Complicated-Extraction-and-Odontectomy.pdf

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

Outlines •1

Indications for Surgical Extraction

•2

Contraindication for Surgical Extraction

•3

Multiple Extractions

•4

Classification of Impacted Teeth

•5

Surgical Procedure

•6

Postoperative Management

1

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

1

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%

1

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)

6) Teeth under dental prostheses • Ridge where an impacted tooth is covered by only soft tissue or 1 or 2 mm of bone

7) Prevention of jaw fracture 8) Management of unexplained jaw pain (1~2%)

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

3

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

3

Multiple Extraction • Summary 1) 2) 3) 4) 5) 6) 7) 8)

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

4

Classification of Impacted Teeth

•1

Angulation

• 2

Relationship to anterior border of ramus

• 3

Relation to occlusal plane of 2nd molar

•1

Angulation – Lower

Mesioangular impaction

43% Least difficult

Horizontal impaction

3% More difficult than mesioangular ones

Vertical impaction

38% Third in difficulty

Distoangular impaction

6% Most difficult

•1

Angulation – Upper

63%

25%

12%

•2

Relationship to anterior border of ramus

Pell and Gregory class 1 impaction

Pell and Gregory class 2 impaction

Pell and Gregory class 3 impaction

•3

Relation to occlusal plane of 2nd molar

Pell and Gregory class A impaction

Pell and Gregory class B impaction

Pell and Gregory class C impaction

5

Surgical Procedure 1. Gain adequate access through a properly designed soft tissue flap 2. Remove bone as little as possible

3. Divide tooth into sections and delivered with elevators 4. Debridement, irrigation and closure of wound

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 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 elevator.

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 elevated in similar fashion

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 rootD of the crown is sectioned off. B. The posterior aspect of the crown is elevated first with a Cryer. C. 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 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-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 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. 3) Remove remnants of dental follicle with mosquitos and hemostats. 4) Final irrigation with saline and thorough inspection 5) Check for adequate hemostasis 6) Closure of the wound

6

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%)