COMPLICATED

EXTRACTION
& ODONTECTOMY
Presenter: R1 鄭瑋之
Instructor: VS 陳靜容醫師
Date: 2012/2/17
Outlines
 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 1st molars)
– Maxillary sinus
– Extensive caries or large restorations
– Retained roots
 Indications for Surgical Extraction

• Impacted teeth
1) Pericoronitis prevention/treatment (25~30%)
2) Prevention of dental disease
• Caries (15%)
• Periodontal disease (5%)
3) Orthodontic Considerations
• Crowding of mandibular Incisors (controversial)
• Interference of orthodontic treatment/orthognathic surgery
4) Root resorption of adjacent teeth: about 7%
 Indications for Surgical Extraction

• Impacted teeth
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%)
Contraindications for Surgical Extraction

• Extremes of age
– Removal of tooth bud at early stage is unnecessary
– Healing response ↓ with ageImpacted teeth
–  fully impacted,  no communication with oral
cavity,  no signs of pathology,  > age 40
• Compromised medical status
– work closely with the patient’s physician
• Surgical damage to adjacent structures
 Multiple Extraction
1. Preextraction treatment planning
– Dentures, soft tissue surgery, implants
2. Extraction Sequencing:
– Maxillary teeth first
 Infiltration anesthetic: more rapid
 Debris may fall into the empty sockets
 With mainly buccal force
– The most posterior teeth first
 more effective use of dental elevators
– The most difficult (molar and canine) last
 Multiple Extraction
• Summary
– Upper posterior teeth, leaving the 1st molar
– Upper anterior teeth, leaving the canine
– Upper 1st molar
– Upper canine
– Lower posterior teeth, leaving the 1st molar
– Lower anterior teeth, leaving the canine
– Lower 1st molar
– Lower canine
Classification of Impacted Teeth
Mesioangular 43%
impaction Least difficult

3%
Horizontal
More difficult than
impaction
mesioangular ones

Vertical 38%
impaction Third in difficulty

Distoangular 6%
impaction Most difficult
63% 25% 12%
Surgical Procedure
1. Gain adequate access through a
properly designed soft tissue flap

Envelope incision
Posteriorlaterally
to avoid lingual n.

Three-cornered flap
Release incision:
M of the 2nd molar.
2. Remove bone as little as possible

A. The bone overlying the O surface of tooth is

removed with a fissure bur.
B. Bone on the B and D sides of impacted tooth
is then removed.
3. Divide tooth into sections and
delivered with elevators

Mesioangular impaction
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

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

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

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

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.
4. Debridement, irrigation and
closure of wound

• 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
 Postoperative Management

• Analgesics
– During the first 24 hours, analgesics are prescribed
routinely; after this time, they are used only when
required. Combination of codeine and
aspirin/acetaminophen or NSAID might be suggested.
• Antibiotics
– Preexisting pericoronitis  antibiotics for a few days
– No preexisting infection  antibiotics is not indicated
• Anti-inflammatory medication
– Steroid or aspirin might be considered.
 Post-OP Complications
• Trismus
– Reaches its peak on the second day and
resolves by the end of the first week.
• Bleeding
– Moist gauze pack ing with pressure
– Socket packed with oxidized cellulose
• Swelling/edema
– Corticosteroids
– Ice packing has no effect on edema
– Reaches its peak by the end of the second day
• Infection (1.7~2.7%)
– Debris left under the mucoperiosteal flap
 Post-OP Complications
• Fracture
– Broken root displaced into submandibular
space, IAN canal, or maxillary sinus
– Radiographic follow-up
• Alveolar osteitis/Dry socket (3%-25%)
– Lysis of a blood clot before replaced with
granulation tissue
– Occurs during the 3rd and 4th days with pain and
malodor
– Irrigation, placement of an obtundent dressing,
changed daily
• Nerve injury (3%)