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


Indications for Surgical Extraction

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

Indications for Surgical Extraction

Impacted teeth
1) Pericoronitis prevention/treatment (25~30%) 2) Prevention of dental disease
Caries (15%) Periodontal disease (5%)

1) Orthodontic Considerations
Crowding of mandibular Incisors (controversial) Interference of orthodontic treatment/orthognathic surgery

Indications for Surgical Extraction

Impacted teeth
5) Prevention of odontogenic cysts/tumors
Follicular sac crown/cyst/odontogenic tumor (1~2%) Neoplastic change: about 3% (decrease with age)

5) Teeth under dental prostheses

Ridge where an impacted tooth is covered by only soft tissue or 1 or 2 mm of bone

5) Prevention of jaw fracture

Contraindications for Surgical Extraction

Extremes of age
Removal of tooth bud at early stage is unnecessary Healing response with ageImpacted teeth fully impacted, no communication with oral cavity, no signs of pathology, > age 40

Compromised medical status

work closely with the patients physician

Multiple Extraction
1. Preextraction treatment planning
Dentures, soft tissue surgery, implants Maxillary teeth first
Infiltration anesthetic: more rapid Debris may fall into the empty sockets With mainly buccal force more effective use of dental

1. Extraction Sequencing:

The most posterior teeth first

Multiple Extraction

1) Upper posterior teeth, leaving the 1st molar 2) Upper anterior teeth, leaving the canine 3) Upper 1st molar 4) Upper canine 5) Lower posterior teeth, leaving the 1st molar 6) Lower anterior teeth, leaving the canine

Classification of Impacted Teeth

Mesioangula r impaction Horizontal impaction

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

Vertical impaction Distoangular impaction




Surgical Procedure

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

Envelope incision Posteriorlaterally to avoid lingual n.

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

2. Remove bone as little as possible

A. The bone overlying the O surface of tooth is removed with a fissure bur. B. Bone on the B and D sides of

3. Divide tooth into sections and delivered with elevators

Mesioangular impaction A. B and D bone are removed B. D of the crown is sectioned. Occasionally the entire tooth. C. Small straight elevator into M side, and the tooth is delivered with a rotational and level motion of

3. Divide tooth into sections and delivered with elevators

Horizontal impaction A. B and D bone are removed B. Crown is sectioned from the roots. C. Roots are delivered together or independently with a Cryer. D. M root is

3. Divide tooth into sections and delivered with elevators

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

3. Divide tooth into sections and delivered with elevators

Distoangular impaction A. O,B,D bone is removed with more D bone. B. Crown is sectioned off. C. Roots are delivered by a Cryer with a wheel-andaxle motion. If the roots diverge, it may be necessary in some cases to split them into

3. Divide tooth into sections and delivered with elevators

Impacted maxillary third molar A. B bone is removed with a bur or a hand chisel. B. Tooth is then delivered by a small straight elevator with rotational and lever types of motion in DB and O direction.

4. Debridement, irrigation and closure of wound

1) Debride the wound of all debris after with periapical curettes 2) Smooth the sharp, rough edges of bone with bone files. 1) Remove remnants of dental follicle with mosquitos and hemostats. 1) Final irrigation with saline and thorough inspection 1) Check for adequate hemostasis 2) Closure of the wound

Postoperative Management
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.

Preexisting pericoronitis antibiotics for a few days No preexisting infection antibiotics is not indicated

Anti-inflammatory medication

Post-OP Complications
Reaches its peak on the second day and resolves by the end of the first week.

Moist gauze pack ing with pressure Socket packed with oxidized cellulose

Corticosteroids Ice packing has no effect on edema Reaches its peak by the end of the second day

Infection (1.7~2.7%)

Post-OP Complications
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%)