Routine & Surgical Extraction of Erupted and Impacted Teeth

Pamela J Hughes, DDS

Assistant Professor Advanced Training Program Director
Division of Oral and Maxillofacial Surgery University of Minnesota

Lecture topics
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Factors that Increase Risk and Difficulty

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Erupted teeth

Factors of difficulty Flap design Technique Classification Indications for removal Factors of difficulty Technique

Impacted teeth

Root Form: long, thin roots, dilacerations, divergent roots, hypercementosis Reduced PDL Endontically treated teeth Evidence of bruxism D Dense, sclerotic l ti b bone, exostoses t Anatomic factors Inferior Alveolar Canal Other teeth/tooth position Maxillary sinus Acute infection Patient behavioral factors Patient medical history

Principles of Surgery
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Surgical diagnosis Aseptic technique Incision and flap design Ti Tissue handling h dli Hemostasis Decontamination/debridement Suturing

Wedge can be used to expand, split, and displace portions of substance that receives it.

Excerpted from Contemporary Oral & Maxillofacial Surgery, Third Edition, 1998

periosteal elevator, used to loosen gingival attachment from tooth.

Handle of small straight elevator, turned so that occlusal side of elevator blade is turned toward tooth.

Excerpted from Contemporary Oral & Maxillofacial Surgery, Third Edition, 1998

Common mistake

Will cause mobility of f th the adjacent dj tt tooth th Only effective if the tooth is mobile and there is no terminal tooth

Beaks of forceps act as wedge to p alveolar expand bone and displace tooth in occlusal direction

Handles of forceps Strong buccal are squeezed, causing forces are beaks to be the used to forced into expand bifurcation and exerts socket. tractional forces on tooth.

Strong lingual forces are used to luxate tooth further.

Tooth is delivered in bucco-occlusal direction with buccal and tractional forces.

The forcep is seated as far apically as possble.

Luxation is begun with labial force.

Slight lingual force is used.

The tooth is removed to the labialincisional.

Excerpted from Contemporary Oral & Maxillofacial Surgery, Third Edition, 1998

Surgical Technique
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Flap Design
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Flap Design

Incisions

Access for visualization Access for bone removal A Access for f sectioning Periodontal health/avoidance of traumatizing tissue

sharp blade of proper size and shape

- #15 blade or #12 blade appropriate for oral incisions

firm, continuous stroke avoid id vital it l structures t t Broad based: apical portion of flap should be wider than the occlusal portion Adequate size: two teeth anterior or posterior, one tooth on the contralateral side To release or not to release?

Flap

Surgical Technique
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Sectioning of tooth

Divide and conquer Avoid excessive forces to bone and adjacent teeth Reduce bulk of crown Split roots Purchase points

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Purchase Point

Sutures and Wound Closures

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Resorbable Sutures

gut and chromic gut polyglycolic acid glycolic-lactic acid (polyglactin) Silk nylon polyester polypropylene

Non-Resorbable Sutures

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Impaired Wound Healing

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Foreign material Necrotic tissue Ischemia Wound tension Patient factors

Impacted Third Molars

Management of Impacted Third Molars

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Pathology
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Failure of eruption of third molars can result in:

inflammation/infection of contiguous soft tissues damage to adjacent functioning teeth Hygiene interference f causing caries or periodontal d l disease destruction of healthy bone development of neoplastic or cystic lesion

Pericoronitis Destruction of osseous tissues Damage to adjacent second molars Involvement with cysts and tumors Crowding of dentition

Most deleterious sequelae are asymptomatic

Pericoronitis
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Pericoronitis

Most common indication for removal of mandibular third molars Stage I: Inflammation limited to peri-coronal area Stage II: Inflammation extends to contiguous mucoperiosteum

Trismus very likely

Stage III: Inflammation extends into adjacent spaces or fascial plane and stimulates a systemic response

Typically will have major facial/deep space infection

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Treatment for Stage I or II

Treatment should be performed on an urgent basis
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Treatment for Stage III

The patient should be treated to manage the response

Removal of the offending g third molar Removal of the traumatizing tooth i.e. maxillary third molar Excision of operculum

acute local regional systemic

Not definitive treatment

Irrigation and antibiotics until tooth can be removed

May need to be admitted to hospital for intravenous antibiotics and surgery Maxillary third molars rarely progress to stage III

Damage to Adjacent Structures

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Cysts and Tumors

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The crown or follicle of an impacted tooth can cause resorption of the bone around the second molar without pain, pressure or other symptoms y p The osseous defect can remain as a periodontal pocket after removal of the third molar

The follicle of an impacted tooth can form cyst or rarely, a tumor, without developing symptoms Th pathology The h l can b be d devastating i before the patient has symptoms

Especially if removed later in life

- After age 25

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Other Conditions
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Management
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The impacted third molar can be the origin of referred pain, become carious or cause periodontitis Th These conditions di i may be b i indications di i for f removal, restoration or observation

Observation Removal

Observation
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To remove or not to remove?

Observation is indicated for a completely impacted third molar that;

is completely covered in bone and fully formed has no existing pathology has no pending pathology risk outweighs the benefit of removal

Annual or biannual recall evaluations

Removal
Indications

Removal
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Presence of pathologic conditions Pending pathologic conditions that make removal prudent Difficult hygiene yg Inadequate room/access to perform adequate restoration Patient will not have room for eruption
Existing crowding while thirds are developing Partially formed thirds are developing in the ramus

Treatment planning
Individuals older than 25 may have:

more pronounced inflammatory response greater risk of nerve injury g j y Increase risk to adjacent teeth/residual periodontal defects on second molars More difficult or prolonged surgical procedure and recovery

Removal of third molars most often fall in the category of

Preventive Dentistry

In general, as the individual ages they are more apt to have to complications either intraoperatively, or postoperatively

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Most Sequelae are Asymptomatic

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Third molar surgery

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Why wait until an impacted tooth develops problems? The extraction is now a g greater p problem with increased risk of surgical and pathologic morbidity Most likely, at this point more damage has been done

Factors to consider

Diagnosis Difficulty in removal Risks k of f procedure d Patient age Systemic disease

Roots Incompletely Formed

Typically in younger individuals P Procedure d less l difficult diffi l Surgical removal less likely to cause IAN damage

Lack of Root Development

Some root development is desired Very i V immature teeth h may be difficult to remove May elect to wait and reassess in about a year

Conical Root/Fused
Typically easier to remove than multi rooted teeth or those that have dilacerated roots May be less likely to cause IAN damage

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Divergent/Dilacerated
Difficult to remove Will require sectioning High risk to the IAN

Large Follicle

Indicates possible pathology present or impending

Video examples

Factors that Increase Risk and Difficulty

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Distoangular, vertical impactions Long, thin roots Dialaceration, divergent roots Reduced PDL (older patients) Dense, sclerotic bone (older patients) Proximity to

IAC 2nd Molar Maxillary sinus

Acute infection

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