Perioperative Comp. of Tooth Ex.
II.FractureofALargeSectionofBoneinTheMaxillaryTuberosity:
➢Fracturesofthemaxillarytuberosityshouldbeviewedasasignificantcomplication.
➢Mostcommonlyresultfromextractionofaneruptedmaxillary2
nd
and3
rd
thirdmolar.
➢Thetreatmentissimilartothatjustdiscussedforotherbonefractures.
➢Themajortherapeuticgoalofmanagementistomaintainthefracturedboneinplaceand
toprovidethebestpossibleenvironmentforhealing.
➢Thismaybeasituationthatcanbestbehandledbyreferraltoanoral-maxillofacial
surgeon..

148. ❑InjurytoRegionalNerves:
➢Causedbyreflectingflapsorbytraumaticextractions.
➢Themostfrequentlyinvolvedspecificbranchesare:
•Theinferioralveolarnerve.
•Thementalnerve.
•Thelingualnerve.
•Thebuccalnerve
•Thenasopalatinenerve.
UDM -AY -Perioperative Comp. of Tooth Ex.

149. UDM -AY -Perioperative Comp. of Tooth Ex.
➢IftheInferioralveolarnerveorthementalnerveisinjured,thepatientwillexperience
temporaryorpermanentparesthesiaofthelipandchin.
➢Ifthelingualnerveisinjured,thepatientwillexperienceparesthesiaofthetongue;andit
rarelyregeneratesifitisseverelytraumatized.
➢Thenasopalatineandlongbuccalnervescanbesurgicallysectionedwithoutlong-lasting
sequelaeormuchbothertothepatient..

150. Thank You For
Your Kind Attention
[email protected]
Office Hours by Appointment -Room 358
UDM -AY -Perioperative Comp. of Tooth Ex.

151. Post-operative Complications of Tooth Extraction
Abed Yakan
DDS, PGDip, MS, PhD -OMFS
Division of Clinical Dentistry -Oral & Maxillofacial Surgery
University of Detroit Mercy
UDM -AY -Postoperative Comp. of Tooth Ex.

152. UDM -AY -Postoperative Comp. of Tooth Ex.
Contents
❑Trismus.
❑Postoperativebleeding.
❑Postextractiongranuloma.
❑Painfulpostextractionsocket.
❑Delayedhealing:
❖Infection.
❖Wounddehiscence.
❖Drysocket.

153. UDM -AY -Postoperative Comp. of Tooth Ex.
❑Trismus
❖Definition: Is a painfulcondition that restricts normal mandibular movementand function
as a result ofmasticatory musculature spasms.

154. UDM -AY -Postoperative Comp. of Tooth Ex.
❖Treatment:
➢Heat therapy:
•Hot mouth rinses.
•Hot compresses are placed extraorally.
➢Gentle massageof the temporomandibular joint area.
➢Physiotherapy:Mouth Spatula, Trismus Screw, TheraBite.
➢Medications:
•Analgesics.
•Anti-inflammatory.
•Muscle Relaxant.
•Sedatives..

155. UDM -AY -Postoperative Comp. of Tooth Ex.
❑Postoperative Bleeding
-Arterial bleeding. -Blood oozing.
-Soft tissue bleeding. -Hard tissue bleeding.
❖Challenges To The Hemostatic Mechanism:
➢The mouth and jaws are highly vascular.
➢The extraction leaves an open wound.
➢It is almost impossible to apply dressing material with enough pressure.
➢Patients tend to explorethe area of surgery with their tongues.
➢The tongue may also cause secondary bleeding by creating small negative pressures
that suction the blood clot from the socket.
➢Salivary enzymes may lyse the blood clot..

156. UDM -AY -Postoperative Comp. of Tooth Ex.
❖Prevention of Bleeding:
➢Obtain a history of bleeding:
•Any existing problems with bleeding or coagulation?
•Family history of bleeding?
•Medications currently being taken that might interfere with coagulation?
•Drugs such as anticoagulantsmay cause prolonged bleeding after extraction?
•Severe liver disease tend to bleed excessively?
When coagulopathy is suspected:
•laboratory testing before surgery is performed.
•Hematologist consultation.
➢Surgery should be as atraumatic as possible.
➢Clean incisions and gentle management of soft tissue.
➢Sharp bony spicules should be smoothed or removed.
➢Granulation tissue should be curettedfrom the periapical region..

157. UDM -AY -Postoperative Comp. of Tooth Ex.
❖Treatment of bleeding:
➢Soft tissue bleeding:
•Arterial bleeding:
Clamping the artery with a hemostat and ligating it with a nonresorbablesuture.
•Blood oozing:
Direct pressure..

158. UDM -AY -Postoperative Comp. of Tooth Ex.
➢Bone bleeding:
•Arterial bleeding from small bony foramen:
✓The foramen can be crushed with the end of a hemostat or closed by bone wax.
✓The bleeding socket is covered with a damp gauze.
✓The patient bites down firmly on this gauze for at least 30 minutes.
✓The surgeon should not dismiss the patient until hemostasis has been achieved.
•Blood oozing:
The absorbable gelatin sponge (Gelfoam), oxidized regenerated cellulose (Surgicel)or collagen
can be placed in the socket to help gain hemostasis..

159. UDM -AY -Postoperative Comp. of Tooth Ex.
✓This material is placedin the extraction socket and is held in place with a figure-
of-eight suture placed over the socket.
✓A gauze pack is then placed over the top of the socket and is held with pressure.

160. UDM -AY -Postoperative Comp. of Tooth Ex.
❖Hematoma (Prolonged Capillary Hemorrhage):
➢blood accumulatesinside the tissues, without any escape from the closed wound
or tightly sutured flaps under pressure.
➢The hematoma may be submucosal, subperiosteal, intramuscular or fascial.
➢Management:
•Placing cold packs extraorallyduring the first 24 h.
•Then heat therapy to help it to subside more rapidly..

161. UDM -AY -Postoperative Comp. of Tooth Ex.
❖SecondaryBleeding:
➢Patientsoccasionallycallthedentistwithbleedingfromtheextractionsite,referredtoas
secondarybleeding.
•Thepatientshouldreturntothedentist.
•Suchpatientsfrequentlyhavelarge“liverclots”
whichmustberemovedfromthemouth.
•Allblood,saliva,andfluidsshouldbesuctionedfromthemouth.
•Thesurgeonshoulddeterminetheprecisesourceofthebleeding.
•Ifitisclearlyseentobeageneralizedoozing,thebleedingsiteiscoveredwithafolded,
dampgauzespongeheldinplacewithfirmpressurebythesurgeon’sfingerfor5minutes.
•IfhemostasisisNOTachieved,thedentistshouldrequestaconsultationfroma
hematologist,whowillordertypicalscreeningtests..

162. UDM -AY -Postoperative Comp. of Tooth Ex.
❑Postextraction Granuloma
➢Occurs 4–5 days after the extraction of the tooth.
➢Presence of a foreign bodyin the alveolus.
➢Foreign bodies irritate the area, so that postextractionhealing ceases and there is
suppuration of the wound.
➢Treatment: Debridementof the alveolus and removal of every causative agent..

163. UDM -AY -Postoperative Comp. of Tooth Ex.
❑Painful Postextraction Socket
➢Occurs if the extractions are difficultand are performed with awkward manipulations.
➢The uneven bone edges injure the soft tissues of the postextractionsocket, resulting in
severe pain and inflammation at the extraction site.
➢Treatment:
•Smoothing of the bone margins of the wound.
•Analgesics.
•Gauze impregnated with eugenol should be placed over the wound margins for 36–48 h..

164. UDM -AY -Postoperative Comp. of Tooth Ex.
❑Delayed healing
➢General factors:
•Blood diseases (agranulocytosis, leukemia).
•Diabetes mellitus.
•Osteopetrosis.
•Osteoporosis.
➢Local factors:
•Infection.
•Wound dehiscence.
•Dry socket.
•Inflammatory hyperplastic granuloma.
•Irradiated region.
•Benign and malignant neoplasms..

165. UDM -AY -Postoperative Comp. of Tooth Ex.
❖Infection:
➢The most common cause of delayed wound healing is infection.
➢Infections are a rare complication after routine dental extraction.
➢Careful asepsis and thorough wound débridementafter surgery can best prevent
infection after surgical procedures..

166. UDM -AY -Postoperative Comp. of Tooth Ex.
❖Wound Dehiscence:
➢Separation of the wound edges.
➢Prevention of Wound Dehiscence
1. Use aseptic technique.
2. Perform atraumatic surgery.
3. Close the incision over intact bone.
4. Suture without tension..

167. UDM -AY -Postoperative Comp. of Tooth Ex.
❖Dry socket (alveolar osteitis -fibrinolytic alveolitis)
➢It is the most common and painful in the healing of extraction wounds.
➢It is NOT associated with an infection (without fever, swelling, and erythema).
➢Develops on the third or fourth day after removal of the tooth.
➢The occurrence of a dry socket:
•Rare after a routine tooth extraction (2% of extractions).
•Frequent after the removal of impacted mandibularthird molars and other
lower molars (20% of extractions)..

168. UDM -AY -Postoperative Comp. of Tooth Ex.
➢Clinical features:
•Throbbing pain, and frequently radiates to the patient’s ear.
•Empty socket, with lost blood clot.
•The bone surfaces of the socket are exposed.
•The area of the socket has a bad odor.
•The patient frequently complains of a foul taste..

169. UDM -AY -Postoperative Comp. of Tooth Ex.
➢The causes of a dry socket:
•Is NOT fully clear, the predisposingfactorsare:
✓Limited local blood supply.
✓Local anaestheticswith adrenalin.
✓Traumatic procedures and excessive forces.
✓Oral contraceptive.
✓Smoking.
✓Osteosclerotic disease.
✓Radiotherapy.
•The blood clot disintegrates and is dislodged.
•Appears to result from fibrinolytic activity results in lysis of the blood clot and subsequent
exposure of bone.
•Resulting in delayed healing and necrosis of the bone surface of the socket..

170. UDM -AY -Postoperative Comp. of Tooth Ex.
➢Prevention of the dry socket:
•Minimize trauma.
•Control bacterial contamination in the area of surgery.
•Small amounts of antibiotics (e.G., Tetracycline) placed in the socket alone or on a
gelatin sponge have been shown to substantially decrease the incidence of dry
socket in mandibular third molars and other lower molar sockets.
•Placement ofsuturesto protect the blood clot.
•Preoperative and postoperative rinseswith antimicrobial mouth rinses such as
chlorhexidine decrease the incidence of dry socket..

171. UDM -AY -Postoperative Comp. of Tooth Ex.
➢The treatment of Dry Socket:
•The goal is relieving the patient’s pain during the period of healing.
•If the patient receives no treatment, no sequela other than continued pain exists
(treatment does not hasten healing).
•Treatment is straightforward and consists of irrigation and insertion of a medicated
dressing:
✓The socket is gently irrigated with sterile saline.
✓The socket should NOT be curetted because this increases the amount of exposed
bone and the pain.
✓The socket is gently suctioned of all excess saline..

172. UDM -AY -Postoperative Comp. of Tooth Ex.
✓A small strip of Gelfoamsoaked in or coated with the medication.
✓The medication contains:
oEugenol, which obtunds the pain from the bone tissue.
oA topical anesthetic such as benzocaine.
oCarrying vehicle such as balsam of peru.

173. UDM -AY -Postoperative Comp. of Tooth Ex.
✓The medicated gauze is gently inserted into the socket, and the patient usually experiences
profound relief from pain within 5 minutes.
✓The dressing is changed every other day for the next 3 to 6 days, depending on the severity
of pain.
✓The socket is gently irrigated with saline at each dressing change.
✓Once the patient’s pain decreases, the dressing should not be replacedbecause it acts as a
foreign body and further prolongs wound healing..

174. Thank You For
Your Kind Attention
[email protected]
Office Hours by Appointment -Room 358
UDM -AY -Postoperative Comp. of Tooth Ex.

175. OS Clinic Protocol & Extraction Evaluation
Abed Yakan
DDS, PGDip, MS, PhD -OMFS
Division of Clinical Dentistry -Oral & Maxillofacial Surgery
University of Detroit Mercy
UDM -AY -OS Clinic Protocol & Ex. Evaluation

176. UDM -AY -OS Clinic Protocol & Ex. Evaluation
Contents
❑OSclinicprotocol.
❖Personalrequirementsintheoralsurgeryclinic.
❖Beforestartcheck.
❖Instrumenttraysystems.
❖Duringtheprocedure.
❖Aftertheprocedure.
❑Extractionevaluation.

177. OS Clinic Protocol
UDM -AY -OS Clinic Protocol & Ex. Evaluation

178. UDM -AY -OS Clinic Protocol & Ex. Evaluation
Personal requirements in the oral surgery clinic:
•Cleanlinessand neat appearance.
•Finger nailsproperly trimmed.
•Open-toed shoes are not permitted.
•Long hair must be appropriately tied back.
•Jewelry cannot be worn during times of treatment..

179. UDM -AY -OS Clinic Protocol & Ex. Evaluation
•Wear mask, gloves, eye protection and gown
while caring for patients in the OMS Clinic.
•Scrub your hands before beginning any
treatment and after touching any unclean
object during treatment.
•Continuously apply all other rules of clean
and/or sterile technique as described in the
School’s Infection Control Guidelines..

180. Beforestartcheck
1.CaseswillbeassignedtoyoubyOSfrontdesk,
2.Callthepatientformwaitingareaandseatyourpatient,
3.Openthepatient’sAxiumChartandcollectalltheinformationneeded,

181. 4.Reviewthepatient’spastandcurrentmedicalfindingsandcurrentsurgicalneeds,
5.Completefocusedpatientassessment..

182. UDM -AY -OS Clinic Protocol & Ex. Evaluation
6.Signtherequiredconsents(oralsurgery,andpostoperative),
7.Bepreparedtoansweranyquestionsaboutthepatientmedicalhistory,consults
responses,andtheproceduretobedone,
8.PresentthecasetotheattendingOSfacultyandgetthestartcheck.
No treatment may be undertaken without the faculty’s authorization..

183. UDM -AY -OS Clinic Protocol & Ex. Evaluation
InstrumentTraySystems:
➢Standardsetsofinstrumentsarepackagedtogether,sterilized,andthenunwrappedat
surgery.
➢Thebasicextractiontrayincludes:
•localanesthesiasyringe,aneedle,alocalanesthesiacartridge.
•Periostealelevator.
•Periapicalcurette.
•Smallandlargestraightelevator.
•Pairofcollegepliers.
•Curvedhemostat.
•Minnesotaretractor.
•Suctiontip.
•2×2-inchor4×4-inchgauze.
**Therequiredforcepswouldbeaddedtothistray..

184. UDM -AY -OS Clinic Protocol & Ex. Evaluation
➢Thesurgicalextractiontrayincludes:
•Theitemsfromthebasicextractiontray.
•Needleholderandsuture.
•Suturescissors.
•Bladehandleandblade.
•Adsontissueforceps.
•Bonefile.
•Tongueretractor.
•Cryerelevators.
•Rongeur.
•Handpieceandbur..

185. UDM -AY -OS Clinic Protocol & Ex. Evaluation
Duringtheprocedure:
➢Incaseofcomplicationasktheattendingfacultyforhelp.
➢OSfacultypermissionismandatoryfor:
•UseofLAmorethan2Lidocaine.
•Checkoutsurgicalkit.
•Checkoutanduseofsharpelevators.
•Useofthescalpelordrill.
➢Avoidbreachinginfectioncontrol:
•UsetheappropriatePPE.
•NoInstruments’packsonthetray.
•NoUsedglovesonthetray.
•Don’ttouchtheneedlewithanysurfacebeforeinjectionorbeforerecapping
•Don’ttouchthekeyboardormousewithglovedhands.
•AvoidanycontactbetweencontaminatedPPEandsurfaces,clothingorpeople.
•DiscardusedPPEinappropriatedisposalbags..

186. UDM -AY -OS Clinic Protocol & Ex. Evaluation
Aftertheprocedure:
➢Asktheattendingfacultytocheckthecase.
➢Completethecodes.
➢Writetheprescription.
➢Writethedetailedpostoperativenote.
➢Allelectronicnotesandotherdatamustbeapprovedandsignedoffbythesupervising
facultypriortodischargingthepatient.
➢Walkyourpatientout.
➢All“sharps”firstremovedfromtheinstrumenttrayandproperlydisposed.
➢Returnthetrayandallinstruments.
➢Cleanthechairandthecubicletoreceiveanotherpatient.
**Incaseofinjuryduringprocedure,fillanincidencereportandsignfromattendingfaculty..

187. Extraction Evaluation
UDM -AY -OS Clinic Protocol & Ex. Evaluation

188. UDM -AY -OS Clinic Protocol & Ex. Evaluation
I.Medical/DentalHistoryReview/PreventionofEmergencies:
➢Complete,orderlyandconciseverbalpresentationtofacultywithnoinaccuracies.
➢Emergenciesareprevented.
➢Theneedforpremedicationandantibioticprophylaxisarerecognizedandverified..

189. UDM -AY -OS Clinic Protocol & Ex. Evaluation
II.PainManagement:
➢Ensuressufficientanesthesiaisachievedpriortoinitiationofprocedure.
➢Demonstratesthoroughknowledgeoflocalanestheticdrugs.
➢Demonstratesthoroughknowledgeoflocalanesthesiadosageanditscomplications..

190. UDM -AY -OS Clinic Protocol & Ex. Evaluation
III.SurgicalManagement:
➢Demonstratesthoroughknowledgeofsurgicalinstrumentsandtheirappropriateuse
includingrecognitionofanyuntowardevents(incompletetoothremoval).
➢Maintainsappropriateprotectionofadjacentteethandstructures.
➢Maintainsappropriatepatientandoperatorpositioning..

191. UDM -AY -OS Clinic Protocol & Ex. Evaluation
IV.SofttissueManagement:
➢Demonstratesormaintainsprotectionofadjacentsofttissues.
➢Providesproperflaportissuereflection.
➢Recognizesindicationforsutures.
➢Placesappropriatesuturesincludingtype,numberandlocation.
➢Provideshemostasis..

192. UDM -AY -OS Clinic Protocol & Ex. Evaluation
V.PostoperativeManagement:
➢Demonstratesthoroughknowledgeandprovisionofpostoperativeinstructions.
➢Afterfinishingthesurgicalprocedure,oralandwritteninstructionsaregiventothe
patient,concerningexactlywhattodointhenextfewdays..

193. UDM -AY -OS Clinic Protocol & Ex. Evaluation
Whatmakesyousubjecttostandardnotmet?
•Wantstobetoldalltheanswers.
•Incomplete,disorganizedpresentationtofacultyand/orcontainsinaccuracies.
•Theneedforpremedicationandantibioticprophylaxisarenotrecognizedand/orverified.
•Isnotpreparedforsession(e.g.,Nocustomtray,missingcriticalmaterials).
•Beginsworkwithoutfacultyapproval.
•Inaccuratelyassessesthelevelofdifficultyoftheprocedure.
•Pushestoprovidecarebeyondyourabilitylevel.
•Workswithadifferentfacultythandirected.
•Emergenciesarenotprevented.
•Ignoresorfailstocommunicatewiththepatient..

194. UDM -AY -OS Clinic Protocol & Ex. Evaluation
Whatmakesyousubjecttostandardnotmet?
•Demonstratesalackofrespectforpatient’sculture.
•Showslackofrespectforthepatient,stafforfaculty.
•Insensitivetopatientanxietylevel.
•Breachesinfectioncontrolguidelines.
•Runsovertime,youareresponsibleforsignificantdelaysinprovidingtreatment.
•Cannotrecognizewhenfacultyassistanceisneeded.
•Donotaskforfacultyassistancewhenitisneeded.
•Argueswithfaculty.
•Doesnotdiscloseasignificantproblemtothefaculty(e.G.,Damagetoadjacenttooth,etc.)
•Dismissingpatientwithoutcheckout..

195. UDM -AY -OS Clinic Protocol & Ex. Evaluation
WhatMakesYouFailinCompetency?
➢Missedinformedconsent.
➢Youmissedrelevantpatientmedicalcondition.
➢Youdon’tknowhowtoselecttype,doseandtechniquesofLA.
➢Failuretorecognizetheproperneedlelengthneededforthetechnique.
➢Failuretoachieveadequatepainmanagement.
➢Failuretorecognizetheproperinstrumentandtheproperwayforinstrumentuse.
➢Failureorincompletetoothremoval.
➢Breachinginfectioncontrol.
➢FailuretoPost-operativemanagementandinstructions.
➢FailuretoDiagnosisandmanagementofpost-operativecomplications.
➢Ignoranceinwritingtheprescription.
➢Inabilitytoevaluateyourperformanceaspartofself-assessment.
➢Failuretopasstheanswerandquestionsession..

196. UDM -AY -OS Clinic Protocol & Ex. Evaluation
See you in OS clinic

197. Thank You For
Your Kind Attention
[email protected]
Office Hours by Appointment -Room 358
UDM -AY -OS Clinic Protocol & Ex. Evaluation

198. Post-extraction patient management
Abed Yakan
DDS, PGDip, MS, PhD -OMFS
Division of Clinical Dentistry -Oral & Maxillofacial Surgery
University of Detroit Mercy
UDM -AY -Post-extraction patient management

199. Contents:
I.Post-extractioncareoftoothsocket.
II.Post-extractioninstructions.
III.Controlofpost-extractionhemorrhage.
IV.Controlofpost-extractionsequelae.
V.Post-extractionfollow-up.
VI.Operative(post-extraction)note.
UDM -AY -Post-extraction patient management

200. I.Post-extractionCareofToothSocket
➢Thebottomofthesocketiscurettedcarefully(aslongasthetoothisnonvital)witha
periapicalcurette,toremoveanyperiapicallesionfromthearea.
➢Thesharpalveolarmarginissmoothedusingrongeurforcepsorabonefile.
➢Thelingualandbuccalplatesarecompressedusingfingerpressure.
➢Hemostasisisaidedbythepatientapplyingpressureonmoistenedgauzeplacedover
thesocketfor30–45min..
UDM -AY -Post-extraction patient management

201. II.Post-extractionInstructions
➢Oncethesurgicalprocedurehasbeencompleted,patientsshouldbegivenproper
instructions.
➢Theinstructionsshouldbegiventothepatientverballyandalsowrittenorprintedon
paper.
➢Postoperativeinstructionsshouldexplainwhatthepatientislikelytoexperience,and
howtomanageandcontroltypicalpostoperativesituations.
➢Thesepostoperativeinstructionsshoulddescribethemostcommoncomplications.
➢Theinstructionsshouldalsoincludeatelephonenumberatwhichthesurgeonordoctor
canbereachedinanemergency..
UDM -AY -Post-extraction patient management

202. III.ControlofPost-extractionHemorrhage
➢Placeasmallpieceofmoistenedgauzedirectlyoverthesocket.
➢Largepacksthatcovertheocclusalsurfacesoftheadjacentteethisineffective!
➢Bitingfirmlyonthisgauzeforatleast30minutes.
➢Oozeisnormalforupto24hoursaftertheextractionprocedure.
➢Withmorebleeding,reapplyingthegauzeforaslongas1hourtogaincontrolofbleeding.
➢Bitingonateabagfor30minutes..

203. ➢AVOIDthefollowingsafterextraction:
•Allactivitiesthatdisturbthebloodclots.
•Talkingminimumfor2to3hours.
•Smokingforthefirst12hours.
•Suckingonastrawwhendrinking.
•Spitingduringthefirst12hours.
•Strenuousexerciseforthefirst12to24hours.
Prolonged oozing, bright red bleeding, or large clots in the patient’s mouth
are indications for a return visit..
UDM -AY -Post-extraction patient management

204. IV.ControlofPost-extractionSequelae
PainandDiscomfort:
➢Thesurgeonmusthelpthepatienttohavearealisticexpectationofwhattypeofpain
mayoccurafterextraction.
➢Patientswhomakeapointofinformingthesurgeonthattheyexpectagreatdealofpain
aftersurgeryshouldNOTbeignoredorautomaticallytoldtotakean(OTC)analgesic.
➢Thesurgeonwhospendssometimediscussingtheseissueswiththepatientbefore
surgerywillbeabletodesignthemostappropriateanalgesicregimen.
➢Itisimportantforthesurgeontoassurepatientsthattheirpostoperativediscomfort
willbeeffectivelymanaged..
UDM -AY -Post-extraction patient management

205. ➢Patientswhoareexpectedtohaveahigherlevelofpain
shouldbegivenaprescriptionanalgesicthatwillcontrolthepain.
➢Thepatientshouldbetoldtotakeatleastibuprofenoracetaminophenpostoperatively
topreventinitialdiscomfortwhentheeffectofthelocalanestheticdisappears.
➢Thesurgeonshouldalsotakecaretoadvisethepatientthatthegoalofanalgesic
medicationismanagementofpainandNOTeliminationofalldiscomfort.
➢Thethreecharacteristicsofthepainthatoccurafterroutinetoothextraction:
(1)ThepainisusuallynotsevereandcanbemanagedwithmildOTCanalgesics.
(2)Thepeakpainexperienceoccursabout12hoursaftertheextraction.
(3)Significantpainfromextractionrarelypersistslongerthan2daysaftersurgery..
UDM -AY -Post-extraction patient management

206. ➢Postoperativepainismuchmoredifficulttomanageifadministrationofanalgesic
medicationisdelayeduntilthepainissevere.
➢Thefirstdoseofanalgesicmedicationshouldbetakenbeforetheeffectsofthelocal
anestheticsubside,anditmaytake60to90minutestobecomefullyeffective.
➢Allpatientsshouldbegiveninstructionconcerninganalgesicsbeforetheyaredischarged..
UDM -AY -Post-extraction patient management

207. ✓Ibuprofen:NSAID-Hasantiplateleteffectbutnotsignificantinpostoperativebleeding.
✓Acetaminophen:Doesnotinterferewithplateletfunction.
✓Opioids:Producedrowsinessandgastrointestinalupset.
The Drug Enforcement Administration (DEA) controls narcotic analgesics.
To write prescriptions for these drugs, the dentist must have a DEA permit and number..
UDM -AY -Post-extraction patient management

208. UDM -AY -Post-extraction patient management

209. Diet:
➢Ahigh-calorie,high-volumeliquidorsoftdietisbestforthefirst12to24hours.
➢Thepatientmusthaveanadequateintakeoffluids,usuallyatleast2liters(L),duringthe
first24hours.
➢Foodinthefirst12hoursshouldbesoftandcooltokeepthelocalareacomfortableand
havelesstendencytocauselocaltraumaorinitiaterebleedingepisodes.
➢Thepatientshouldbeadvisedtoreturntoanormaldietassoonaspossible.
➢Patientswhohavediabetesshouldbeencouragedtoreturntotheirnormalinsulinand
caloricintakeassoonaspossible..
UDM -AY -Post-extraction patient management

210. OralHygiene:
➢Keepingthewholemouthreasonablycleanresultsinamorerapidhealing.
➢Maygentlybrushtheteeththatareawayfromtheareaofsurgeryintheusualfashion.
➢Avoidbrushingtheextractionsitetopreventanewbleedingepisode.
➢Avoiddisturbingsutures.
➢Thenextday,patientsshouldbegingentlerinseswithdilutesaltwater.
➢Thewatershouldbewarmbutnothotenoughtoburnthetissue.
➢Mostpatientscanresumetheirpreoperativeoralhygienemeasuresbythethirdorfourth
dayaftersurgery..
UDM -AY -Post-extraction patient management

211. Edema:
➢Simplesingleextractionwillprobablynotresultinswellingthatthepatientcansee.
➢Surgicalextractionmayresultinmoderatelylargeamountsofswelling.
➢Swellingusuallyreachesitsmaximum36to48hours.
➢Swellingbeginstosubsideonthethirdorfourthday.
➢Itisusuallyresolvedbytheendofthefirstweek..
UDM -AY -Post-extraction patient management

212. Whathelpinreduceswellingafterextraction?
•UsingIcebagimmediatelyfor20minonand20minofffor12to24hours.
•Secondday,neithericenorheatshouldbeappliedtotheface.
•Thirdday,applicationofheatmayhelpresolvetheswellingmorequickly.
•Sleepinginamoreuprightpositionbyusingextrapillowswillhelpreducefacialedema..
UDM -AY -Post-extraction patient management

213. PreventionandRecognitionofInfection:
➢Adherecarefullytothebasicprinciplesofsurgery:
•Minimizetissuedamage.
•Removesourcesofinfection.
•Cleanthewound.
➢Patientswithimmunedeficiencymayrequireantibioticstopreventinfection.
➢Antibioticsafterroutineextractionareusuallynotnecessaryinhealthypatients.
➢Infectionsafterroutineextractionsareunusual..
UDM -AY -Post-extraction patient management

214. ➢Thetypicalsignsofinfectionare:
•Fever.
•Increasedswelling.
•Reddeningofskin.
•Afoultasteinthemouth.
•Worseningpain3to4daysaftersurgery.
•Oralwoundslookedinflamed.
•Somepurulenceisusuallypresent..
UDM -AY -Post-extraction patient management

215. Trismus:(limitationinmouthopening).
Trismusisusuallynotsevereanddoesnothamperthepatient’snormalactivities.
Howmayitresult?
➢Traumaandtheresultinginflammationinvolvingthemusclesofmastication:
•Surgicalextractionofimpactedmandibularthirdmolarsusuallyresultsinsomedegreeof
trismusbecausetheinflammatoryresponsetothesurgicalprocedureissufficiently
widespreadtoinvolveseveralmusclesofmastication.
➢Multipleinjectionsofthelocalanestheticandpenetratethemuscles:
•Themusclemostlikelytobeinvolvedisthemedialpterygoidmuscle,whichmaybe
penetratedbythelocalanestheticneedleduringtheIANblock.
Patients should be warned that Trismus might occur and will likely resolve within a week..
UDM -AY -Post-extraction patient management

216. Ecchymosis:
➢Bloodoozessubmucosallyandsubcutaneously,whichappearsasabruise,
isknownasecchymosis.
➢Ecchymosisisnotdangerousanddoesnotincreasepainorinfection.
➢Ecchymosisisusuallyseeninolderpatientsbecauseoftheir:
•Decreasedtissuetone,
•Increasedcapillaryfragility,
•Weakerintercellularattachments.
➢Typically,theonsetofecchymosisis2to4daysaftersurgeryandusuallyresolveswithin7
to10days..
UDM -AY -Post-extraction patient management

217. V.Post-extractionFollow-up
➢Thesurgeoncancheckthepatient’sprogressafterthesurgery.
➢Uncomplicatedprocedures,afollow-upvisitat1weekisusuallyadequate.
➢Suturesshouldberemoved,asneeded,atthe1-weekpostoperativeappointment.
➢Ifanyproblemarises,patientshouldrequestanearlierfollow-upvisit.
➢Themostlikelyreasonsforanearlierfollow-upvisitare:
•Prolongedbleeding.
•Painthatisnotresponsivetotheprescribedmedication.
•Andsuspectedinfection.
•Drysocket..
UDM -AY -Post-extraction patient management

218. VI.Operative(Post-extraction)Note
➢Thesurgeonmustenterintotherecordsanoteofwhattranspiredduringeachvisit.
➢Wheneversurgeryisperformed,somecriticalfactorsshouldbeenteredintothechart:
These details may be recorded in various ways, depending on the software program used..

219. Post-extractionnote(Simple)
•Extractionoftoothnumber(s):
•Vitalsandchair-sidetests:---------------
•PMH,Meds,andAllergiesreviewed.
•Risksandbenefitsofprocedurereviewed.
•Consentread,signed,andunderstood.
•STO:studentname,assistantname,facultyname,Time:--------am/pm.
•Patientwaspreppedanddrapedinanormaloralsurgicalmanner.
•-----carpulesof-------was/wereusedtoanesthetizethe-------Nerve/Nerves.
•Aperiostealelevatorwasusedtoseparatethegingivafromthetooth/root.
•Astraightelevatorwasthenusedtoluxatethetooth.
•Thetooth/rootwasremovedusing-----forceps.*
•Theextractionsitewasinspectedandallgranulationand/orinfectedtissuewasremoved.*
•Ahemostaticpackwasplaced.
•Thepatientwasgivenverbalandwrittenpost-operativeinstructions.
•Thepatientsignedthepostoperativeinstructions.
•Therewerenointraoperativecomplications,andthepatienttoleratedtheprocedurewell.
•Goodhemostasiswasobtained,andthepatientwasdischargedhome.
•Follow-up:PRN/------------
•Prescriptions:None/------------
** Post-extraction note (Surgical) ADD:
•A full thickness buccal mucoperiosteal envelope flap was raised.
•The tooth was sectioned with a hall drill and removed using -------.
•The bone edges were smoothed with a bone file.
•The wound was irrigated with normal saline and debris were suctioned.
•The flap was replaced in its anatomic position and held with ----sutures.
UDM -AY -Post-extraction patient management

220. Thank You For
Your Kind Attention
[email protected]
Office Hours by Appointment -Room 358
UDM -AY -Post-extraction patient management