Complicated Extraction and Odontectomy


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Complicated Extraction and Odontectomy

  1. 1. COMPLICATED EXTRACTION & ODONTECTOMY Presenter: R1 鄭瑋之 Instructor: VS 陳靜容醫師 Date: 2012/2/17
  2. 2. Outlines
  3. 3. Indications for Surgical Extraction <ul><li>Erupted teeth </li></ul><ul><ul><li>Excessive forced may cause a fracture of bone/tooth </li></ul></ul><ul><ul><li>Heavy or dense bone (aging, bruxism) </li></ul></ul><ul><ul><li>Root condition: hyper-cementosis (aging), divergent (maxillary 1 st molars) </li></ul></ul><ul><ul><li>Maxillary sinus </li></ul></ul><ul><ul><li>Extensive caries or large restorations </li></ul></ul><ul><ul><li>Retained roots </li></ul></ul>
  4. 4. <ul><li>Impacted teeth </li></ul><ul><ul><li>Pericoronitis prevention/treatment (25~30%) </li></ul></ul><ul><ul><li>Prevention of dental disease </li></ul></ul><ul><ul><ul><li>Caries (15%) </li></ul></ul></ul><ul><ul><ul><li>Periodontal disease (5%) </li></ul></ul></ul><ul><ul><li>Orthodontic Considerations </li></ul></ul><ul><ul><ul><li>Crowding of mandibular Incisors (controversial) </li></ul></ul></ul><ul><ul><ul><li>Interference of orthodontic treatment/orthognathic surgery </li></ul></ul></ul><ul><ul><li>Root resorption of adjacent teeth: about 7% </li></ul></ul>Indications for Surgical Extraction
  5. 5. <ul><li>Impacted teeth </li></ul><ul><ul><li>Prevention of odontogenic cysts/tumors </li></ul></ul><ul><ul><ul><li>Follicular sac  crown/cyst/odontogenic tumor (1~2%) </li></ul></ul></ul><ul><ul><ul><li>Neoplastic change: about 3% (decrease with age) </li></ul></ul></ul><ul><ul><li>Teeth under dental prostheses </li></ul></ul><ul><ul><ul><li>Ridge where an impacted tooth is covered by only soft tissue or 1 or 2 mm of bone </li></ul></ul></ul><ul><ul><li>Prevention of jaw fracture </li></ul></ul><ul><ul><li>Management of unexplained jaw pain (1~2%) </li></ul></ul>Indications for Surgical Extraction
  6. 6. Contraindications for Surgical Extraction <ul><li>Extremes of age </li></ul><ul><ul><li>Removal of tooth bud at early stage is unnecessary </li></ul></ul><ul><ul><li>Healing response ↓ with ageImpacted teeth </li></ul></ul><ul><ul><li> fully impacted,  no communication with oral cavity,  no signs of pathology,  > age 40 </li></ul></ul><ul><li>Compromised medical status </li></ul><ul><ul><li>work closely with the patient’s physician </li></ul></ul><ul><li>Surgical damage to adjacent structures </li></ul>
  7. 7. Multiple Extraction <ul><li>Preextraction treatment planning </li></ul><ul><ul><li>Dentures, soft tissue surgery, implants </li></ul></ul><ul><li>Extraction Sequencing: </li></ul><ul><ul><li>Maxillary teeth first </li></ul></ul><ul><ul><ul><li>Infiltration anesthetic: more rapid </li></ul></ul></ul><ul><ul><ul><li>Debris may fall into the empty sockets </li></ul></ul></ul><ul><ul><ul><li>With mainly buccal force </li></ul></ul></ul><ul><ul><li>The most posterior teeth first </li></ul></ul><ul><ul><ul><li>more effective use of dental elevators </li></ul></ul></ul><ul><ul><li>The most difficult (molar and canine) last </li></ul></ul>
  8. 8. Multiple Extraction <ul><li>Summary </li></ul><ul><ul><li>Upper posterior teeth, leaving the 1 st molar </li></ul></ul><ul><ul><li>Upper anterior teeth, leaving the canine </li></ul></ul><ul><ul><li>Upper 1 st molar </li></ul></ul><ul><ul><li>Upper canine </li></ul></ul><ul><ul><li>Lower posterior teeth, leaving the 1 st molar </li></ul></ul><ul><ul><li>Lower anterior teeth, leaving the canine </li></ul></ul><ul><ul><li>Lower 1 st molar </li></ul></ul><ul><ul><li>Lower canine </li></ul></ul>
  9. 9. Classification of Impacted Teeth
  10. 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. 11. 63% 25% 12%
  12. 14. Surgical Procedure
  13. 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
  14. 16. <ul><li>The bone overlying the O surface of tooth is removed with a fissure bur. </li></ul><ul><li>Bone on the B and D sides of impacted tooth is then removed. </li></ul>2. Remove bone as little as possible
  15. 17. <ul><li>Mesioangular impaction </li></ul><ul><li>B and D bone are removed </li></ul><ul><li>D of the crown is sectioned. Occasionally the entire tooth. </li></ul><ul><li>Small straight elevator into M side, and the tooth is delivered with a rotational and level motion of elevator. </li></ul>3. Divide tooth into sections and delivered with elevators
  16. 18. <ul><li>Horizontal impaction </li></ul><ul><li>B and D bone are removed </li></ul><ul><li>Crown is sectioned from the roots. </li></ul><ul><li>Roots are delivered together or independently with a Cryer. </li></ul><ul><li>M root is elevated in similar fashion </li></ul>3. Divide tooth into sections and delivered with elevators
  17. 19. <ul><li>Vertical impaction </li></ul><ul><li>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. </li></ul><ul><li>The posterior aspect of the crown is elevated first with a Cryer. </li></ul><ul><li>Small straight no. 301 elevator ito lift M of the tooth with a rotary and levering motion. </li></ul>3. Divide tooth into sections and delivered with elevators
  18. 20. <ul><li>Distoangular impaction </li></ul><ul><li>O,B,D bone is removed with more D bone. </li></ul><ul><li>Crown is sectioned off. </li></ul><ul><li>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. </li></ul>3. Divide tooth into sections and delivered with elevators
  19. 21. <ul><li>Impacted maxillary third molar </li></ul><ul><li>B bone is removed with a bur or a hand chisel. </li></ul><ul><li>Tooth is then delivered by a small straight elevator with rotational and lever types of motion in DB and O direction. </li></ul>3. Divide tooth into sections and delivered with elevators
  20. 22. <ul><li>Debride the wound of all debris after with periapical curettes </li></ul><ul><li>Smooth the sharp, rough edges of bone with bone files . </li></ul><ul><li>Remove remnants of dental follicle with mosquitos and hemostats . </li></ul><ul><li>Final irrigation with saline and thorough inspection </li></ul><ul><li>Check for adequate hemostasis </li></ul><ul><li>Closure of the wound </li></ul>4. Debridement, irrigation and closure of wound
  21. 23. Postoperative Management <ul><li>Analgesics </li></ul><ul><ul><li>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. </li></ul></ul><ul><li>Antibiotics </li></ul><ul><ul><li>Preexisting pericoronitis  antibiotics for a few days </li></ul></ul><ul><ul><li>No preexisting infection  antibiotics is not indicated </li></ul></ul><ul><li>Anti-inflammatory medication </li></ul><ul><ul><li>Steroid or aspirin might be considered. </li></ul></ul>
  22. 24. <ul><li>Trismus </li></ul><ul><ul><li>Reaches its peak on the second day and resolves by the end of the first week. </li></ul></ul><ul><li>Bleeding </li></ul><ul><ul><li>Moist gauze pack ing with pressure </li></ul></ul><ul><ul><li>Socket packed with oxidized cellulose </li></ul></ul><ul><li>Swelling/edema </li></ul><ul><ul><li>Corticosteroids </li></ul></ul><ul><ul><li>Ice packing has no effect on edema </li></ul></ul><ul><ul><li>Reaches its peak by the end of the second day </li></ul></ul><ul><li>Infection (1.7~2.7%) </li></ul><ul><ul><li>Debris left under the mucoperiosteal flap </li></ul></ul>Post-OP Complications
  23. 25. <ul><li>Fracture </li></ul><ul><ul><li>Broken root displaced into submandibular space, IAN canal, or maxillary sinus </li></ul></ul><ul><ul><li>Radiographic follow-up </li></ul></ul><ul><li>Alveolar osteitis/Dry socket (3%-25%) </li></ul><ul><ul><li>Lysis of a blood clot before replaced with granulation tissue </li></ul></ul><ul><ul><li>Occurs during the 3 rd and 4 th days with pain and malodor </li></ul></ul><ul><ul><li>Irrigation, placement of an obtundent dressing, changed daily </li></ul></ul><ul><li>Nerve injury (3%) </li></ul>Post-OP Complications