1. The document discusses surgical extraction of impacted and complicated teeth, including indications for surgery, classification of impacted teeth, surgical procedures, postoperative management, and potential complications. 2. Common indications for surgical extraction include impacted teeth, excessive force required for non-impacted extractions, and prevention of cysts/tumors. Impacted teeth are classified based on their angle of impaction. 3. The surgical procedure involves raising soft tissue flaps, removing surrounding bone, sectioning and removing the tooth in segments using elevators. Postoperative care includes analgesics, antibiotics, and management of pain, swelling and potential complications like infection, nerve injury or dry socket.

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

2. Outlines

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

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

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

6. Contraindications for Surgical Extraction Extremes of age Removal of tooth bud at early stage is unnecessary Healing response ↓ with ageImpacted teeth  fully impacted,  no communication with oral cavity,  no signs of pathology,  > age 40 Compromised medical status work closely with the patient’s physician Surgical damage to adjacent structures

7. Multiple Extraction Preextraction treatment planning Dentures, soft tissue surgery, implants Extraction Sequencing: Maxillary teeth first Infiltration anesthetic: more rapid Debris may fall into the empty sockets With mainly buccal force The most posterior teeth first more effective use of dental elevators The most difficult (molar and canine) last

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

9. Classification of Impacted Teeth

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

11. 63% 25% 12%

14. Surgical Procedure

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

16. The bone overlying the O surface of tooth is removed with a fissure bur. Bone on the B and D sides of impacted tooth is then removed. 2. Remove bone as little as possible

17. Mesioangular impaction B and D bone are removed D of the crown is sectioned. Occasionally the entire tooth. Small straight elevator into M side, and the tooth is delivered with a rotational and level motion of elevator. 3. Divide tooth into sections and delivered with elevators

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

19. Vertical impaction Bone on O, B, D of crown is removed, and the tooth is sectioned into M and D. If fused single root  D of the crown is sectioned off. The posterior aspect of the crown is elevated first with a Cryer. Small straight no. 301 elevator ito lift M of the tooth with a rotary and levering motion. 3. Divide tooth into sections and delivered with elevators

20. Distoangular impaction O,B,D bone is removed with more D bone. Crown is sectioned off. Roots are delivered by a Cryer with a wheel-and-axle motion . If the roots diverge, it may be necessary in some cases to split them into independent portions. 3. Divide tooth into sections and delivered with elevators

21. Impacted maxillary third molar B bone is removed with a bur or a hand chisel. Tooth is then delivered by a small straight elevator with rotational and lever types of motion in DB and O direction. 3. Divide tooth into sections and delivered with elevators

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

23. Postoperative Management Analgesics During the first 24 hours, analgesics are prescribed routinely; after this time, they are used only when required. Combination of codeine and aspirin/acetaminophen or NSAID might be suggested. Antibiotics Preexisting pericoronitis  antibiotics for a few days No preexisting infection  antibiotics is not indicated Anti-inflammatory medication Steroid or aspirin might be considered.

24. Trismus Reaches its peak on the second day and resolves by the end of the first week. Bleeding Moist gauze pack ing with pressure Socket packed with oxidized cellulose Swelling/edema Corticosteroids Ice packing has no effect on edema Reaches its peak by the end of the second day Infection (1.7~2.7%) Debris left under the mucoperiosteal flap Post-OP Complications

25. Fracture Broken root displaced into submandibular space, IAN canal, or maxillary sinus Radiographic follow-up Alveolar osteitis/Dry socket (3%-25%) Lysis of a blood clot before replaced with granulation tissue Occurs during the 3 rd and 4 th days with pain and malodor Irrigation, placement of an obtundent dressing, changed daily Nerve injury (3%) Post-OP Complications