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Exodontia Practice

Oral and maxillofacial surgery is a medical specialty

concerned with diagnosis and treatment of diseases of

jaws, teeth, mouth and face.

Exodontia can be defined as painless removal

of a tooth or tooth root from its socket with

minimal injury to the bone and surrounding

structure so that postoperative healing is

uneventful.

Dentistry is one of the fastest growing science of

medicine. With the introduction of many newer

instruments and anesthesia, extraction is a routinely

carried out procedure in dental office. Tooth extraction

remains an essential component of both the art and

science of dentistry despite the enormous progress in

the prevention of dental disease made during the last

three decades of the twentieth century. The effect of

the fluoride revolution and increasing public awareness

of oral health means that people in the western world

are retaining their teeth longer and fewer teeth are being

extracted, particularly in adolescents and young adults.

This trend towards the retention of the natural dentition

into later life is resulting in more extractions being needed

in older patients, who have more complicated medical

history and bone is more brittle than the young. Thus,

the difficulty and complexity of extraction procedures

is increasing with the average age of our patients.

Dental surgeons, especially those in practice, are

required to face these challenges in medico-legal climate

in which litigation exists when complications arise for

whatever reason. It is therefore more important that

the principles and techniques of removing teeth are

understood by all those in the dental profession who

would pick up a pair of extraction forceps.

Having a tooth extracted may also pose a daunting

challenge to patients whose imagination of what is

to happen are often governed by misbeliefs, others

experience and existing social taboos could get the better

of them. Calm, reassuring approach by the dental

surgeon whilst explaining the procedure goes a long

way towards allowing such fears and building their

confidence. The successful outcome of tooth extraction

depends not only on the surgeon's practical skills, but

also on his or her ability to emphasize with patients and

the way they perceive the problem.

The extraction of tooth is a surgical procedure

involving bony and soft tissue of oral cavity, access to

which is restricted by the lips and cheeks and further

complicated by the movement of tongue and mandible.

An additional hazard is that this cavity communicates

with pharynx which in turn opens into larynx and

oesophagus. Further this field of operation is flooded

by saliva and inhabited by the largest number and variety

of microorganisms. Finally it lies close to the vital centres.

It is therefore essential that this aspect of oral surgery

be properly understood judiciously performed and be

based on sound surgical principles as it applies to any

other part of human body. No operation performed

by the dentist is fraught with such great danger to the

patient as those of oral surgery, a large part of which

is the extraction of teeth.

While the great majority of extractions can be done

in the dental office, some patients require hospitalization

for this surgery because of predisposing systemic

conditions which increases the surgical risks.

Dental extraction has always been considered to be

an unpleasant procedure for the patients due to pain

F i g u r e 1.1: Tooth extraction: Traditional method

Introduction

phobia. With the advent of local anesthetic drugs

techniques and standardization of surgical procedure,

extraction is no longer considered to be painful

experience to the patients. Gone are the days when

extraction was supposed to be one of the crude procedure

(Figure 1.1).

The control of the patient is fear and anxiety has

long been a challenge to the dental practitioner. Today's

extraction procedure is painless and anxiety-free provided

that one employs good principles of patient management

and pharmacokinetics (Figure 1.2).

In the initial few chapters of this book armamentarium

required for tooth extraction, principles of exodontia,

various methods of extraction are described. Then a brief

idea about anatomical considerations and anesthesia

is described. Next few chapters describe special techni-

ques like pediatric extractions serial extractions and

F i g u r e 1.2: Extraction of tooth in dental office

extractions for medically compromised patients. Lastly,

the complications are described in details with their

management.

Armamentarium

Exodontia Practice

The purpose of this chapter is to introduce the instru-

ments that are required to perform routine oral surgical

procedures. These instruments are used for a wide variety

of purposes, including both soft tissue and hard tissue

procedures. This chapter deals primarily with a

description of the instruments; subsequent chapters

discuss the actual use of the instruments in the variety

of ways for which they are intended.

INSTRUMENTS USED TO EXTRACT TOOTH

(DENTAL FORCEPS)

Dental forceps were used in Greek times and were first

illustrated by Albucasis. He described a short handled pairs

which were first applied to the crown of the tooth to shake

it up and then the long handled forceps were used to

complete the extraction. Cyrus Fay in 1826 was first to

describe forceps design to fit the neck of the tooth and

these were said not to apply any force to the crown. The

credit for anatomically designed forceps is frequently given

to Sir John Toms (1841), and there is no doubt his

instruments were superior to those of Fay and it is from

his design modern forceps have developed (Figure 2.1).

The dental forcep is the most widely used instrument

in the extraction of teeth. The use of this instrument makes

it possible for the operator to grasp the root portion of

a tooth and to luxate the latter from its socket by exerting

pressure upon it. The forceps have blades and handles

united by a hinge joint. The larger the ratio between

the length of the handles and the length of the blades

the greater is the force which can be exerted upon the

root. The length of the handle must be such that the

forceps fits the operator hand. Greater the distance

between the hinge joint and operator's hand, the greater

is the movement of the forceps within the hand. Thus,

greater energy may be dissipated to the tooth.

The blades of the forceps are forced into the

periodontal ligaments to separate it from the tooth. Thus,

the blades should be always sharp. The blades of stainless

steel forceps can be sharpened with a sandpaper disk

applied to the outside of the tips.

Ideally the whole of the inner surface of the blade

should fit the root surface. In practice the size and shape

of roots vary so greatly that it is not possible to achieve

this aim and root is grasped by the edges of the blades

F i g u r e 2 . 1 : Dental forceps: Various designs in literature

Armamentarium

F i g u r e s 2.2A a n d B: Effective use of forceps: (A) Maxillary, (B) Mandibular

establishing a two point contact. If there is a single point

contact between the tooth and blade, the tooth will

probably crushes when it is gripped. It is better to use

forceps with blades which are slightly narrow than a

forceps with blades which are too broad.

The effective use of various instrument depends on

understanding the design of the instruments and their

principles. Forceps permits controlled force application

on the tooth that allows dilatation of alveolar socket,

luxation of tooth and its subsequent removal.

The forceps can be classified as American pattern

of forceps and English pattern of forceps. In the Indian

subcontinent the English pattern is more popular.

The forceps used for the maxillary and mandibular

teeth differ in their design.

In mandibular forceps, the beaks are at right angle

to the long axis of the handle while in maxillary forceps

beaks are in the same line, i.e. parallel to the long axis

of the handle.

The handles of forceps are held differently depending

on the position of tooth to be removed. Maxillary forceps

are held with the palm underneath the forceps. So that

the beak is directed in a superior direction. The forceps

used for the removal of mandibular teeth are hold with

palm on top of the forceps so that beak is pointed down

towards the tooth (Figures 2.2A and B ) .

MAXILLARY FORCEPS

Maxillary Anterior Forcep

This forcep has beaks in approximation with each other

and the handle is straight without curvature. Beaks are

symmetrical and are placed in the same line as the

handle. Beaks are shorter than the handle. This forcep

is used for the extraction of maxillary incisors and

canine (Figure 2.3).

Maxillary Premolar Forcep

This forcep is having beaks which are approximating each

other and placed parallel to handle. Handle is having

concavity on one side and convexity on other side (Figure

2.4). This provides better grip and allows the forcep

Exodontia Practice

F i g u r e 2.3: Maxillary anterior forcep

F i g u r e 2.4: Maxillary premolar forcep

to reach inside more posterior in oral cavity. This forcep

is used for removal of maxillary premolars and rarely

upper roots.

Maxillary Molar Forcep

These forceps are paired forceps having beaks which

are asymmetrical and broader as compare to anterior

forceps. The one beak is pointed to engage the bifurcation

of the tooth on buccal side and other engages the

palatal root. Depending upon the position of pointed

beak the forceps can be identified as right and left. The

handle is same as that of maxillary premolar forceps

(Figure 2.5).

F i g u r e 2.5: Maxillary molar forceps (right and left)

F i g u r e 2.6: Maxillary cow horn forceps (right and left)

Maxillary Cow Horn Forcep

These are the paired forceps having design same as that

of maxillary molar forceps except they are having beaks

that appear as the horn of the cow and called as cow

horn forceps. One beak is pointed which goes in buccal

bifurcation other beak is having notch which engages

the palatal root. These are paired forceps used for right

and left side separately (Figure 2.6). They are used for

maxillary molars which are badly carious in nature. The

major disadvantage is that they crush alveolar bone when

used on intact teeth.

Armamentarium

F i g u r e 2.7: Maxillary bayonet forcep Figure 2.8: Maxillary third molar forcep

Maxillary Bayonet Forcep

This forcep is designed for removal of maxillary roots.

Beaks are symmetrical and closely approximate to each

other. The beaks are narrow to fit it to the circumference

of the root (Figure 2.7). Handle is having angulations

so that it can reach as much posteriorly as possible.

Maxillary Third Molar Forcep

This forcep is specially designed for removal of maxillary

third molar. The forceps have beaks which engage the

crown of third molar and is having long handle to reach

the posterior most region in maxilla (Figure 2.8).

MANDIBULAR FORCEPS

Mandibular Anterior Forcep

This forcep is having beaks similar to maxillary incisor

forcep which approximate with each other. Beaks are

at right angle to the handles. This forcep is used for

extraction of mandibular incisor and canine (Figure 2.9).

F i g u r e 2.9: Mandibular anterior forcep

Mandibular Premolar Forcep

This forcep has same design as that of mandibular

anterior forcep except the space in between two beaks

is more compared to incisor forcep to accommodate the

crowns of premolar which are having greater diameter

(Figure 2.10).

Mandibular Molar Forcep

These are unpaired forceps having beaks broader and

stout. The beaks are symmetrically pointed so that sharp

pointed tips can engage the bifurcation both at buccal

and lingual surfaces. The beaks are at right angles to

the handle. These forceps are used for the extraction

of mandibular molars (Figure 2.11).

Exodontia Practice

F i g u r e 2.10: Mandibular premolar forceps

F i g u r e 2 . 1 1 : Mandibular molar forceps

Mandibular Cow Horn Forceps

The design of this forcep is same as that of mandibular

molar forcep except the beaks are pointed and conical

in shape. These forceps are used for the extraction of

mandibular molars.

Universal Forcep

This forcep is having the beaks similar to the mandibular

molar forcep except that they are facing forward towards

each other at right angle to the handle. This is a specially

designed forcep mainly used for extraction of third molars

(Figure 2.12).

INSTRUMENTS USED FOR TOOTH LUXATION

(ELEVATORS)

Elevators are the instruments used to elevate the tooth

or root from the alveolar socket. Elevation of tooth before

application of forcep makes a difficult extraction easy.

The elevators are designed on two basic patterns. In

general all the elevators have handle, shank and a blade.

In the straight pattern all these three components are

Figure 2.12: Universal forceps

placed in one plane. In the other design the blade and

shank are in one plane and handle is placed at right

angle to them. There are so many elevators available

commercially but a few are widely used because of their

efficiency and convenience.

The elevators deliver the force based on various

mechanical principles to drive the tooth or root along

its path of delivery or line of withdrawal. It represents

the direction along which the tooth move out of the

alveolar socket with economy of force and economy of

instrumentation. Hence, successful use of an elevator

depends on the determination of the convenient path

of its delivery. Principles of use of elevators are described

in the principles of exodontia chapter.

TYPES

The elevators which are widely used in the dental practice

are (Figure 2.13):

1. Straight elevator

2. Apexo elevator (Right and left)

3. Cross bar elevator

F i g u r e 2.13: Different types of elevators. (A,B) Straight

elevator, (C) Apexo elevator, (D) Cross bar elevator

Armamentarium

Straight Elevator

The blade, handle and shaft are in one line. The blade

is pointed or broad and bluff as in coupland elevator.

The blade is having concave surface on one side, so

that it can be used in same fashion as shoehorn.

The elevator is used to elevate the mandibular and

maxillary molars to luxate the teeth in case of multiple

extraction. It is usually avoided in anterior teeth (Figure

2.14).

F i g u r e 2.14: Straight elevators. A—Straight pattern, B—

Coupland pattern

Apexo Elevator

These elevators are paired having handle, shank and

blade which are in same plane. The blade is having

angulations so that it reaches the root apices. This elevator

works on the principle of wedge (Figure 2.15).

Cross Bar Elevator

These are paired elevators having blade and shank at

right angle and shank and handle at right angle to each

other. This is indicated for the removal of the mandibular

roots where the other root has already been removed.

In such cases the tip of the elevator is introduced to the

depth of the empty socket with the concave surface of

F i g u r e 2.15: Apexo elevator (Paired elevators)

the elevator facing the root to remove. By applying wheel

and axle principle with rotatory movement, the inter-

radicular septum and the root are elevated out of alveolar

socket. The same elevator is used for elevating the distal

root on the right side and the mesial root on the left

side (Figure 2.16).

F i g u r e 2.16: Cross bar elevators (Paired elevators)

Winter Cryer Elevator

This elevator is same as that of cross bar except handle

is parallel to the working end. This is a set of elevators

used for removal of root apices (Figure 2.17).

Axio Elevator

These are specially designed elevators which are used

for elevation of mandibular third molars (Figure 2.18).

Exodontia Practice

F i g u r e 2.17: Winter crayer elevator (Paired elevators)

F i g u r e 2.18: Axio elevator (Paired elevators)

INSTRUMENTS TO INCISE TISSUE

Most surgical procedures begin with an incision. The

instrument for making an incision is the scalpel, which

is composed of a handle and sharp blade. The most com-

monly used handle is the No. 3 handle, but occasionally

the longer, more slender No. 7 handle is used. The tip

of the scalpel handle is prepared to receive a variety of

differently shaped scalpel blades that can be inserted onto

a slotted receiver (Figure 2.19).

The most commonly used scalpel blade for intraoral

surgery is the No. 15 blade. It is relatively small and can

F i g u r e 2.19: Scalpels for making incision

(BP handle No. 3 and No.

be used to make incisions around teeth and through

mucoperiosteum. It is similar in shape to the large

No. 10 blade, which is used for skin incisions. Other

commonly used blades for intraoral surgery are the'

No. 11 and the No. 12 blades. The No. 11 blade is

sharp pointed blade that is used for making stab incisions,

such as for incising an abscess. The hooked No. 12 blade

is useful for mucogingival surgery procedures where

incisions must be made on the posterior aspect of teeth.

The bard parker handle is of different number, i.e.

No. 3 handle is used to receive blades No. 15, No. 11,

No. 12, and No. 4 handle is used to receive No. 10

blade (Figure 2.20).

F i g u r e 2.20: Different types of blades. BP handle blade

The scalpel blade is carefully loaded onto the handle

with a needle holder to avoid lacerating the operator's

fingers. The blade is held on the superior edge where

it is reinforced with a small rib, and the handle is held

so that the male portion of the fitting is pointing upward.

The blade is then slid onto the handle until it clicks into

position. The knife is unloaded in a similar fashion. The

needle holder grasps the most proximal end of the blade

Armamentarium

F i g u r e 2 . 2 1 : Loading and unloading of scalpel blades

and lifts it to disengage it from the male fitting. It is then

slid off the knife handle in the opposite direction. The

used blade is discarded into a proper container (Figure

2.21).

When using the scalpel to make an incision, the

surgeon holds it in the pen grasp to allow maximal con-

trol of the blade as the incision is made. Mobile tissue

should be held firmly to stabilize it so that as the incision

is made, the blade will incise, not displace, the mucosa.

Whole length of the blade must be drawn for incising

tissue. If only one end is used cutting is inefficient and

uncontrolled. When a mucoperiosteal incision is made,

the knife should be pressed down firmly so that the

incision penetrates the mucosa and periosteum with the

same stroke. Other principles of mucoperiosteal incision

and flap design are described in subsequent chapters.

Scalpel blades are designed for single patient usage.

They are dulled very easily when they come into contact

with hard tissue such as bone and teeth. If several inci-

sions through mucoperiosteum to bone are required,

it may be necessary to use a second blade during a

single operation. It is important to remember that dull

blades do not make clean, sharp incisions in soft tissue

and therefore should never be used.

INSTRUMENTS FOR ELEVATING

MUCOPERIOSTEUM

After an incision through mucoperiosteum has been

made, the mucosa and periosteum should be reflected

from the underlying bone in a single layer with a

periosteal elevator (Figure 2.22). The instrument that is

most commonly used is the Molt periosteal elevator. This

instrument has a sharp, pointed end and a broader flat

end. The pointed end is used to confirm the depth of

incision and reflect dental papillae form between teeth,

The broad end is used for elevating the tissue from the

bone.

F i g u r e 2.22: Periosteal elevators

The periosteal elevator can be used to reflect soft

tissue by three methods. First, the pointed end can be

used in a prying motion to elevate soft tissue. This is

most commonly used when elevating a dental papilla

form between teeth. Second is the push stroke in which

Exodontia Practice

the broad end of the instrument is slid underneath the

flap, separating the periosteum from the underlying bone.

This is the most efficient stroke and results in the cleanest

reflection of the periosteum. The third method is a pull

stroke or scrape stroke. This is occasionally useful in some

areas but tends to tear the periosteum unless it is done

carefully.

The periosteal elevator can also be used as a retractor.

Once the periosteum has been elevated, the broad

blade of the periosteal elevator is pressed against the

bone with the mucoperiosteal flap elevated into its

reflected position.

When teeth are to be extracted, the soft tissue attach-

ment around the tooth needs to be released from the

tooth. The instrument most commonly used for this is

the moons probe. This instrument is relatively small and

delicate and can be used to loosen the soft tissue via

the gingival sulcus (Figure 2.23).

F i g u r e 2.23: Moon's probe

INSTRUMENTS FOR CONTROLLING

HEMORRHAGE

When incisions are made through tissue, small arteries

and veins are incised, causing bleeding that may require

more than simple pressure to control. When this is neces-

sary, an instrument called a hemostat is used. Hemostats

come in a variety of shapes, may be relatively small and

delicate or larger, and are either straight or curved. The

hemostat most commonly used in oral surgery is a curved

hemostat (Figure 2.24).

A g o o d hemostat must have tips that opposes

accurately with each other. Blades must be closed firmly

on first ratchet and light should not pass through the

blades when handle is fully closed. Hemostat gets spoiled

if hard and bulky material is caught with it. Method of

application of hemostat includes visualization of bleeding

point, application of hemostat at right angle direction

to direction of force of blood. Catch the tip with

Figure 2.24: Hemostats (curved and straight artery forceps)

minimum amount of surrounding tissue as bulky ligation

may slip. In addition to its use as an instrument for

controlling bleeding, the hemostat is especially useful

in oral surgery to remove granulation tissue from tooth

sockets as well as to pick up small root tips from tooth

sockets.

INSTRUMENTS TO GRASP TISSUE

In performing soft tissue surgery, it is frequently neces-

sary to stabilize soft tissue flaps in order to pass a suture

needle. Tissue forceps most commonly used for this

purpose is the Adson forceps. These are delicate forceps

with small teeth that can be used to gently hold tissue

and thereby stabilize it. Adson forceps are also available

without teeth (Figure 2.25A).

F i g u r e 2.25A: Adson forcep

In some types of surgery, especially when removing

larger amount of fibrous tissue as in an epulis fissuratum

forceps with locking handles and teeth that will grip the

tissue firmly are necessary. In this situation Ellis forceps

are used. The locking handle allows the forceps to be

placed in the proper position and then to be held by

an assistant to provide the necessary tension for proper

dissection of the tissue. The Ellis forceps should never

be used on tissue that is to be left in the mouth because

Armamentarium

they cause a relatively large amount of crushing injury.

The Ellis forceps are most commonly used instrument

having straight blades and tip slightly curved or angulated

for better grip. Tip is provided with interlocking teeth.

They are three to four in number and interlock with each

other (Figure 2.25B).

F i g u r e 2.25B: Ellis forcep

INSTRUMENTS FOR REMOVING BONE

RONGEUR FORCEPS

The instrument most commonly used for removing bone

is the rongeur forceps. These instruments have sharp

blades that are squeezed together by the handles cutting

or pinching though the bone. Rongeur forceps have a

spring between the handle so that when hand pressure

is released the instrument will open. This allows the

surgeon to make repeated cuts of bone without making

special efforts to open the instrument. There are two

major designs for rongeur forceps, a side-cutting forceps,

end-cutting forceps (Figure 2.26).

The end-cutting forceps are more practical for most

dentoalveolar surgical procedures that require bone

removal. These forceps can be inserted into sockets for

F i g u r e 2.26: Rongeur forcep

removal of inter-radicular bone. They can also be used

to remove sharp edges of bone. Rongeurs can be used

to remove large amounts of bone efficiently and quickly.

Because rongeurs are relatively delicate instrument, the

surgeon should not use the forceps to remove large

amounts of bone in single bites. Rather, smaller amounts

of bone should be removed in each of multiple bites.

Likewise, the rongeurs should not be used to remove

teeth, since this practice will quickly dull and destroy the

instrument. Rongeurs are usually quite expensive so care

should be taken to keep them in working order.

CHISEL AND MALLET

One of the obvious methods of bone removal is to use

a surgical chisel and mallet. Bone is usually removed

with a mono bevel chisel, and teeth are usually sectioned

with a bi-bevel chisel. The success of chisel use depends

on the sharpness of the instrument. Therefore, it is

necessary to sharpen the chisel before it is sterilized for

the next patient. Some chisels have carbide tips and can

be used more than once between sharpening. A mallet

with a nylon facing imparts less shock to the patient,

is less noisy, and is therefore recommended (Figure 2.27).

F i g u r e 2.27: Chisel and and osteotome

BONE FILE

Final smoothing of the bone before suturing the

mucoperiosteal flap back into position is usually

performed with a small bone file. The bone file is usually

a double ended-instrument with a small and large end

(Figure 2.28). It cannot be used efficiently for removal

of large amounts of bone, and it is used only for final

smoothing. The teeth of the bone file are arranged in

such a fashion that they remove bone only on a pull

stroke. Pushing the bone file results only in burnishing

and crushing the bone and should be avoided (Figure

2.28).

Exodontia Practice

Figure 2.28: Bone file

BUR AND HANDPIECE

A fine method for removing bone is with a bur and

hand-piece. This is the technique that most surgeons

use when removing bone. Relatively high-speed

handpieces with sharp carbide burs remove cortical bone

efficiently. Burs such as fissure bur, round bur are

commonly used. Occasionally, large amounts of bone

need to be removed such as in torus reduction. In these

situations, a large bone bur that resembles an acrylic

bur is used (i.e. carbide trimmer) (Figure 2.29).

F i g u r e 2.29: Different types of burs

The handpiece that is used must be completely

sterilizable in a steam autoclave. When a handpiece is

purchased, the manufacturer's specifications must be

checked carefully to ensure that sterilization is possible.

It should have relatively high speed and torque. This

allows the bone removal to be done rapidly and allows

efficient sectioning of teeth. The handpiece must not

exhaust air into the operative field as dental drills do.

Most high-speed turbine drills used for routine restorative

dentistry cannot be used. The reason is that the air

exhausted into the wound may be forced into deeper

tissue planes and produce tissue emphysema, a

potentially dangerous phenomenon.

INSTRUMENTS TO REMOVE SOFT TISSUE

FROM BONY DEFECTS

The curette, sometimes called the periapical curette, is

an angled, double-ended instrument used to remove soft

tissue from bony defects (Figure 2.30). The principle

use is to remove granulomas or small cysts from

periapical lesions, but it is also used to remove small

amounts of granulation tissue debris from the tooth

socket. The periapical curette is distinctly different from

the periodontal curette in design and function.

F i g u r e 2.30: Bone curette

INSTRUMENTS FOR SUTURING MUCOSA

Once a surgical procedure has been completed, the

mucoperiosteal flap is returned to its original position

and held in place by sutures. The needle holder is the

instrument used to place the sutures.

NEEDLE HOLDER

The needle holder is an instrument with a locking handle

and a short, stout beak. For intraoral placement of

sutures, a 6-inch (15 cm) needle holder is usually

recommended. The beak of the needle holder is shorter

and stronger than the beak of the hemostat. The face

of the beak of the needle holder is crosshatched to permit

a positive grasp of the suture needle and suture (Figure

2.31). The hemostat has parallel grooves on the face

of the beaks, thereby decreasing the control over needle

and suture. Therefore, the hemostat should not be used

for suturing.

Figure 2 . 3 1 : Needle holder

Armamentarium

In order to properly control the locking handles and

to direct the relatively long needle holder, the surgeon

must hold the instrument in the proper fashion.

Thumb and ring finger are inserted through the rings.

The index finger is held along the length of the needle

holder to steady and direct it. The second finger aids

in controlling the locking mechanism. The index finger

should not be put through the finger ring, because this

will result in dramatic decrease in control.

SUTURE CUTTING SCISSOR

Usually sutures are cut at the end of eighth day. Scissor

used for this purpose is specially designed so that it can

reach to the most posterior teeth (Figure 2.32).

F i g u r e 2.32: Suture cutting scissor

NEEDLE

The needle is held approximately two thirds of the

distance between the tip and the end of the needle. This

allows enough of the needle to be exposed to pass

through the tissue, while allowing the needle holder to

grasp the needle in its strong portion to prevent bending

of the needle (Figures 2.33A to C ) . The needle used in

closing mucosal incisions is usually a small half circle

or three-eighth circle suture needle. It is curved to allow

the needle to pass through a limited space where a

straight needle can not reach. Suture needles come in

a large variety of shapes from very small to very large.

The tips of suture needles are either tapered, such as

a sewing needle, or have triangular tips that allow them

to be cutting needles. A cutting needle will pass through

mucoperiosteum more easily than the tapered needle.

The cutting portion of the needle extends about one-

third the length of the needle, and the remaining portion

of the needle is round. The suture can be threaded

through the eye of the needle or can be purchased

already swaged. If the dentist chooses to load his own

1/4 ( ircle 3/81

ircle

1/2 (

J _

ircle , 5/8 c

J ^

Straight

Micropoint spatula £

C. A n a t o m y of a s u r g i c a l needle

F i g u r e s 2.33A to C: Shape, size and anatomy of sutural

needles

E x o d o n t i a P r a c t i c e

T a p e r c u t ^ ^ Z ^

F i g u r e 2.34A: Different shapes at needle

F i g u r e 2.34B: Tissue disrup- Figure 2.34C: Tissue disrup-

tion is more by double surface t i o n m i n i m i z e d by s i n g l e
stand with eyed needle s u t u r e s t r a n d s w a g e d to

needle

needles for the sake of economy, he must use needles

that have eyes, as has a typical sewing needle. Needles

that have eyes are larger at the tip and may cause slightly

increased tissue injury when compared to the swaged-

on needles (Figures 2.34A to C ) .

SUTURE MATERIAL

Many types of suture materials are available for use.

The materials are classified as resorbable and non-

resorbable, natural and synthetic, monofilament and

polyfilament.

The size of suture is designated by a series of zeros.

The size most commonly used in the suturing of oral

mucosa is 3-0 (000). A larger size suture would be

2-0, or 1-0. Smaller sizes would be 4-0, 5-0, and 6-0

sutures. Sutures of very fine size such as 6-0 are usually

used in conspicuous places on the skin such as the face,

since smaller sutures, usually cause less scarring. Sutures

of size 3-0 are large enough to prevent tearing through

mucosa, are strong enough to withstand the tension

placed on them intraorally, and are strong enough for

easy knot-tying with a needle holder.

Sutures may be resorbable or non-resorbable. Non-

resorbable suture materials include types as silk, nylon

and stainless steel. The most commonly used non-

resorbable suture in the oral cavity is silk. Nylon and

stainless steel are rarely used in the mouth. Resorbable

sutures are primarily made of gut. While the term catgut

is often used to designate this type of suture, gut actually

is derived from the serosal surface of sheep intestines.

Plain catgut resorbs relatively quickly in the oral cavity,

rarely lasting longer than 5 days. Gut that has been

treated by tanning solutions (chromic acid) and is

therefore called chromic gut lasts longer, up to 10 to 12

days. Several synthetic resorbable sutures are also

available. These are materials that are long chains of

polymers braided into suture material. Examples are

polyglycolic acid and polylactic acid. These materials are

slowly resorbed, taking up to 4 weeks before they are

resorbed. Such long-lasting resorbable sutures are rarely

indicated in the oral cavity.

Finally, sutures are classified based on whether or not

they are monofilament or polyfilament. Monofilament

sutures are sutures such as chromic gut. If the dentist

chooses to use the disposable needles, then the suture

will be swaged onto the needle.

Armamentarium

INSTRUMENT TO HOLD THE MOUTH OPEN

When performing extractions or other types of surgery

that requires patients to hold their mouths open widely

for prolonged period of time, dentists commonly use

instruments to assist patients. The bite block is just what

the name implies. It is a rubber block upon which the

patient can rest the teeth. The patient opens his or her

mouth to a comfortably wide position and the rubber

bite block is inserted, which holds the mouth in the

desired position. Should the surgeon need the mouth

to open wider, the patient must open wide and the bite

block must be positioned more to the posterior of the

mouth.

The side action mouth gag can be used by the

operator to open the mouth wider if necessary. This

mouth gag has a ratchet-type action opening the mouth

wider as the handle is closed. This type of mouth gag

should be used with caution as great pressure can be

applied to the teeth and temporomandibular joint and

injury may occur with injudicious use. This type of mouth

gag is useful in patients who are deeply sedated.

F i g u r e 2.35: Suction tip

INSTRUMENT TO HOLD TOWELS AND DRAPES

IN POSITION

When drapes are placed around a patient, they must

be held together with a towel clip. This instrument has

a locking handle and finger and thumb rings. The action

ends of the towel clip are sharp, curved points that

penetrate the towels and drapes (Figure 2.36). When

this instrument is used, the operator must take extreme

caution not to pinch the patient's underlying skin.

INSTRUMENT FOR PROVIDING SUCTION

In order to provide adequate visualization, blood, saliva,

and irrigating solutions must be suctioned from the

operative site. The surgical suction is one that has a

smaller orifice than the type used in general dentistry,

so that the tooth sockets can be suctioned in case a

root tip is fractured and adequate visualization is

necessary. Many of these suctions are designed with

several orifices, so that the soft tissue will not become

aspirated into the suction hole and cause tissue injury

(Figure 2.35).

The suction has a hole in the handle portion that

can be covered as the need dictates. When hard tissue

is being cut under copious irrigation, the hole is covered

so that the solution is removed rapidly. When soft tissue

is being suctioned, the hole is uncovered to prevent tissue

injury.

Figure 2.36: Towel clips

INSTRUMENTS FOR IRRIGATION

When a handpiece and bur are used to remove bone,

it is essential that the area be irrigated with a steady stream

of irrigating solution, usually sterile saline. The irrigation

cools the bur and prevents bone damaging heat

build-up. The irrigation also increases the efficiency of

the bur by washing away bone chips from the flutes of

the bur and by providing a certain amount of lubrication.

Additionally, once a surgical procedure is completed and

before the mucoperiosteal flap is sutured back into

Exodontia Practice

position, the surgical field should be irrigated thoroughly

with saline. There are two major systems for accomp-

lishing this. The bulb syringe can be used effectively and

can be refilled easily with one hand. However, the

disadvantage is that it is difficult to sterilize. More

commonly, a large plastic syringe with a blunt 18-gauge

needle is used for irrigation purposes. Although the

syringe is disposable, it can be sterilized multiple times

before it must be discarded. The irrigation needle should

be blunt and smooth so that it does not damage soft

tissue, and it should be angled for more efficient direction

of the irrigating stream.

Anatomical

Considerations

Exodontia Practice

Differential diagnosis of the source, or the course, of

pathology in the facial area may, in many instances,

depends on depth understanding of the structure and

relations of the alveolar processes. The extraction of teeth,

surgical exposure of root tips, surgical access to the

maxillary sinus, surgical preparation for oral prosthesis,

etc. must obviously proceed from a familiarity with the

detail and variation found in alveolar structures and their

relations. Planning local anesthesia where the anesthetic

fluid must penetrate the cortical plates to reach the nerves

within the medullary bone clearly depends on knowing

the structural minutiae details of these parts.

ALVEOLAR PROCESS OF THE MAXILLA

The alveolar process of the maxilla is in relation with

the floor of the nasal cavity and the floor of the maxillary

sinus. Its relation to these cavities is determined by the

functional structure of the maxilla. The canine pillar of

the maxilla, arising from the socket of the canine and

extending upward along the lateral border of the piriform

aperture into the frontal process of the maxilla, is the

most constant bony structure in the base of the alveolar

process (Figure 3.1). The canine pillar is situated lateral

to the entrance into the nasal cavity. Being a functional

reinforcement of the bone, it determines the medial and

anterior expansion of the maxillary sinus, which replaces

nonfunctional bone. It is, therefore, a general rule that

the incisors are below the floor of the nasal cavity, the

premolars and molars are below the floor of the maxillary

sinus, and the canine occupies a neutral position between

the two cavities. This is true even if the nasal cavity is

abnormally wide, because the widening does not

markedly involve the area in front of the incisive canal.

The relations of the apices of the incisors to the nasal

floor are dependent on two factors: height of the face,

especially height of the upper alveolar process, and length

of the incisor roots. Since these two measurements are

not correlated, it is necessary to examine each case

individually and to ascertain the relations between the

incisor sockets and the nasal floor by radiographic

examination. It is a general rule that the root of the lateral

incisor does not show as close a relation to the nasal

floor as does the root of the central incisor, because the

root of the lateral incisor tends to curve toward the outer

rim of the nasal aperture. In addition, it has to be

remembered that the floor of the nasal cavity ascends

slightly laterally, which also increases the distance

between the fundus of the socket of the lateral incisor

and the nasal floor (Figures 3.2A and B ) .

In persons with a relatively short alveolar process and

long roots, the central incisor may actually reach the thin

F i g u r e 3 . 1 : Relation of maxillary teeth with

nasal floor and maxillary sinus

F i g u r e 3.2A: Maxillary teeth

Anatomical Considerations

F i g u r e 3.2B: Thickness of alveolar process

of maxillary teeth

compact bony plate that forms the floor of the nasal

cavity. The apex of the tooth is then separated from the

nasal cavity by only a thin plate of bone. In the other

extreme a rather thick layer of spongy bone may be

interpose between the nasal floor and the socket of the

central incisor.

The apex of the lateral incisor shows, in principle,

the same variations in its relation to the nasal floor, but

it rarely actually comes into contact with the nasal floor

(Figure 3.3) The configuration of the alveolar process

in the incisal region is, dependent on the formation of

the palate. The inner plate of the alveolar process ascends

at a moderate angle if the palate is low and then curves

without a break into the horizontal roof of the oral cavity.

If the palate is high, the inner plate of the alveolar process

is steep in its anterior part, and there is a fairly sharp

angle between the alveolar process and the roof of the

mouth. These variations decisively influence the amount

and the configuration of the spongy bone, the

retroalveolar spongiosa, between the outer and inner

Figure 3.3: Lateral incisor in alveolar bone

plates of the alveolar process and the nasal floor. In a

flat or low palate this space is roughly triangular and

rather wide. In a high palate the retroalveolar spongiosa

is restricted and occupies, a more rectangular area.

It has to be remembered that the difference between

a low and a high palate is expressed not only in

quantitative measurements but also in the changed

configuration of the palate. In the incisor region the

differences in shape and in the molar region the differen-

ces in relative size are more prominent, whereas the

premolar area is a zone of transition. In the anterior

region of the maxilla the inclination of the inner alveolar

plate, or palatine plate, is slight in the low palate and

steep in the high palate. In the molar region of the maxilla

the angle between the oral roof and the inner surface

of the alveolar process is always nearly a right angle,

so that the high palate is characterized mainly by an

increase in the length of the alveolar process.

The sockets of the incisors are eccentrically placed

in the alveolar process, the axis of the root and socket

being more nearly vertical than the axis of the alveolar

process. Thus, the alveolar bone proper on the labial

surface of the root fuses with the external plate of the

alveolar bone, whereas palatally a wedge-shaped area

Exodontia Practice

of spongy bone is found between the alveolar bone

proper and the palatine or inner plate of the alveolar

process. This is why abscesses originating in the incisor

teeth in most instances perforate the labial plate of the

alveolar process and open into the vestibule of the oral

cavity. There is, however, one important exception to

this rule. In a rather high percentage of incisors the apical

part of the root of the lateral incisor is sharply curved

lingually, and its apical foramen is placed in or near the

center of the retroalveolar spongiosa and rather distant

from the outer alveolar plate.

The relations of the incisors to the nasal floor explain

the fact that an abscess arising from the central incisor

may open into the nasal cavity or that a radicular cyst

of an incisor may bulge into the inferior nasal meatus,

even causing an occlusion of the nostril.

The canine is embedded in the lower part of the

canine pillar of the maxilla . If this pillar contains a great

amount of spongy bone, it is continuous with the retro-

alveolar spongiosa in the incisal region (Figure 3.4).

Because of the position of the canine tooth in the canine

pillar, neither nasal cavity nor maxillary sinus has intimate

relations to the socket and the root of the canine. In

extreme cases, however, the maxillary sinus may extend

Figure 3.4: Canine position in the maxillary alveolus

forward so that it approaches the distolingual circum-

ference of the socket of the canine in a rather broad

front. The same is sometimes true for the nasal cavity,

which approaches the mesiolingual surface of the canine.

The relation of the canine to the plates of the alveolar

process is, in principle, the same as that of the incisors,

its root being eccentrically embedded in the alveolar

process. The compactness and the size of the canine

root cause an even greater bulging of the socket toward

the labial surface of the alveolar process, and the alveolar

eminence of the canine tooth is the most prominent

in the upper jaw.

The premolars and molars are, as a rule, situated

below the floor of the maxillary sinus. Whether the

relations between the tooth and the sinus are intimate

or not depends on the development of the inferior

alveolar recess of the maxillary sinus. But even in cases

in which the base of the alveolar process is deeply

excavated by the maxillary sinus, the first premolar is

almost always farther removed from the floor of the

sinus than are the second premolar and the molars,

because in the premolar area the floor of the sinus arises

before continuing into the anterior wall. This, in turn,

is correlated to the widening of the canine pillar at its

base. Thus, with exception of extreme expansion of the

maxillary sinus, the alveolar fundus of the first premolar

is separated from the sinus floor by a layer of spongy

bone.

The transition of the inner plate of the alveolar process

into the horizontal part of the hard palate occurs in the

region of the first premolar in a more pronounced angle,

and differences between a low and a high palate are

here of a more quantitative character than they are in

the anterior region of the maxilla. The relation of the

first premolar socket to the alveolar process as a whole

and to the retroalveolar spongiosa varies according to

the formation of the root. If the first premolar has a single

root, the socket is in close relation to the outer alveolar

plate and is separated from the inner plate by spongy

bone. As in the incisor-canine area, the outer alveolar

plate is, in reality, a fusion between the alveolar bone

Anatomical Considerations

proper and the alveolar plate and often is extremely thin.

In many persons the outer plate may even be defective,

or fenestrated, especially in the apical third of the alveolar

eminence. If the first premolar possesses two roots, the

buccal one is closely applied to the outer alveolar plate,

whereas the socket of the lingual root is placed almost

in the center of the retroalveolar spongiosa.

The relation of the second premolar to the maxillary

sinus is closer than that of the first premolar. Only if the

alveolar recess of the maxillary sinus is absent or poorly

developed does a layer of spongy bone intervenes

between the socket of the second premolar and the floor

of the sinus. In the majority of persons the floor of the

sinus dips down into the immediate neighborhood of

the second premolar. Its socket is then separated from

the sinus only by a thin layer of compact bone. The sinus

may even extend below the level of the alveolar fundus

of the second premolar, and the socket causes a slight

prominence at the floor of the sinus. If the expansion

of the sinus goes further, the thin bony plate between

the sinus and the socket of the second premolar may

F i g u r e 3.5: Premolar in maxillary alveolar bone

showing relation with maxillary sinus

even disappear, so that only soft tissues separate the apex

of the root from the cavity of the sinus; in other words,

the periodontal tissue is then in direct contact with the

mucoperiosteal lining of the sinus. In the region of the

second premolar the inner alveolar plate is more nearly

vertical, except in cases of extremely low palate. The

retroalveolar spongiosa is reduced, and it almost

disappears in the region of the molars (Figure 3.5).

Intimate relations between the tooth and the maxillary

sinus are the rule in the region of the molars. The inter-

vention of a substantial layer of bone between the

alveolar fundus and the maxillary sinus is here an

exception. The sockets of the molars almost always reach

the floor of the sinus, and frequently the apices of some

or all of the molar roots protrude into the sinus, where

small rounded prominences at the floor of the sinus

mark the position of the root apices. Bony defects at

the height of these prominences are not at all rare and

sometimes are of fairly large extent. The divergence of

the molar roots, especially in the first molar, frequently

permits an extension of the sinus downward toward the

furcation of the roots. Often sickle-shaped buttresses of

bone traverse the floor of the sinus in a frontal plane

between the molars whose roots protrude into the sinus.

Sometimes these ridges connect the prominence of one

of the buccal roots with that of the lingual root. Branches

of the alveolar nerves, destined for the palatal roots of

the molars, use these sickle-shaped folds as bridges; they

run in narrow canals that often are open toward the

sinus for a variable length. The bony crests divide the

alveolar process into several chambers, a peculiarity that

should be kept in mind in the search for a root fragment

that has been displaced into the sinus.

Differences in the relation between the first and the

second molars to the sinus are caused mainly by the

greater divergence of the palatal and the buccal roots

in the first molar. The palatal root of the first molar

frequently extends toward the base of the bony partition

between the nasal cavity and the maxillary sinus and

may, in extreme cases, even extend toward the lateral

area of the nasal floor.

Exodontia Practice

Behind the socket of the upper third molar the

posterior end of the alveolar process forms a variably

large knob-shaped bony prominence, the alveolar

tubercle. The junction of the maxilla and the pterygoid

process of the sphenoid bone, mediated usually by the

palatine bone, occurs at a variable level-above the free

margin of the alveolar process behind the last molar.

If this junction is high and if the alveolar tubercle is

hollowed out by the maxillary sinus, the bone behind

the maxillary third molar is weak. If the extraction of

a third molar is attempted by applying an instrument

that exerts pressure distally, the entire corner of the

maxilla may be broken off and the wisdom tooth is not

removed from its socket, but the tooth and socket are

separated from the maxilla. As a consequence of this

fracture, the oral cavity and the maxillary sinus

communicate through a wide opening. The possibility

of this alveolar fracture should caution against attempts

to extract or to loosen the upper third molar by

introducing an elevator between the second and third

molars and exerting pressure distally.

The vertical position of the inner plate of the alveolar

process in the molar region restricts the retroalveolar

spongiosa to small areas lingual to the mesiobuccal root

because the lingual root is situated alongside the

F i g u r e 3.6: Position of the molar in

maxillary cellular process

distobuccal root. The socket of the lingual root fuses

with the inner plate of the alveolar process or is at least

close to it. Mesial to the lingual root, however, a block

of spongy bone intervenes between the socket of the

mesiobuccal root and the lingual plate of the alveolar

process. This arrangement of the spongy bone is the rule

in the region of the first and the second molars; it is,

however, often obscured around the third molar because

of the great variability of third molar roots (Figure 3.6).

ALVEOLAR PROCESS OF THE MANDIBLE

Conforming to the great strength and more uniform

solidity of the mandible, the lower alveolar process is

in most areas far stronger than that of the upper jaw.

Only in the incisor and canine areas are the outer and

inner plates of the alveolar process thin; distally,

however, they increases rapidly in thickness (Figure 3.7).

F i g u r e 3.7: Alveolar process of the mandible

It is of clinical importance that the relation of the

alveolar bone proper to the compact plates and the

spongiosa of the alveolar process varies widely. In the

anterior part of the mandible, in the region of the incisors

and the canine, the alveolar process is narrow in the

labiolingual direction, and in most jaws the alveolar bone

proper fuses for the entire length of the root, or at least

for most of its length, with the outer and the inner alveolar

plates (Figures 3.8A and B). Only rarely is there a restricted

zone of spongiosa lingual to the apical part of the socket.

Anatomical Considerations

of the alveolar process. The alveolar bone proper is then

fused for a variable length with one of the alveolar plates.

The premolars and the first molar are mostly in close

relation to the outer alveolar plate. The second and third

molars, however, often show a reversed relation, which

is almost a rule for the third molar. This is not so much

the consequence of a different inclination of the last

mandibular teeth but of a medial shift of the alveolar

process itself in relation to the bulk of the mandibular

body. The oblique line on the outer surface of the

mandible in the region of the second and third molars,

and a fairly thick layer of spongy bone is interposed

between the socket and the outer compact layer of the

bone, but this bone cannot be regarded as part of the

alveolar process in a strict sense. The described relations

are of clinical importance because an inflammation

originating in the second and especially in the third molar

will often perforate the inner plate of the mandible. The

variable relations of the socket and root can best be

evaluated in buccolingual sections through the mandible

at the level of the third molar. In such sections the socket

of the wisdom tooth projects on the inner, or medial,

surface of the mandible somewhat like a balconu. and

F i g u r e s 3.8A a n d B: (A) Incisor and canine in

mandibular alveolar process

The position of the sockets of the premolars and

molars in the spongy bone of the mandible varies (Figure

3.9). Only infrequently is the socket symmetrically placed

between the outer and inner plates. In most cases the

position of the socket is asymmetrical; that is, the axis

of the root and the socket is inclined against the axis

F i g u r e 3.9: Position of premolar in the F i g u r e 3.10: Position of molar in the

mandibular alveolar process mandibular alveolar process

Exodontia Practice

in some persons it is shifted entirely inside the arch of

the mandibular body. The further the socket projects

inward, the thinner is its lingual wall and the closer is

the apex of the root to the inner surface of the bone

(Figure 3.10).

At or above the level of the fundus of the socket the

mylohyoid line can be seen on the medial surface of

the jaw. The variations in the relation of this line to the

third molar are of great importance because the

mylohyoid muscle, which forms the floor of the oral

cavity, is attached to this line. The relations of the

mylohyoid line to the apex of the third molar depend

on three factors: the height of the mandibular body, the

anteroposterior length of the mandibular alveolar

process, and the length of the roots of the third molar.

The level of the apex of the third molar roots is found,

as a rule, below the level of the mylohyoid ridge,

especially if the roots of the wisdom tooth are long, if

the alveolar process is relatively short, and if the

mandibular body is of below-average height. It is clear

that in such cases a perforating abscess of the wisdom

tooth will not appear in the oral cavity but below its floor

in the connective tissue of the submandibular region.

Lateral, or buccal, to the alveolus of the lower third molar,

the massive bone forms either a variably wide horizontal

edge or a variably wide and variably deep groove. The

outer edge of this bony field is the oblique line where

it turns anteriorly and inferiorly in continuation of the

anterior border of the mandibular ramus. According to

the relative length of the alveolar process, the wisdom

tooth is either entirely in front of the ascending ramus

or its distal part is flanked by the most anterior part of

the ramus. In the latter case the accessibility of the lower

wisdom tooth is restricted; especially if the superficial

tendon of the temporal muscle is well developed and

accentuates the anteriorly projecting border of the ramus.

Of special importance are the relations of the lower

teeth to the mandibular canal and to its contents, the

inferior alveolar nerve and the accompanying blood

vessels. The second premolar and the molars may be

rather close relation to the mandibular canal itself,

whereas the first premolar shows relation to the mental

canal. Canines and incisors are placed in the region of

the narrow incisive canal, the anterior continuation of

the mandibular canal.

In the relation of the root apices to the mandibular

canal three types can be established. The most frequent

type is that in which the canal is in contact with the

alveolar fundus of the third molar, and the distance

between the canal and the roots increases anteriorly.

When the canal is in proximity to the third molar root,

the thin lamella of bone that bounds the mandibular canal

may even show a fairly large defect, and the periapical

connective tissue of the third molar is in direct contact

with the contents of the mandibular canal. Severe pain

of a neuralgic character after the extraction of a lower

wisdom tooth or during inflammations of its periodontal

ligament is easily explained by these relations.

The other two types of topography of the mandibular

canal occur only in a small number of persons. In cases

of a relatively high mandibular body combined with

roots of moderate length, the mandibular canal has no

intimate relations to any one of the posterior teeth. The

reverse is true in those who have a low mandible and

relatively long roots. In these cases the mandibular canal

may be in close contact with the roots of all the three

molars and the second premolar (Figure 3.11).

The last-described type is normal for children and

most young persons in whom the definite height of the

mandible has not yet been attained. During further

F i g u r e 3 . 1 1 : Relation of tooth apices with inferior

alveolar nerve and mandibular canal

Anatomical Considerations

growth, the mandibular body increases in height by

apposition at the free border of the alveolar process,

and the teeth, by their correlated vertical eruption, move

away from the mandibular canal.

The frequent impaction of the lower third molar may

bring about a still closer and more complicated relation

of its root to the mandibular canal and its contents. In

impaction of the wisdom tooth the developing roots

grow into the bone. If the tooth is in an oblique or nearly

vertical position, and if the growing roots are not stunted

or bent, they frequently extend beyond the level of the

mandibular canal. However, an actual meeting between

roots and canal is rare, although a routine radiograph

may give this illusion. Since the impacted lower third

molar is usually lingually inclined, its roots pass the

mandibular canal on its buccal side. Only in a minority

of cases are the roots located lingual to the canal if the

wisdom tooth is abnormally inclined and especially if

there is a considerable lingual shift of the posterior end

of the alveolar process.

In rare instances the roots of an impacted third molar

grow straight toward the mandibular canal and then, con-

tinuing to grow, envelop its contents. The wisdom tooth

then has a root that is, to a variable extent, divided into

a buccal and a lingual part. The mandibular canal may

lie in this abnormal bifurcation, or, if the apices of the

roots fuse below the canal, the alveolar nerve and blood

vessels may pass through a canal in the roots of the

wisdom tooth. The complications caused by this

fortunately rare situation during extraction of such a

wisdom tooth are self-evident. It is as though the loosened

wisdom tooth were held in its socket by an elastic band.

Cutting of this "band" means cutting the alveolar nerve

and blood vessels. In view of these complications, the

routine radiographs should be supplemented by one

taken in vertical projection with the film in the occlusal

plane. If by such a picture the diagnosis of the described

situation can be made, division of the wisdom tooth

into a buccal and a lingual part should be attempted

to liberate the contents of the mandibular canal.

The relations of the first premolar to the mental canal

and foramen deserve special attention. Ordinarily the

mental canal arises from the mandibular canal in the plane

of the first premolar; sometimes its origin is slightly distal

to this plane. From its origin inside the mandible, the

short mental canal runs outward, upward, and backward

to open at the mental foramen, situated between the

two premolars or in the plane of the second premolar.

The oblique course of the mental canal makes it

understandable that its outer end is at a higher and more

posterior level than its inner end. This explains the fact

that in radiographs the mental foramen often is projected

on the apex of the second premolar but rarely on the

apex of the first premolar. Since at this point the

mandibular canal is seldom in the immediate contact to

the apices of these teeth, the mental foramen appears

to have no connection with the mandibular canal and

often is diagnosed wrongly as a pathologic defect of the

bone, for instance as a periapical granuloma.

It was mentioned that in the premolar and molar

region the outer and inner plates of the lower alveolar

process consist of a fairly thick layer of compact bone.

Attempts to anesthetize the inferior dental nerves by

subperiosteal or supraperiosteal injections in this region

are failure. In the region of the canine and incisors this

method of injection is successful if the anesthetic is

injected into the mental fossa above the mental

tuberosity. Two facts make it advisable to inject fairly

close to the lower border of the mandible and rather

far below the level of the apices of the anterior teeth.

The first fact is that the incisal canal is situated at a lower

level than the mandibular canal itself; the second is that

the outer compact of the mandible in the mental fossa

is always perforated by a few small openings that allow

an entrance of the injected fluid into the spongy core

of the bone and thus to the incisive nerve.

Chapter

Indications

and

Contraindications

Exodontia Practice

INDICATIONS

Following are the indications of exodontia.

PERIODONTAL DISTURBANCES

They form the common cause for dental extraction in

India. When the teeth are periodontally involved, the

clinician must decide whether to extract the tooth or not.

The final decision depends on (a) the success of

periodontal therapy, (b) patient's attitude towards the

concept of conserving such teeth and (c) economic and

time factors. Even if the patient desires to save the tooth,

loss of more than 40% of periodontal support warrants

extraction.

DENTAL CARIES

When the tooth is extensively damaged by dental caries,

the dental surgeon must evaluate the feasibility of

conserving the carious tooth. Even if the patient and the

dental surgeon desire to save the tooth, it is indicated

for extraction if all the conservative procedures have

failed. This may be either because of technical reasons

or if the patient fails to cooperate. Sometimes, the sharp

margins of the teeth repeatedly ulcerate the mucosa.

Multiple carious teeth may lead to deteriorating oral

hygiene. In such cases, removal of teeth will improve

the oral hygiene.

PULP PATHOLOGY

If endodontic therapy is not possible or if the tooth is

having pulpal pathology, extraction is indicated.

APICAL PATHOLOGY

If the teeth fail to respond to all conservative measures

to resolve apical pathology, either because of technical

reasons or because of the systemic factors, such teeth

are indicated for extraction before the apical pathology

widens with the consequent involvement of the adjoining

teeth.

ORTHODONTIC REASONS

During the course of orthodontic treatment, a few teeth

may require extraction. They fall into any one of the

following reasons:

Therapeutic Extractions

To gain pace during the realignment of malposed teeth,

extraction of teeth like premolars or molars are indicated.

Malposed Teeth

The teeth in the dental arch are malpositioned.

Orthodontist may find it difficult to realign them. In

such circumstances, those teeth are indicated for

extraction.

Serial Extraction

During mixed dentition period, dental surgeon may have

to extract a few deciduous teeth in a chronological order

to prevent malocclusion as the child grows. As part of

preventive dentistry, judicious extraction of deciduous

teeth provides enough space eruption of permanent

successors in a sequential way. This is known as serial

extraction. However before advising extraction, these

teeth require proper evaluation and expert orthodontic

opinion. Otherwise, instead of achieving stability of the

dental arch, injudicious extraction can lead undesirable

esthetics like spacing between teeth may even produce

unacceptable facial profile Therefore, decision for

extraction of teeth for orthodontic reasons should be

based on:

a. Orthodontic assessment

b. Evaluation of the soft tissues like lips, tongue, etc.

PROSTHETIC CONSIDERATIONS

Extraction of teeth is indicated for providing efficient

dental prosthesis. For example, to provide better design

and success of partial dentures, a few selected teeth may

have to be extracted. At the same time, caution is required

if a patient requests the dental surgeon to extract a few

Indications and Contraindications

remaining teeth to enable him to have complete dentures.

It is a known fact that atrophies of the bone results in

decreased denture bearing area and the consequent

decreased denture stability. But the retention of a few

teeth like canines control the atrophy of the jaws.

Likewise, intentional retention of a few teeth may be

helpful to utilize them as abutments. Hence, careful

evaluation by the prosthodontist is necessary for

extracting teeth for prosthetic considerations.

IMPACTIONS

Retention of unerupted teeth beyond the chronological

eruption may sometimes be responsible for facial pain,

periodontal disturbances of the adjoining teeth temporo-

mandibular joint problems, bony pathology like cysts and

pathological fracture of the jaws. Impact ions may

predispose to anterior overcrowding of teeth. Careful

evaluation of such patients including general condition

and professional competence of the dental surgeon are

some of the important considerations for removal of such

impacted teeth.

SUPERNUMERARY TEETH

These teeth may be malpositioned or unerupted. Such

teeth predispose to malocclusion, periodontal distur-

bances, facial pain, bony pathology or may even

predispose to esthetic problems. Unless retention of such

supernumerary teeth are advantageous to the patients,

they are indicated for extraction.

TOOTH IN THE LINE OF FRACTURE

This has been controversial over the course of years.

The present concept is to extract the tooth in the line

of fracture if (a) it is a source of infection at the site

fracture, (b) the tooth itself is fractured, (c) the retention

may interfere with fracture reduction or with healing of

the fracture. Formerly, all the teeth in the line of fracture

were routinely removed. But now, a conservative

approach is advocated and hence extraction of such

teeth requires guarded approach.

TEETH IN RELATION TO BONY PATHOLOGY

They are indicated for extraction. For example, they are

involved in cyst formation, neoplasm or osteomyelitis,

extraction is indicated. However, carefully evaluation is

required before extracting teeth involved in the cyst

formations. If any chance exists for guiding the tooth

to erupt to normal occlusion, efforts must be directed

to conserve such teeth. Hence, proper decision must be

taken based on the individual case.

ROOT FRAGMENTS

They may remain dormant for a long period. Hence,

every patient must be carefully evaluated to decide

whether removal of root fragments is necessary.

For example, roots may be at the submucosal level

producing recurrent ulceration under the denture. Such

ulceration may be painful or may undergo neoplastic

changes. Such roots warrant removal. Sometimes, root

fragment may be involved in the initiation of bony

pathology like osteomyelitis, cyst or neoplasm. If such

fragments are in close association with neurovascular

bundle, the patient may complain of facial pain or

numbness. Statistically, it has been observed that many

broken root fragments remain symptomatic. This has

resulted in the controversy as to whether they are

indicated for removal. As a general rule, very small

fragments may be left alone and the patient is to be kept

under periodical observation. All the other root fragments

are indicated for removal. As the age advances, the

patients become medically compromised. Hence,

removal is indicated as soon as it is diagnosed, instead

of waiting for the symptoms to appear before general

health of the patient presents any problems.

TEETH PRIOR TO IRRADIATION

Irradiation is one of the modalities of treating oral

carcinomas. Previously as a prophylactic measure, all

the teeth in the region of irradiation used to be extracted.

But now, all the precautions are taken to conserve the

teeth prior to irradiation. Hence, all the patients before

Exodontia Practice

irradiation must be carefully examined so that a decision

is taken regarding the extraction of such teeth. If the

oral hygiene can be maintained satisfactorily, routine

prophylactic extraction of these teeth are not to be

encouraged. Only teeth which cannot be maintained in

a sound condition require removal.

FOCAL SEPSIS

Sometimes, teeth may appear apparently sound. But

radiological evaluation is a guiding factor to decide

whether any teeth are to be considered as foci of

infection. In such circumstances, weightage is in favor

of the underlying systemic disorders like dermatological

lesions, facial pain, uncontrollable ophthalmic problems

etc. In such conditions, doubtful teeth are extracted

instead of resorting to any conservative methods of

management.

ESTHETICS

Due to certain compelling reasons like marriage and

job opportunities, some teeth may require attention

for esthetic considerations. But due to time factor, it

may not be possible to improve esthetics by any

conservative orthodontic or surgical means. If so,

such teeth are indicated for extraction, provided it is

followed by immediate prosthetic restoration in a shorter

duration.

ECONOMIC CONSIDERATIONS

Sometimes, the dental surgeon and the patient are faced

with economic constraints even though technically

conservation of teeth may be feasible. In such cases,

extraction may be the only other alternative method of

choice. However, the benefit of doubt is left to the

discretion to the patient in such circumstances and

extraction of teeth is indicated as a last resort.

CONTRAINDICATIONS

Even if the tooth is indicated for removal, the presence

of certain factors makes the tooth contraindicated for

extraction. They may be relative or absolute contraindi-

cations. They can be considered relative, if the

contraindication is provided with additional care, one

can overcome the complication. In other words,

given the situation, the patient is made fit to undergo

extraction, once the underlying condition is treated. On

the contrary, there are a few conditions which are

absolute contraindications. These factors will be the

impediments for extraction, even if care is taken. If

extraction is carried out in the presence of such absolute

contraindications, the outcome may be even fatal. Hence,

it is essential to differentiate between these two types

of contraindications. To avoid legal consequences, it is

preferable to avoid extraction, if the contraindication is

absolute.

The contraindications may also be classified as

systemic or local factors. The presence of absolute

systemic contraindications indicates that this group of

diseases exists in an uncontrolled state. No attempt should

be made by the dental surgeon to thrust extraction on

such patients. By doing so the clinician will be inviting

disaster, e.g. (a) metabolic disorders like uncontrolled

diabetes, (b) uncontrolled cardiac problems, (c) leukemia

(d) renal failure and (e) liver disorders like cirrhosis of

liver. On the contrary, the following contraindications

are examples of relative contraindications. That means,

extraction is to be deferred until the underlying conditions

deserve attention to make the patient fit to undergo

extraction. In such patients, the underlying condition

is to be treated by way of precautions so that;

complications can be avoided due to extraction.

DIABETES AND HYPERTENSION

Usually patients with these systemic problems are under

medication to keep them under control. Hence, patients

with controlled hypertension and diabetes can undergo

extraction. However, it is good to investigate the state

of these disorders in every patient and extraction should

be carried out only after confirming that they are under

control. Such precautions will be a sure way of preventing

any potential complications subsequently.

Indications and Contraindications

PATIENTS ON STEROID THERAPY

If patient gives history of cortisone therapy, then, dental

surgeon has to take certain precautions. A physician's

opinion must be taken. Otherwise, the normal precaution

would be to safely double the dose of steroid, one or

two days prior to extraction and to continue one or two

days postoperatively. Then, the dose must be tapered

gradually to the usual dose. Otherwise, the patient is

liable to exhibit adrenal crisis due to stress.

PREGNANCY

The clinician should bear in mind the existence of the

possibility of obstetric complications during the first and

the last trimester. Hence, if possible, extraction can be

carried out after obtaining the obstetrician's expert

opinion.

BLEEDING DISORDERS

The patients who give definite history of bleeding

episodes need careful evaluation. It is not an absolute

contraindication. Complications can be avoided, if the

patient is properly evaluated and adequate precautions

are taken. If necessary, close coordination with the

hematologist is necessary to ensure uncomplicated

recovery of the patient following dental extractions.

Patients with anticoagulant therapy can undergo extrac-

tion after obtaining prior advice from the patient's

physician/cardiologist.

MEDICALLY COMPROMISED PATIENTS

In general, it is better to evaluate these patients pre-

operatively. Great caution should be exercised before

treating this group of patients. Failure to do so may result

in systemic complications.

ACTIVE INFECTIONS

These are relative contraindications. For example,

extraction in the presence of active and uncontrolled

infection will lead to the regional or systemic spread.

Hence, it is preferable to control the infection and

extraction can be safely carried out under the umbrella

of antibiotic therapy.

EXTRACTION OF TEETH IN RECENTLY IRRADIATED PATIENTS

These cases deserve special mention. Irradiation of the

jaws reduces blood supply due to fibrosis.

Principles of

Exodontia

Exodontia Practice

Dental extraction has always been considered to be an

unpleasant procedure for the patients due to pain phobia.

Geoffrey L Howe: The ideal tooth extraction is

the painless removal of the whole tooth, or tooth

root, with minimal trauma to the investing tissues,

so that the wound heals uneventfully and no post-

operative prosthetic problem is created.

Extraction procedure can be:

1. Simple exodontia or closed method of extraction or

intraalveolar extraction

2. Complicated exodontia or open method of extraction

or transalveolar extraction

Complex extractions are defined as those extractions,

not involving impaction, which cannot be removed by

a simple application of elevators and forceps. Complex

extractions are retrieval of tooth root and teeth which

are likely to fracture or for some other reason and have

an obstacle to extraction.

Extraction of teeth is a surgical operation involving

the bony and soft tissues of the oral cavity, access to

which is restricted by the lips, cheeks, tongue and

movements of the mandible.

Additionally the oral cavity communicates with the

pharynx, which in turn opens into the larynx and

esophagus. The field of operation is flooded by saliva

and is inhabited by the largest number of greatest variety

of microorganisms found in the human body. It also lies

close to the vital centers. Extraction of teeth is a procedure

that incorporates principles of surgery, and many from

physics and mechanics. Most of the teeth can be removed

intact after these principles are followed strictly.

Atraumatic extraction of tooth is a procedure that requires

finesse, knowledge and skill on part of the surgeon. It

is essential to give some careful study and application

of sound surgical principles as is given to surgery in any

other part of the body.

OBJECTIVES

Extraction is one of the most common surgical proce-

dures performed by dental or an oral surgeon. The main

objective is to serve the periodontal attachment carefully

and elevate the tooth out of alveolar socket without

damaging the adjacent structures. While doing extraction

certain amount of trauma is inevitable. Hence, success

in exodontia depends on how the trauma is kept

minimum. The skill and practical wisdom of any clinician

is directly proportional to personal experience and the

knowledge gain.

In general, according to difficulty faced the cases are

classified into four types:

Type 1—easy patient easy case

Type 2—easy patient difficult case

Type 3—difficult patient easy case

Type 4—difficult patient difficult case

Every clinician should bear in mind this classification

as a general rule before undertaking every minor surgery.

GENERAL PRINCIPLES INVOLVED IN

EXODONTIA

• Clinical evaluation

• Radiographic evaluation

• Patient and surgeon preparation

• Patient position

• Operator position

• Principles of extraction

• Principles of elevators

• Postoperative instructions

BASIC REQUIREMENTS

Following are the basic requirements of exodontia:

1. A good radiograph

2. Adequate anesthesia

3. Instruments

4. Adequate illumination

5. Efficient assistance

6. Suction apparatus

CLINICAL EVALUATION

In preoperative assessment period the tooth to be

extracted should be examined carefully to assess the

difficulty of extraction.

Principles of Exodontia

• Access—The first factor to see is the adequacy of

mouth opening. Any limitation of opening may

compromise the ability to do routine extraction.

The cause of limited mouth opening should be

ruled out. Plane for surgical removal is done.

• Status of the supporting structures—The status of

surrounding structure should be evaluated. Presence

of any infection periodontal problems should rule

out. Relation with adjacent vital structure and

maxillary sinus is also determined.

• Status of tooth and crown—The assessment of crown

of the tooth before extraction is always needed.

The presence of large carious lesion, root canal filled

tooth and large restoration should be checked. The

presence of calculus the condition of adjacent tooth

is also evaluated. One must check for the presence

of mobility of teeth.

INTERPRETATION OF A PREOPERATIVE RADIOGRAPH

• Radiographic anatomy

• Condition of surrounding bone

• Assessment of adjacent vital structures

• Assessment of condition of adjacent teeth

• Assessment of tooth in question

As bone density increases, the amount of socket

expansion obtained during forceps extraction becomes

less and tooth removal thus requires more force.

The more dense the bone, the greater the risks for

root fracture and/or fracture of alveolar bone.

Bone density may be interpreted radiographically by

the relative amount of trabeculation. This is only possible

by standardizing the radiographic procedure in your

office. Assessment of radiograph is discussed in details

in the subsequent chapter of exodontia.

PATIENT AND SURGEON PREPARATION

• The concept of universal precautions states that

all patients must be viewed as having blood borne

diseases that can be transmitted to the surgical

team.

• Before extraction: Patients should vigorously rinse

their mouths with an antiseptic mouth rinse such as

chlorhexidine.

To prevent teeth or fragments of teeth from falling

into the mouth and potentially being swallowed or

aspirated into the lungs, it is preferable to place a

4 x 4 inch gauze loosely into the back of the mouth.

However, it should not make the patient gag.

CHAIR POSITION FOR FORCEPS EXTRACTION

• Position of patient, operator and chair are critical for

successful completion of the extraction. Best position

is the one that is most comfortable for the operator

and the patient.

• A proper chair position allows for maximal control

over the force that is being delivered to the patient's

tooth through the forceps.

• A correct position allows:

a. The surgeon to keep the arms close to the body

b. Provide support and stability

c. To keep the wrists straight enough to deliver the

force with the arm and shoulder, and N O T with

hand.

For a Maxillary Extraction

The chair should be tipped backward so that the maxillary

plane is at 45° to the floor (Figure 5.1).

Height of the chair is such that the mouth is at

or slightly below the operator's elbow level (Figure 5.2).

Howe: Site of operation is about 8 cm below the

shoulder level of operator.

Archer: Occlusal plane is at 45° to 90°

• Maxillary right quadrant: The patient's head should

be turned substantially toward the operator for

adequate access and visualization (Figure 5.3).

• Maxillary left quadrant: Patient's head is turned

slightly toward the operator (Figure 5.4).

• Maxillary anterior portion: Patient should be looking

straight ahead (Figure 5.5).

F i g u r e 5 . 1 : Maxillary occlusal plane at

45°

to the floor

F i g u r e 5.4: Maxillary left quadrant tooth extraction

F i g u r e 5.2: Position of patient's head on chair

F i g u r e 5.3: Maxillary right quadrant tooth extraction

• Placement of fingers during extraction

• Maxillary teeth: For the left and anterior teeth,

the left index finger of the surgeon should reflect

the lip and cheek tissue, thumb should rest on

the palatal alveolar process.

For the right side, the index finger is positioned

on the palate and thumb on the buccal aspect

(Figures 5.6A to C ) .

For a Mandibular Extraction

Patient to be positioned in a more upright position so

that the occlusal plane is parallel to the floor when the

mouth is opened widely (Figure 5.7).

F i g u r e 5.5: Maxillary anterior tooth extraction

Exodontia Practice

Principles of Exodontia

F i g u r e s 5.6A to C: Position of fingers during extraction of

maxillary teeth

F i g u r e 5.7: Mandibular occlusal plane parallel to floor

The chair should be lower than for extraction of

maxillary teeth, and the surgeon's arm is inclined

downward to approximately a 120° angle at the elbow

(Figure 5.8).

• Mandibular right posterior teeth: Patient's head is

turned toward the surgeon to allow adequate access

to the jaw and the surgeon should maintain proper

arm and hand position. Surgeon is usually at the side

of the patient or at the back at 11° clock position

(Figure 5.9).

• Mandibular anterior region: Surgeon is at the side

or at the front of the patient at 8° clock position (Figure

5.10).

F i g u r e 5.8: Patient's head position on chair

Exodontia Practice

F i g u r e 5.9: Operator position for extraction of mandibular

right posterior teeth

Figure 5.10: Extraction of teeth from mandibular anterior

region

• Mandibular left posterior region: Surgeon should

stand in front of the patient (Figure 5.11).

The operator should stand with his feet apart,

distributing his body weight equally.

Some surgeons prefer to approach the mandible from

the posterior portion. The left hand then goes around

the patient's head and supports the jaw.

PLACEMENT OF FINGERS DURING EXTRACTION
OF MANDIBULAR TEETH

• For the left posterior and anterior teeth, the index

finger of the left hand reflects the cheek and lips as

it is placed in the buccal vestibule.

F i g u r e 5.11: Extraction of teeth from mandibular left

posterior region

• The middle finger reflects the tongue as it is placed

in the lingual vestibule.

• The thumb is placed below the chin so that the jaw

is held between the fingers and the thumb.

• This technique provides less tactile information, but

during extraction of mandibular teeth the need to

support the mandible supersedes the need to support

the alveolar process (Figures 5.12A to C ) . For

mandibular right side, the thumb reflects the tongue,

the index fingers reflects the lip and middle finger

supports lower border of mandible.

• A useful alternative is to place a bite block between

the teeth on the contralateral side. It allows the patient

to provide stabilizing forces to limit the pressure on

the TMJ. However, the surgeon's hand should

continue to provide additional support.

ROLE OF OPPOSITE HAND

The opposite hand plays an active role in the procedure:

1. Reflecting soft tissues to p r o v i d e adequate

visualization of the area of surgery.

2. Protection of other teeth from the forceps.

3. Stabilization of the patient's head during extraction.

4. Most importantly it supports the alveolar process and

provides tactile information to the operator

concerning the expansion of the alveolar process

during luxation.

5. Compress the socket after removal of the tooth.

Principles of Exodontia

Figures 5.12A to C: Placement of fingers during extraction

of mandibular teeth. (A) left quadrant, (B) anterior quadrant,
(C) right quadrant

ROLE OF ASSISTANT DURING THE EXTRACTION
PROCEDURE

1. Helps the surgeon to get an unobstructed view and

access to the surgical field.

2. Suction away blood, saliva, irrigating solutions

used.

3. Support the mandible when required.

4. Provide psychologic and emotional support for the

patient.

However, the assistant must not make casual

and offhand comments that may increase patient's

anxiety.

MECHANICAL PRINCIPLES OF ELEVATORS

The removal of teeth from the alveolar process employs

the use of following mechanical principles and simple

machines:

a. Lever

b. Wedge

c. Wheel and axle

LEVER PRINCIPLE

The elevator is a lever of first class. The fulcrum lies

between the effort arm and load arm. The lever principle

has three components fulcrum, power and weight. While

extracting a tooth controlled force is delivered in a

predetermined direction. The power is represented by

handle and the weight is represented by the beaks. Lever

is a mechanism by which modest force is transmitted

at long power arm so that the mechanical advantage

is derived at the short weight arm. This principle is used

when elevators are used for extraction.

WEDGE

It is an established physical principle that a wedge can

be used to split, expand or displace the portion of

substance that receives force. The wedge is a movable

inclined plane which overcomes a large resistance applied

at right angles to the applied effort. The effort is applied

to the base of the plane and the resistance has its effect

on the slant side.

The sharper the angle of the wedge, the less effort

required to make it overcome a given resistance.

Exodontia Practice

• Wedge principle as applicable to extraction with

forceps:

Beaks of extraction forceps are usually narrow at their

tips. They usually broaden as they go superiorly.

The tips of the forceps are forced into the

periodontal ligament space to expand the bone and

force the tooth out of the socket.

• Wedge principle as applicable to the use of elevators:

A small apexo elevator displaces the root toward

the occlusal plane and therefore out of the socket.

WHEEL AND AXLE PRINCIPLE

It is a modified form of lever. The effort is applied to

the circumference of the wheel which turns the axle so

as to raise a weight.

It can be used as a sole work principle in removing

teeth.

It can also be used in conjunction with the wedge

principle and in some cases with the lever principle.

PRINCIPLES OF EXODONTIA

Forcep is the primary instrument used to remove a tooth

from the alveolar process:

1. Expansion of bony socket, i.e. the forcep creates

micro fracture in the alveolar process by the use of

wedge shaped beaks and movement of the tooth itself

with the forceps.

2. Lever principle—this works same as that for elevator.

3. Wedge principle—the tip of the forceps beak is

narrower anteriorly and broadens posteriorly. When

the tip is forced between the mucoperiosteum and

tooth it causes expansion of bony socket so that the

tooth displaced out of socket.

POSTEXTRACTION CARE

• Socket should be debrided only if necessary

• Careful curettage of periapical lesion if it is visible

on a radiograph

• Obvious debris such as tooth fragments, calculus,

amalgam must be gently removed

• Expanded buccolingual plates should be compressed

back to their original configuration.

• Sharp edges of bone to be smoothed with a bone

file.

• To gain control over the hemorrhage, a moistened

gauze to be kept over the socket so that it fits into

the space previously occupied by the crown of the

tooth.

INSTRUCTIONS TO PATIENTS

• Bleeding—The gauze pack to be held firmly between

the jaws for a full half hour to 45 minutes. After the

operation bleeding in the form of oozing may

continue beyond 24 hours in some individuals without

need for alarm. Force full spitting and excessive

physical activity tend to increase bleeding.

• Hygiene—Mouthwash to be avoided for 24 hours

after surgery. Then rinse the mouth with warm saline

and one tea spoon of salt. Do clean the teeth with

your routine tooth brush. Food debris needs to be

cleaned at the site of extraction.

• Swelling—Swelling and discoloration often follow any

procedure in oral cavity. Application of ice cap to

the face briefly and intermittently for first day only.

• Diet—For first 24 hours soft and cold diet is advisable.

Then take diet as near to normal as possible. Chew

on side opposite to that of surgery. Avoid food that

is difficult to masticate.

• Pain—To avoid pain take prescribed medications by

the dentist within 45 minutes of extraction. This will

avoid the medication to take effect before the effect

of anesthesia is worn off.

• To prevent stiffness and to stimulate circulation, jaw

exercises may be done.

• If any reason you are alarmed or unduly concerned

about the condition of your mouth please call your

dentist.

Chapter

Intra-alveolar

Extraction (Simple

Exodontia)

Exodontia Practice

Extraction of teeth is the most commonly performed

procedure in the dental office. This chapter aims the basic

steps involved in the extraction of individual teeth.

Dental forceps are used to extract the majority of

erupted teeth. These instruments enable the operator to

grasp the root of the tooth and exert force directly to

the root mass in order to displace it from the surrounding

bone.

Extraction of teeth is a procedure that incorporates

the principles of surgery as well as many principles

from physics and mechanics. When these principles are

applied correctly, a tooth can most likely be removed

intact from the alveolar process without untoward sequel.

This chapter presents the principles and mechanics of

uncomplicated exodontia, i.e. closed method of

extraction. In addition to a discussion of fundamental

underlying principles there also is a detailed description

of techniques for removal of specific tooth with specific

instrument.

It should be always remembered that the removal

of a tooth does not require a larger amount of force

but rather can be accomplished with finesse and control-

led force in such a manner that the tooth is gently lifted

from alveolar process. During preoperative assessment

if we feel that the degree of difficulty is high, a deliberated

surgical approach and not an application of excessive

force should be done. Excessive force may injure local

tissues and destroy surrounding bone and tooth.

PROCEDURE FOR CLOSED EXTRACTION

An erupted tooth can be extracted in one of two major

ways: closed or open. The closed technique is also known

as the simple, or forcep technique. The open technique

is also known as the surgical, or flap, technique. The

closed technique is the most frequently used technique

and is given primary consideration for almost every

extraction. The open technique is used when there is

reason to believe that excessive force is necessary to

remove the tooth or when a substantial amount of the

crown is missing and access to the root of the tooth

is difficult. The correct technique for any situation should

lead to a atraumatic extraction; the wrong technique

may result in an excessively traumatic extraction.

Whatever technique is chosen, the fundamental

requirements for a good extraction remain the same:

1. Adequate access and visualization of the field of

surgery,

2. An unimpeded pathway for the removal of the tooth,

and

3. The use of controlled force to luxate and remove the

tooth.

For the tooth to be removed from the bony socket,

it is necessary to expand the alveolar bony walls to allow

the tooth root an unimpeded pathway, and it is necessary

to tear the periodontal ligament fibers that hold the tooth

in the bony socket. The use of elevators and forceps as

levers and wedges with steadily increasing force can

accomplish these two objectives.

GENERAL STEPS

There are five general steps in the closed-extraction

procedure.

Step 1: Loosening of Soft Tissue

Attachment from the Tooth

The first step in removing a tooth by the closed-ex-

traction technique is to loosen the soft tissue from around

the tooth with a sharp instrument such as the moon's

probe. The purpose of loosening the soft tissue from

the tooth is two-fold. First, it allows surgeons to assure

both themselves and the patient that profound

anesthesia has been achieved. When this step has been

performed, the dentist informs the patient that the

surgery is about to begin and that the first step will be

to push the soft tissue away from the tooth. A small

amount of pressure is felt at this step, but there is no

sensation of sharpness or discomfort. The surgeon then

begins the soft tissue-loosening procedure, gently at first

and then with increasing force (Figure 6.1).

Intra-alveolar Extraction (Simple Exodontia)

F i g u r e 6 . 1 : Loosening of the soft tissue attachment from

the tooth

The second reason that the soft tissue is loosened

is to allow the tooth-extraction forcep to be positioned

more apically without interference from or impingement

on the soft tissue of the gingiva. As the soft tissue is

loosened away from the tooth, it is slightly reflected,

which thereby increases the width of the gingival sulcus

and allows easy entrance of the beveled wedge tip of

the forceps beaks.

If a straight elevator is to be used to luxate the tooth,

the moon's probe is also used to reflect the tooth's adja-

cent gingival papilla where the straight elevator will be

inserted, which allows the elevator to be placed directly

onto alveolar bone without crushing or injuring the

gingival papilla

Step 2: Luxation of theTooth with a Dental Elevator

The next step is to begin the luxation of the tooth with

a dental elevator, usually the straight elevator. Expansion

and dilation of the alveolar bone and tearing of the

periodontal ligament require that the tooth be luxated

in several different ways. The straight elevator is inserted

perpendicular to the tooth into the interdental space after

reflection of the interdental papilla. The elevator is then

turned in such a way that the inferior portion of the blade

rests on the alveolar bone and the superior or occlusal

portion of blade is turned toward the tooth being

extracted. Strong, slow, forceful turning of the handle

moves the tooth in a posterior direction, which results

in some expansion of the alveolar bone and tearing of

the periodontal ligament. If the tooth is intact and in

contact with stable teeth anterior and posterior to it, the

amount of movement achieved with the straight elevator

will be minimal. The usefulness of this step is greater

if there is no tooth posterior to the tooth being extracted

or if it is broken down to an extent that the crowns do

not inhibit movement of the tooth (Figure 6.2).

In certain situations the elevator can be turned in the

opposite direction, and more vertical displacement of

the tooth will be achieved, which can possibly result in

complete removal of the tooth.

Luxation of teeth with a straight elevator should be

performed with caution. Excessive forces can damage

and even displace the teeth adjacent to those being

extracted. It must be kept in mind that this is only the

initial step and that the forceps are the major instrument

for tooth luxation in most situations.

Step 3: Adaptation of the Forceps to the Tooth

After placing the left hand in position and thus obtaining

a clear view of the tooth to be extracted, the forceps

blade are applied to the buccal and lingual surface of

the roots of the tooth.

F i g u r e 6.2: Application of dental elevator

Exodontia Practice

The goals of forcep use are two-fold

1. Expansion of bony socket by use of the wedge shaped

beaks of the forceps and the movement of the tooth

itself with forceps.

2. Removal of the tooth from the socket.

C e r t a i n r u l e s m u s t b e o b s e r v e d i n the

application of forceps to the tooth.

• The correct forcep must be selected.

• Don't grasp the forcep near the beaks, instead hold

them so that the ends of the handles are almost

covered by the palm of the hands.

• The long axis of the forceps's beaks must be parallel

to the long axis of the tooth (Figure 6.3).

• Forcep beaks must be placed on sound root structure

and not on the enamel of the crown (Figure 6.4).

• The root structure must be grasped firmly so that when

pressure is applied the beaks do not move on the

cementum, otherwise breakage may occur (Figure

6.3)

Figure 6.3: Correct method of application of forcep to the tooth

• Make certain that beaks of the forceps will not impinge

on adjacent teeth during the application of force.

• Beaks should not touch the crown when the roots

are gripped (Figure 6.3).

• The root or root mass of the tooth is always gripped

with the forceps (Figure 6.3).

It is a good practice to apply the forceps blade to

the less accessible side to the tooth first under direct vision

and then apply the other blade. If either the buccal or

lingual surface of the tooth is destroyed by cervical caries,

the appropriate blade should be applied to the carious

side first, and the first movements made towards the

carious side. This will allow the forceps blade to grip

the sound tooth structure and reduce the risk of fracture

of tooth (Figure 6.4).

F i g u r e 6.4: Application of forcep to the tooth

(B—Buccal, L—Lingual)

The proper forceps are then chosen for the tooth to

be extracted. The beaks of the forceps should be shaped

to adapt anatomically to the tooth apical to the cervical

line—that is, to the root surface. The forceps are then

seated onto the tooth so that the tips of the forceps beaks

grasp the root underneath the loosened soft tissue. The

lingual beak is usually seated first and then the buccal

beak. Care must be taken to confirm that the tips of the

Intra-alveolar Extraction (Simple Exodontia)

forceps beaks are beneath the soft tissue and not en-

gaging the adjacent tooth. Once the forceps have been

positioned on the tooth, the surgeon grasps the handles

of the forceps at the ends to maximize mechanical advan-

tage and controlled force is applied.

If the tooth is malposed in such a fashion that the

usual forceps cannot grasp the tooth without injury to

adjacent teeth, another forceps should be employed. The

maxillary root forceps can often be useful for crowded

lower anterior teeth.

The beaks of the forceps must be held parallel to the

long axis of the tooth, because the forces generated by

the application of pressure to the forceps handle must

be delivered along the long axis of the tooth for maximal

effectiveness in dilating and expanding the alveolar

bone. If the beaks are not parallel to the long axis of

the tooth, there is increased likelihood of fracturing the

tooth root (Figure 6.3).

The forceps are then forced apically as far as possible

to grasp the root of the tooth as apically as possible.

This accomplishes two things. First, the beaks of the

forceps act as wedges to dilate the crestal bone on the

buccal and lingual aspects. Second, by forcing the beaks

apically the center of rotation (or fulcrum) of the forces

applied to the tooth is displaced toward the apex of the

tooth, which results in greater effectiveness of bone

expansion and less likelihood of fracturing the apical end

of the tooth.

At this point the surgeon's hand should be grasping

the forceps firmly with the wrist locked and the arm held

against the body; the surgeon should be prepared to

apply force with the shoulder and upper arm without

any wrist pressure. He or she should be standing straight

with the feet comfortably apart.

Step

Application of Forces to the Tooth with the

Forceps

Once the forcep is properly applied to the tooth certain

forces are used to deliver tooth from its socket. They

are apical force, labial or buccal force, lingual or palatal

force, rotational force, and fractional force.

Apical force: As already explained beaks act as a

wedges between the alveolar socket and tooth surface.

Very little movement of the tooth in the apical direction

takes place. Instead this movement expands the bony

socket and helps in securing a firm grip over a larger

area of the tooth. Teeth with single conical roots

may jump out of the socket during this phase like an

orange seed jumping off the two fingers when pressure

is applied.

A second major accomplishment of apical pressure

with the extraction forceps is that the fulcrum, the center

of the tooth's rotation is placed more apically. Since the

tooth is moving in response to the force placed on it

by the forceps, the forcep becomes the instrument of

expansion. If the fulcrum is high, there is a large amount

of force on apical region of tooth, which increases

the chance of root fracture. If the beaks of the forcep

are forced a bit into the periodontal ligament space,

the center of rotation is moved apically, which results

in greater movement of forces at the crest of the

ridge and less force moving the apex of the tooth. This

process decreases the chance of apical root fracture

(Figure 6.5).

Figure 6.5: Apical force decrease the chance of apical

root fracture

Exodontia Practice

F i g u r e 6.6: Buccal force application

Labial or buccal force: By keeping a continuous apical

pressure buccal force is added which expands the bony

socket still further. During this movement the forcep

takes fulcrum from the crest of the alveolus. When buccal

force is applied the expansion of buccal cortical plate

occurs at crest and lingual cortical plate at apical region

(Figure 6.6).

Lingual or palatal force: Then the lingual or palatal

force is applied to the tooth. This will cause the socket

expansion at the lingual crestal bone and at the

same time avoiding excessive pressure on buccal apical

bone.

Socket expansion is maximum in younger jaws and

gradually decreases as age advances.

Dilatation of the alveolar socket during extraction

can be conveniently compared to the removal of pole

from the ground. When the pole is mobilized laterally,

the tip of the pole embedded in the ground moves in

the opposite direction. This results in the dilatation of

the hole near the tip of the embedded portion of the

pole. If the pole is moved in the opposite direction there

will be dilatation in the opposite side (Figure 6.7).

F i g u r e 6.7: Principle of pole dilatation

Rotational forces: This is applied by using wheel and

axle principle in the form of an arc with fulcrum of the

lever principle on the crest to the buccal alveolus. This

is the most important phase in the tooth extraction

technique. Upper central incisor and lower second

premolars can be removed by applying rotational forces

along the long axis of root. Teeth that have multiple roots

are more likely to fracture (Figure 6.8).

F i g u r e s 6.8A a n d B: (A) Application of rotational force.

(B) Figure of eight force

Tractional forces: This type of force is useful in the

terminal phase of the tooth delivery out of the bony socket.

Hence, this should be as gentle as possible (Figure 6.9).

The surgeon begins to luxate the tooth by using the

motions discussed earlier. The major portion of the force

Intra-alveolar Extraction (Simple Exodontia)

F i g u r e 6.9: Tractional force

is directed toward the thinnest and therefore weakest

bone. The surgeon uses slow, steady force to displace

the tooth bucally. The motion is deliberate and slow and

gradually increases in force. The tooth is moved again

toward the opposite direction with slow, deliberate, strong

pressure. As the alveolar bone begins to expand, the

forceps are reseated apically with a strong deliberate

motion, which causes additional expansion of the

alveolar bone and further displaces the center of the rota-

tion apically. Buccal and lingual pressures continue to

expand the alveolar socket. For some teeth rotational

motions are then used to help expand the tooth socket

and the periodontal ligament attachment.

Beginning surgeons have a tendency to apply

inadequate pressure for insufficient amounts of time.

Three factors must be reemphasized: first, the forceps

need to be seated apically as far as possible and reseated

periodically during the extraction; second, the forces

applied in the buccal and lingual directions should be

slow, deliberate pressures and not jerky wiggles; and third,

the force should be held for several seconds to allow

the bone to expand. It must be remembered that teeth

are not pulled but rather gently lifted from the socket

once the alveolar process has been sufficiently expanded.

Step

Removal of the Tooth from the Socket

Once the alveolar bone has expanded sufficiently and

the tooth has been luxated, a slight tractional force,

usually directed buccally, can be used. Tractional forces

should be minimized, since this is the last motion that

is used once the alveolar process is sufficiently expanded

and the periodontal ligament completely severed.

It is useful to remember that luxation of the tooth

with the forceps and removal of the tooth from the bone

are separate steps in the extraction. Luxation is directed

toward expansion of the bone and disruption of the

periodontal ligament. The tooth is not removed from

the bone until these two goals are accomplished. The

surgeon should realize that the major role of the forceps

is not to remove the tooth but rather to expand the bone

so that the tooth can be removed.

For teeth that are malopposed or have unusual

positions in the alveolar process, the luxation with the

forceps and removal from the alveolar process will be

in unusual directions. The surgeon must develop a sense

for the direction the tooth wants to move and then be

able to move it in that direction. Careful preoperative

assessment and planning help to make this determination

during the extraction.

ROLE OF THE OPPOSITE HAND

When using the forceps and elevators to luxate and

remove teeth, it is important that the surgeons opposite

hand play an active role in the procedure. For the right-

handed operator, the left hand has a variety of functions.

It is responsible for reflecting the soft tissues of the cheeks,

lips, and tongue to provide adequate visualization of the

area of surgery. It helps to protect other teeth from the

forceps, should they release suddenly from the tooth

socket. It helps to stabilize the patient's head during the

extraction process. In some situations large amounts of

force are required to expand heavy alveolar bone, and

therefore the patient's head requires active assistance in

Exodontia Practice

being held steady. The opposite hand plays an important

role in supporting and stabilizing the lower jaw when

mandibular teeth are being extracted. It is often necessary

to apply significant pressure to expand heavy mandibular

bone, and such forces can cause discomfort and even

injury to the temporomandibular joint unless they are

counteracted by a steady hand. Finally, the opposite hand

supports the alveolar process and provides tactile

information to the operator concerning the expansion

of the alveolar process during the luxation period. In

some situations it is impossible for the opposite hand

to perform all of these functions at the same time, so

the surgeon requires an assistant to help with some of

them.

ROLE OF ASSISTANT DURING EXTRACTION

For a successful outcome in any surgical procedure, it

is essential to have a competent assistant. During the

extraction the assistant plays a variety of important roles

that contribute to making the surgical experience

atraumatic to the patient.

The assistant helps the surgeon to visualize and gain

access to the operative area. The assistant reflects the

soft tissue of the cheeks and tongue so that the surgeon

can have an unobstructed view of the surgical field. Even

during a closed extraction the assistant can reflect the

soft tissue so that the surgeon can apply the instruments

to loosen the soft tissue attachment as well as adapt the

forceps to the tooth and tooth root in the most effective

manner.

Another major activity of the assistant is to suction

away blood, saliva, and the irrigating solutions used dur-

ing the surgical procedure. This prevents fluids from accu-

mulating and makes proper visualization of the surgical

field possible. Suctioning is also important for patient

comfort, since most patients are unable to tolerate an

accumulation of blood or other fluids in their mouths.

During a surgical procedure it is almost impossible for

the assistant to suction too much.

During the extraction the assistant should also help

to protect the teeth of the opposite arch, which is

especially important when removing lower posterior

teeth. If traction forces are necessary to remove a lower

tooth, occasionally the-footh releases suddenly and the

forceps strike the maxillary teeth and sometimes fracture

a tooth cusp. The assistant should hold either a suction

tip or a finger against the maxillary teeth to protect them

from an unexpected blow.

During the extraction of mandibular teeth the assistant

may play an important role by supporting the mandible

during the application of the extraction forces. A surgeon

who uses his or her own hand to reflect the soft tissue

may not be able to support the mandible. If this is the

case, the assistant plays an important role in stabilizing

the mandible to prevent temporomandibular joint

discomfort. Most often the surgeon stabilizes the

mandible which makes this role less important for the

assistant.

The assistant also provides psychological and

emotional support for the patient by helping to alleviate

patient anxiety.

DIRECTIONS TO MOVE TEETH FOR

EXTRACTION

Exodontia is an art that must be learned and the operator

gaining experience will begin to appreciate the feel of

each tooth as it moves and so exploit the line of least

resistance. There are however, several rules for each tooth

based on the root form and the local bony anatomy of

the alveolus.

MAXILLARY TEETH

Bone in the maxilla has a higher proportion of cancellous

to cortical structure than the mandible and as a result

is generally less dense than mandibular bone. The

alveolar bone is thinner on its buccal or labial surface

by comparison with the thicker palatal side. Therefore,

the normal direction of tooth displacement is bucally.

However, the buccal plate is buttressed in the first moral

region by the zygomatic process of maxilla. The number

and shape of roots affects the way in which a root is

removed (Figure 6.10).

Intra-alveolar Extraction (Simple Exodontia)

F i g u r e 6.10: Diagrammatic representation of maxillary

alveolus with number of roots

This section describes specific techniques for the

removal of each tooth in the mouth. In some situations

several teeth are grouped together—for example, the

maxillary anterior teeth—since the technique for their

removal is essentially the same.

MAXILLARY TEETH

In the correct position for extraction of maxillary left

or anterior teeth, the left index finger of the surgeon

should reflect the lip and cheek tissue, and the thumb

should rest on the palatal alveolar process. In this

way the left hand is able to reflect the soft tissue of

the cheek, stabilize the patient's head, support the

alveolar process, and provide tactile information to

the surgeon regarding the progress of the extraction.

When such a position is used during the extraction of

a maxillary molar, the surgeon can frequently feel with

the left hand, the palatal root of the molar becoming

free in the alveolar process before realizing it with the

forceps or extracting hand. For the right side, the index

finger is positioned on the palate and the thumb on

the buccal aspect.

Maxillary incisor teeth: The maxillary incisor teeth

are extracted with the upper incisor forcep.The maxillary

incisors generally have conical roots with the lateral ones

being slightly longer and more slender. The lateral incisor

is more likely also to have a distal curvature on the apical

one-third of the root, so this must be checked radio-

graphically before extraction. The alveolar bone is thin

on the labial side and heavier on the palatal side, which

indicates that the major expansion of the alveolar process

will be in the buccal direction. The initial movement is

slow, steady, and firm in the labial direction, which

expands the crestal buccal bone. A less vigorous palatal

force is then used, followed by a slow, firm, rotational

force. Rotational movement should be minimized for the

lateral incisor especially if a curvature exists on the tooth.

The tooth is delivered in the labial-incisal direction with

a small amount of tractional force (Figure 6.11).

F i g u r e 6 . 1 1 : Extraction of maxillary central incisor

Exodontia Practice

Maxillary Canine

The maxillary canine is usually the longest tooth in the

mouth. The root is oblong in cross-section and usually

produces a bulge on the anterior surface of the maxilla

called the canine eminence. The result is that the bone

over the labial aspect of the maxillary canine is usually

quite thin. In spite of the thin labial bone, this tooth can

be difficult to extract simply because of its long root.

Additionally, it is not uncommon for a segment of labial

alveolar bone to fracture from the labial plate and be

removed with the tooth.

As with all extractions, the initial placement of the

beaks of the forceps on the canine tooth should be as

far apically as possible. The initial movement is to the

buccal aspect with return pressure to the palatal. As the

bone is expanded and the tooth mobilized, the forceps

should be repositioned apically. A small amount of

rotational force may be useful in expanding the tooth

socket especially if the adjacent teeth are missing or have

just been extracted. After the tooth has been well luxated,

it is delivered from the socket in a labial-incisal direction

with labial tractional forces (Figure 6.12).

If during the luxation process with the forceps, the

surgeon feels a portion of the labial bone fracture, a

decision must be made concerning the next step. If the

palpating finger indicates that a relatively small amount

of bone has fractured and is attached to the canine tooth,

the extraction should continue in the usual manner with

caution-taken not to tear the soft tissue. However, if the

palpating finger indicates that a relatively large portion

of labial alveolar plate has fractured, the surgeon should

stop the surgical procedure at this point. Usually the

fractured portion of bone is attached to periosteum and

therefore is viable. The surgeon should use a thin

periosteal elevator to raise a small amount of mucosa

from around the tooth down to the level of the fractured

bone. The canine tooth should then be stabilized with

the extraction forceps, and the surgeon should attempt

to free the fractured bone from the tooth with the

periosteal elevator as a lever to separate the bone from

the tooth root. If this can be accomplished, the tooth

can be removed and the bone left in place attached to

the periosteum. Normal healing should occur. If the bone

becomes detached from the periosteum during these

attempts, it should be removed, because it is most likely

non-vital and may actually prolong wound healing. This

procedure can be used whenever alveolar bone is

fractured during extraction.

Maxillary First Premolar

The maxillary first premolar is a single-rooted tooth in

its first two thirds with a bifurcation into a buccal and

lingual root usually occurring in the apical one-third to

one half. These roots may be extremely thin and are

subject to fracture especially in older patients in whom

bone density is great and bone elasticity is small. Perhaps

F i g u r e 6.12: Extraction of maxillary canine

Intra-alveolar Extraction (Simple Exodontia)

the most common root fracture when extracting teeth

in adults occurs with this tooth. As with other maxillary

teeth, the buccal bone is relatively thin when compared

with the palatal bone.

The forceps of choice once again is the upper

premolar forceps. Because of the bifurcation of the tooth

into two relatively thin root tips, extraction forces should

be carefully controlled during removal of the maxillary

first premolar. Initial movements should be buccal. Palatal

movements are made with relatively small amounts of

force to prevent fracture of the palatal root tip, which

is harder to retrieve. When the tooth is luxated buccally,

the most likely tooth root to break is the labial. When

the tooth is luxated in the palatal direction, the most

likely root to break is the palatal root. Of the two root

tips, the labial is easier to retrieve because of the thin,

overlying bone. Therefore, buccal pressures should be

greater than palatal pressures. Any rotational force should

be avoided. Final delivery of the tooth from the tooth

socket is with tractional force in the occlusal direction

and slightly buccal (Figure 6.13).

Maxillary Second Premolar

The maxillary second premolar is a single-rooted tooth

for the root's entire length. The root is thick and has

a blunt end. Consequently, the root of the second

premolar fractures rarely. The overlying alveolar bone

is similar to that of other maxillary teeth in that it is

relatively thin toward the buccal with a heavy palatal

alveolar palate.

The forceps are forced as far apically as possible so

as to gain maximal mechanical advantage in removing

this tooth. Since the tooth root is relatively strong and

blunt, the extraction requires relatively strong movements

to the buccal, back to the palate, and then in the buccal-

occlusal direction with a rotational, tractional force

(Figure 6.14).

Maxillary Molar

The maxillary first molar has three large and relatively

strong roots. The buccal roots are usually relatively close

together, and the palatal root diverges widely toward

the palate. If the two buccal roots are also widely

divergent, it becomes difficult to remove this tooth by

closed, or forceps, extraction. Once again the overlying

alveolar bone is similar to that of other teeth in the

maxilla; the buccal plate is thin and the palatal cortical

plate is thick and heavy. When evaluating this tooth

radiographically, one should note the size, curvature,

and apparent divergence of the three roots. Additionally,

F i g u r e 6.13: Extraction of maxillary first premolar

Exodontia Practice

Figure 6.14: Extraction of maxillary second premolar

the dentist should look carefully at the relationship of

the tooth roots to the maxillary sinus. If the sinus is in

close proximity to the roots and the roots are widely

divergent, there is increased likelihood of sinus

perforation caused by removal of a portion of the sinus

floor during tooth removal. If this appears to be likely

after preoperative evaluation, the surgeon should

strongly consider a surgical extraction.

The forceps usually used for extraction of the

maxillary molars are the paired forceps. These forceps

have tip projections on the buccal beaks to fit into the

buccal bifurcation. Cow horn forceps are useful if the

crown of the molar tooth has large caries or large

restorations.

The upper molar forceps are adapted to the tooth

and seated apically as far as possible in the usual fashion.

The basic extraction movement is to use strong buccal

and palatal pressures with stronger forces toward the

buccal than toward the palate. Rotational forces are not

useful for extraction of this tooth because of its three

roots. As was mentioned in the discussion of the

extraction of the maxillary first premolar, it is preferable

to fracture a buccal root than a palatal root, because

it is easier to retrieve the buccal roots. Therefore, if the

tooth has widely divergent roots and the dentist suspects

that one root may be fractured, the tooth should be

luxated in such a way as to prevent fracturing the palatal

root. One must minimize palatal force, since this is the

force that fractures the palatal root. Strong, slow, steady,

buccal pressure expands the buccal cortical plate and

tears the periodontal ligament fibers that hold the palatal

root in its position. Palatal forces should be used but

kept to a minimum (Figure 6.15).

The maxillary second molar's anatomy is similar to

that of the maxillary first molar except that the roots tend

to be shorter and less divergent with the buccal roots

more commonly fused into a single root. This means

that the tooth is more easily extracted by the same

technique described for the first molar.

The erupted maxillary third molar frequently has

conical roots and is usually extracted with third molar

forceps, which are universal forceps used for both the

left and right sides. The tooth is usually easily removed,

since the buccal bone is thin and the roots are usually

fused and conical. The erupted third molar is also

frequently extracted by the use of elevators alone. It is

important to visualize the maxillary third molar clearly

on the preoperative radiograph, because the root

Intra-alveolar Extraction (Simple Exodontia)

F i g u r e 6.15: Extraction of maxillary molar

anatomy of this tooth is quite variable and often small,

dilacerated, hooked roots exist in this area. Retrival

of fractured roots in this area can be very difficult.

MANDIBULAR TEETH

The mandible has a more ratio of cortical to cancellous

bone than maxilla. Consequently the alveolar bone

supporting lower teeth is more dense and less readily

deformed. Making the displacement of mandibular teeth

more difficult. Buccal and lingual cortices tend to be of

similar thickness in the anterior mandible. Distally in

molar region buccal cortical plate is thickened by external

oblique ridge. Therefore, incisors canine and premolars

requires strong buccal force and molars require strong

lingual pressure.

MANDIDULAR ANTERIOR TEETH

The mandibular incisors and canines are similar in shape

with the incisors being shorter and slightly thinner and

the canine roots being longer and somewhat heavier.

The incisor roots are more likely to be fractured, since

they are somewhat thin and therefore should be removed

only after adequate pre-extraction luxation. The alveolar

bone that overlies the incisors and canines is quite thin

on the labial as well as the lingual sides. The bone over

the canine may be somewhat thicker especially on the

lingual side.

The usual forceps employed to remove these teeth

is the lower anterior forceps. The forceps beaks are

positioned onto the teeth and seated apically with strong

force. The extraction movements are generally in the

labial and lingual directions with equal pressures both

ways. Once the tooth has become luxated and mobile,

rotational movement may be used to expand the alveolar

bone further. The tooth is removed from the socket with

fractional forces in a labial-incisal direction (Figure 6.17).

STORIES TECHNIQUE

If the extraction of multiple anterior teeth is indicated,

straight elevator is inserted both the lower incisors and

rotated. This will loosen both the adjacent teeth and

facilitate the extraction (Figure 6.16).

Figure 6.16: Stobie's technique for extraction of adjacent teeth

Exodontia Practice

F i g u r e 6.17: Extraction of mandibular anterior tooth

MANDIBULAR PREMOLARS

The mandibular premolars are among the easiest of all

teeth to remove. The roots tend to be straight and conical,

sometimes slender. The overlying alveolar bone is thin

on the buccal aspect and somewhat heavier on the lingual

side.

The forceps usually chosen for extraction of the

mandibular premolars are the lower premolar forceps.

The forceps are forced apically as far as possible with the

basic movements being toward the buccal aspect,

returning to the lingual aspect, and finally rotating. Rota-

tional movement is used more when extracting these teeth

than any others except the maxillary central incisor. The

tooth is then delivered in the occlusal-buccal direction.

Careful preoperative radiographic assessment must be

performed to assure the operator that no root curvature

exists in the apical third of the tooth. If such a curvature

does exist, the rotational movements should be reduced

or eliminated from the extraction procedure (Figure 6.18).

MANDIBULAR MOLARS

The mandibular molars are usually two-rooted with roots

of the first molar more widely divergent than those of

the second molar. Additionally, the roots may converge

at the apical one-third, which increases the difficulty of

extraction. The roots are generally heavy and strong.

The overlying alveolar bone is heavier than the bone

on any other teeth in the mouth. The combination of

relatively long, strong, divergent roots with heavy

overlying buccal and lingual bone makes the mandibular

first molar the most difficult of all teeth to extract.

The forceps usually used for extraction of the

mandibular molars are mandibular forceps. The forceps

are adapted to the root of the tooth in the usual fashion,

and strong apical pressure is applied to set the beaks

of the forceps apically as far as possible. Strong buccal

and lingual motion is then used to expand the tooth

socket and allow the tooth to be delivered in the buccal-

occlusal direction. The lingual alveolar bone around the

second molar is thinner than the buccal plate so the

second molar can be more easily removed with stronger

lingual than buccal pressures (Figure 6.19).

If the tooth roots are clearly bifurcated, the cow horn,

forceps can be used. These forceps are designed to be

closed forcefully with the handles, thereby squeezing

the beaks of the forceps into the bifurcation. This creates

Figure 6.19: Extraction of mandibular molar

Exodontia Practice

force against the crest of the alveolar ridge on the buccal

and lingual aspects and literally forces the tooth superiorly

directly out of the tooth socket. If initially this is not

successful, the forceps are given buccal and lingual

movements to expand the alveolar bone, and more

squeezing of the handles is performed. Care must be

taken with these forceps to prevent damaging the

maxillary teeth, since the lower molar may actually pop

out of the socket and thus release the forceps to strike

the upper teeth.

Erupted mandibular third molars usually have fused

conical roots. Since there is not usually a bifurcation,

the short-beaked, right-angled universal forceps is used

for extraction. The lingual plate of bone is definitely thinner

than the buccal cortical plate, so most of the extraction

forces should be delivered to the lingual aspect. The third

molar is delivered in the lingual-occlusal direction. The

erupted mandibular third molar that is in function can

be a deceptively difficult tooth to extract. The dentist

should give serious consideration to using the straight

elevator to achieve a moderate degree of luxation before

applying the forceps. Pressure should be gradually

increased, and attempts to mobilize the tooth should be

made before final strong pressures are delivered.

Transalveolar

Extraction

(Complicated

Exodontia)

Exodontia Practice

Exodontia or tooth extraction is painless removal of a

whole tooth or tooth-root, with minimal trauma to the

investing tissues, so that the wound heals uneventfully

and no postoperative prosthetic problem is created.

DEFINITION OF COMPLETE EXODONTIA

Complex extractions are defined as those extractions,

not involving impaction, which cannot be removed by

a simple application of elevators and forceps.

PETERSON

Complex extractions are retrieval of tooth root and teeth

which are likely to fracture for some other reason and

have an obstacle to extraction.

The surgical removal of tooth is the method used for

recovering roots that were fractured during routine

extraction or teeth that cannot be extracted by close

method of extraction. This chapter discusses the

technique for surgical removal of teeth, with different

principles involved.

FACTORS THAT COMPLICATE THE

EXTRACTION PROCEDURE

Factors that complicate the extraction procedure from

simple to complicated extraction are as follows. These

factors can be evaluated clinically and radiographically

before going for extraction of any tooth.

1. Crown

2. Roots

3. Bone

4. Diminished access

5. Adjacent/non-adjacent teeth

6. Adjacent vital structures

7. Prosthetic concerns

CROWN

In cases where crown is destroyed by caries, complex

restorations, fixed prosthesis, etc. the nature of the

coronal portion of the tooth may prevent the application

of instruments and therefore the application of forces.

Crowns may get crushed or shattered when gripped by

the forceps (Figure 7.1). Teeth which have lost their

crowns due to caries or fracture should be evaluated for

necessity to undergo open extraction.

F i g u r e 7 . 1 : Badly carious tooth

ROOTS

All those roots that result in unfavorable path of removal

or increased resistance are enumerated as under:

a. Multiple roots

b. Bulbous roots

c. Root canal treated teeth

d. Hypercementosis

e. Ankylosed teeth

f. Divergent roots

g. Dilacerated roots

Multiple Roots

In teeth that have multiple roots individual roots may

have different long axes. It is essential to apply the forces

along the long axes of the tooth and hence it is necessary

to remove each root along its long axis. Hence, there

might be a need for transalveolar extraction of that tooth

(Figure 7.2).

Bulbous Roots

In teeth that have bulbous roots there is mechanical

obstruction to retrieval of the root. Inspite of expansion

of the socket there might not be enough space for delivery

Transalveolar Extraction (Complicated Exodontia)

F i g u r e 7.2: Multiple roots

of the root from the socket. Hence, such teeth should

be considered for open extractions.

Root Canal Treatment

Teeth become brittle following root canal treatment

mainly because of two reasons, viz. cutting of the tooth

structure for endodontic treatment and because of

dehydration of dentin following cessation of blood supply.

The dentin becomes dessicated and hence, becomes

brittle. Thus the tooth may crush during application of

extraction forces due to either reduced bulk of the tooth

or brittleness of the remaining tooth structure (Figure 7.3).

accelerated elongation of tooth, tooth repair and Paget's

disease. It is difficult to remove the root in such cases

through the available root socket because of smaller

diameter of the socket at the cervical level. Due to

difficulty in delivery of the root the operator might use

increased forces which may cause root/bone fracture.

Such roots require thorough radiographic evaluation and

extractions by open technique (Figure 7.4).

F i g u r e 7.3: Root canal treated tooth

Hypercementosis

Hypercementosis occurs because of continuous deposi-

tion of cementum forming large bulbous roots especially

in apical region. It occurs in chronic inflammation,

F i g u r e 7.4: Hypercementosis

Ankylosis

In this condition tooth is fused to alveolar bone. There

is no intervening periodontal ligament. During extraction

tooth is delivered from socket after severing of perio-

dontal ligament. Hence, in ankylosed tooth delivery of

tooth from socket is not possible. If excessive force is

applied fracture of root or alveolar bone will occur. This

condition is diagnosed using radiographs. On radio-

graphic examination there is no periodontal ligament

seen surrounding the root and there is bony union of

tooth. On clinical examination dull tone is heard when

tooth is percussed and no mobility can be felt when

luxation of the root is attempted (Figure 7.5).

Exodontia Practice

F i g u r e 7.5: Ankylosed tooth

Divergent Root

It occurs in some multirooted teeth; especially maxillary

molars. Due to non-parallelism of long axes of the roots

there is increased difficulty to extract tooth in one piece.

Hence, transalveolar extraction needs to be carried out

to extract the tooth uneventfully (Figure 7.6).

F i g u r e 7.6: Divergent root

Dilacerated Roots

In dilacerated roots there is hooking of root to alveolar

bone. Hence, there is an increased resistance to delivery

of tooth while normal extraction forces are applied

and it is difficult to deliver the tooth from the socket

without fracture of the root at the point of hooking

(Figure 7.7).

F i g u r e 7.7: Dilacerated roots

BONE

The points to be considered are as follows:

a. Periodontal health

b. Increased bone density

c. Increased bone bulk

Periodontal Health

The periodontal health determines firmness of tooth and

hence, difficulty of extraction. In case the periodontal

health is weak, the tooth will be mobile and hence, will

be easily delivered from the socket. Conversely, in case

of teeth with good periodontal health more is the

difficulty while extracting the teeth. In cases such as long

standing tooth, para-functional habits like bruxism,

clenching there is an increase in the width of periodontal

ligament. Hence, it becomes difficult to shear the

periodontal ligament from bone and tooth, and the

delivery of the tooth becomes difficult.

Increased Bone Density

In cases of bruxism and localized osteitis there is a significant

increase in bone density chiefly on buccal cortical plate.

The extraction depends chiefly on expansion of buccal

Transalveolar Extraction (Complicated Exodontia)

cortical plate. In cases of increased bone density expansion

of socket is difficult and hence, there is difficulty in

extraction of the tooth. This necessitates use of trans-

alveolar method of extraction (Figure 7.8).

F i g u r e 7.8: Increased bone density around the tooth

Increased Bulk

Increase in bulk of bone occurs due to presence of bony

exostosis on the buccal or lingual cortical plate. This

increases the difficulty in socket expansion and therefore

extraction of the concerned tooth.

DIMINISHED ACCESS

Diminished access results chiefly from trismus resulting

from infection of sub-masseteric space, oral submucous

fibrosis, scleroderma. In case of sub-masseteric space

infection trismus is the hallmark due to inflammation and

spasm of Masseter muscle. Scleroderma or systemic

sclerosis is a condition wherein there is progressive fibrosis

of skin and various organs of the body. Oral manifesta-

tions are that lips become thin, firm and partially fixed

leading to microstomia. Gingiva becomes firm. The

reduced mouth opening is due to involvement of

temporomandibular joint tissues. This makes dental care

difficult. Due to decreased oral opening, application of

instruments along long axes of teeth is difficult and

sometimes impossible. This results in inability to apply

correct forces. Difficulty is much more in posterior teeth

than anterior.

ADJACENT TEETH

In case of highly carious, heavily restored, endo-

dontically treated adjacent teeth there are chances of

fracture of the teeth due to either wrong application

of elevator force or transmitted force. In case of

periodontally compromised teeth there are chances of

inadvertent extraction of the adjacent tooth causing

grevious injury due to wrong application of force or

transmitted forces. A long maxillary molar or canine has

dense bone surrounding it with strong periodontal

attachment due to the increased functional load that

it bears. This causes difficulty in socket expansion and

extraction. In case of maxillary molar, the maxillary sinus

may have expanded to include roots of the molar.

Extraction may result in removal of part of sinus floor

and formation of oroantral communication. In divergent

roots these chances increase.

PROXIMITY TO VITAL STRDCTURES

The vital structures that could be in close proximity

to the teeth are inferior alveolar bundle, lingual

nerve, maxillary sinus. In case of inferior alveolar nerve,

risk of nerve injury during extraction of mandibular third

molar is mainly during elevation of a mesioangular tooth.

If the nerve is close to the apices of the tooth it might

come in the arc of rotation and get compressed causing

neuropraxia. In case of lingual nerve, due to its supra-

periosteal course close to the 3rd molar, there are chances

of damage during raising of mucoperiosteal flap. In

addition, in cases of difficult extraction, due to trauma

to the surrounding soft tissue during the extraction, the

lingual nerve might get damaged. The maxillary

sinus when close to the apices of maxillary molars carries

the risk of formation of an oro-antral communication.

Hence, when tooth is in close proximity to the vital

structures, it is essential to consider open extractions

(Figure 7.9).

Exodontia Practice

F i g u r e 7.9: Tooth in close proximity to inferior

alveolar nerve

PROSTHETIC CONCERNS

These include preservation of alveolus. When intra-

alveolar extraction will cause more bone loss than

transalveolar extraction, it is more prudent to opt for open

extraction rather than try to perform a closed extraction.

The next concern is maintaining correct alveolar contour.

In case there is a existing bony undercut due to

proclination of teeth, and an alveoloplasty is essential

before prosthetic rehabilitation can be done, then

performing an open extraction and performing an

alveoloplasty at the same time is advisable. The third

concern is preservation of attached gingiva of the

adjacent teeth which might get damaged due to excessive

trauma to the surrounding soft tissues due to overzealous

attempt to perform a difficult extraction and will lead

to loss of attached gingiva, pocket formation.

Once all these parameters are evaluated the following

technical observations are taken in to consideration:

1. Basic steps such as severing periodontal ligament,

expanding alveolus, and applying traction don't

work.

2. Correct application of forceps not possible or inspite

of correct application of forceps correct delivery of

forces not possible.

3. Need to alter ability to apply the correct force and

achieve the treatment objective

Following are the technical goals to be achie-

ved at the time of complicated exodontia:

1. To improve the mechanical advantage

2. To reduce resistance

3. To correct an inadequate path of withdrawal.

1. Improved access: This is done by raising a

mucoperiosteal flap and adequate bone removal

2. Improved mechanical advantage: This is achieved by

bone removal and preparation of purchase point.

3. Reduce resistance: This is achieved by removal of

bone support and sectioning of teeth (Odontectomy)

4. Correct path of removal: This is achieved by removal

of bone and sectioning of teeth.

Following are the principles involved during

the surgical removal of teeth:

1. Flap design

2. Bone removal

3. Sectioning teeth

4. Wound closure.

PRINCIPLES OF FLAP DESIGN

INCISION

A gingival margin incision which divides the mandibular

interdental papillae will permit the insertion of a periosteal

elevator and the reflection of either the buccal or lingual

mucoperiosteum or both. If necessary, the papillae can

be divided from one side molar around to the other

without the operator encountering any sizeable vessel.

Similarly, an incision along the crest of the mandibular

edentulous ridge will also permit buccal and lingual

mucoperiosteal flaps to be raised. Such flaps are

described as envelope flaps.

If required the incision can be extended backwards

into the retromolar region and then distobucally up the

external oblique ridge and anterior border of the coronoid

process. No vessel of a size requiring formal ligation will

be encountered until this upwards extension of the

incision reaches a point just below the level of the occlusal

surface of the upper 3rd molar. Here the buccal artery

and long buccal nerve lie side by side and cross the

Transalveolar Extraction (Complicated Exodontia)

anterior border of the coronoid from medial to lateral

on the superficial aspect of the buccinator muscle. The

deep facial vein runs either with the artery and nerve

or a little higher up.

By dividing the interdental papillae or by incising

along the edentulous ridge, depending upon whether

teeth are present or not. And then raising flaps, the outer

and palatal aspects of the maxillary alveolar process can

be exposed in a similar fashion. Again no sizeable vessel

will be cut while making these incisions.

A second incision can be added which starts at one

end of the crestal incision and is carried towards the

buccal sulcus. The second incision can be a straight one

which leaves the first at an obtuse angle, or with the

edentulous ridge the crestal incision can be continued

in a curve onto the buccal aspect of the alveolar process.

In the dentulous patient the oblique relieving incision

should include an interdental papilla at the corner to

locate the flap on replacement. This two-sided, or

triangular, flap is easy to retract and allows sufficient

access for many small dentoalveolar procedures to be

carried out, and is easy to suture. The addition of a

second buccal incision at the other end of the crestal

incision so creating a three sided quadrangular flap

increases still further the degree of surgical access. By

curving the sulcus ends of the incisions along the bottom

of the sulcus in a direction away from the center of the

flap the length of these relaxing incisions can be increased.

This permits the reflection of the tissues to a higher level

in the case of the maxilla or a lower one in the case

of the mandible.

It is a basic principle of flap design that the base of

the flap should be as wide as is practical to ensure a

good blood supply. However, where teeth are standing,

the angle at the gingival margin should be no more than

around 100° or a narrow V shaped strip will be left which

will have an inadequate blood supply at its tip.

In order to raise the flap along the gingival margin

of the teeth the papillae needs to be divided

interdentally. A No. 15 scalpel blade on a No. 3 handle

is held parallel to the long axis of the teeth with the

back of the blade interproximally and the cutting tip

used to incise vertically downwards, first the distal

attachment of the papilla then the mesial attachment

so dividing it like a wedge of cake. The blade may then

be passed along the gingival crevice to divide the next

papilla, but if this is done it should not cut the periodontal

fibers below the alveolar crest. Often as the flap is

reflected it will separate readily from the alveolar bone

and the neck of the tooth so that the connecting incisions

are not essential. In the edentulous jaw, however, the

attachment of the mucoperiosteum to the crest of the

ridge is particularly strong and not only the crestal incision

be made firmly down to bone but reflection of the flap

may need the assistance of the knife to cut the tough

fibrous connections and to free it from the adjacent bone.

The use of excessive force with a periosteal elevator may

tear the flap, either at this narrow zone of strong

attachment, or at the sulcus end of a two limbed incision.

It is important to design the incision so that a complete

interdental papilla is present at each end of a three-sided

flap, because this facilitates suturing through each

interdental space. Bringing together the buccal and

lingual papillae in this way produces excellent healing

without clinically detectable increase in the depth of the

gingival crevices. If such an incision is made in the

experimental animal and the healing studied, a small

down growth of epithelium will be found at the depth

of the gingival crevice. The extent is microscopic, and

not detectable clinically.

Recommendations have been made from time to time

that the marginal gingiva should be avoided when

outlining a flap, in order to prevent injury to epithelial

attachment. Those who follow this advice make a

horizontal incision 2-3 millimeters away from, and

parallel to, the gingival margin. Unfortunately the strip

of gingiva which is left covers the margin of the alveolar

bone. Should the excision of bone be carried too close

to the concealed socket margin while, for example,

removing an unerupted upper canine, the crestal

alveolar bone may be damaged. Loss of the marginal

bone will not be repaired and permanent damage to

Exodontia Practice

the tooth attachment will result. Retention of such a

strip of gum also reduces surgical access with the result

that it becomes traumatized both during the operation

and when suturing, so producing necrosis with

breakdown of the suture line. In addition, at the end

of the operation, a bone cavity, such as the socket of

a tooth or a cyst cavity, may lie close to the line of closure

so that the wound edges are not adequately supported,

Again the suture line will tend to break down and the

flap fall into the underlying bony defect.

'In general incision lines should be planned so that

at the end of the operative procedure there is still an

untouched zone of bone at the cavity margin to support

the edge of the flap that has been reflected. This will

provide a broad area of contact through which the

process of healing can reattach the wound margin and

develop an adequate degree of early wound strength

to resist any tension during movement of the face and

jaws in the period immediately after the removal of the

sutures.

Mucoperiosteal flaps are relatively thin and do not

possess layers which can be closed separately, of necessity

any surgically created bone cavity forms a dead space

and creates a hematoma. It is important to seal this

effectively from the mouth and the possible ingress of

infection. Failure to achieve primary wound healing for

this or other reasons leads to exposure of the underlying

clot, leaving a cavity which will be repaired slowly by

'secondary intention'.

As alveolar wounds cannot be closed in layers a valve-

like closure is the best that can be achieved. Sitting the

incision so that there is a zone of intact bone between

the cavity margin and the line of the soft tissue wound

provides for such a valve-like closure. Where unavoidably

the incision line crosses the cavity, eversion of the wound

edge by mattress sutures creates an additional zone of

tissue contact, but not as secure a closure as one

supported on bone.

Provided incisions are confined to the mucoperio-

steum of the alveolar process or the palate, that is the

masticatory mucosa, the sutured wound is subject to

little tension. The sulcus tissues in contrast are elastic

and the wound edges contract away from one another,

though normally not so as to create a significant tension

in the sutured wound. Incisions made in the sulcus

radially or at right angles to the outer aspect of the jaw

are not subject to muscular pull and are readily closed

with little risk of wound dehiscence during healing. On

the other hand, horizontally aligned incisions in the sulcus

in some parts of the mouth are subject to tension during

movements of the jaws, lips and cheeks and are best

avoided. If such an incision is necessary, special care

is required in its closure to avoid wound breakdown.

For example, the design of flap often used when an

apicectomy is performed upon an anterior tooth is a

semilunar one with the convexity towards the gingival

margin. The incision for such a flap should not approach

closer to the gingival margin than one third of the depth

of the sulcus. Such a flap suffers from all of the dis-

advantages mentioned above. If the incision approaches

closer to the gingival margin, the remaining strip of gum

may slough, because its blood supply may be inadequate,

particularly after sutures have been passed through it.

Furthermore, it is not always easy to predict how large

the surgical cavity may be at the end of the operation,

particularly if a small cyst is to be dealt with during the

apicectomy, and the flap may be inadequately supported

at its margin. Finally the suture line will be under tension.

This can be seen as soon as the sutures are inserted

because the wound edges will gape between the sutures.

Some operators attempt to overcome this problem by

using horizontal mattress sutures, but there is a danger

with such a small wound that they will be drawn too

tight and strangulate the wound margin, particularly on

the gingival side. A three-sided flap which includes the

gingival margin of the tooth to be operated upon and

its interdental papillae is more satisfactory.

The problem of tension from muscular activity is

encountered again when horizontal incisions are made

either to 'deglove' the chin or to expose the anterior part

of the maxilla during a Le Fort I level osteotomy. Such

incisions should be made so that a generous skirt of

Transalveolar Extraction (Complicated Exodontia)

sulcus mucosa is left on the gingival aspect. In the case

of the mandible the incision should be carried out on

the labial aspect of the sulcus and then obliquely

downwards through the mentalis muscles to provide a

sufficient thickness of tissues on the gingival side to hold

sutures, A continuous horizontal mattress suture line will

bring the deeper tissues together and evert the wound

margin, but should not be drawn excessively tight, nor

should large bites of tissue be taken at each horizontal

step or the wound edge will be strangulated and slough.

The epithelial edges are coadapted by oversewing with

a continuous plain suture.

INSTRUMENTATION

In general incisions in the perioral tissues are made with

a No. 15 blade. The scalpel handle is held at an acute

angle with the proposed incision line but with the flat

of the blade at right angles to the surface. This way much

of the length of the cutting edge will be employed in

making the incision and it will be deepened progressively

down to the level of the tip of the blade. If the knife

is held with the blade vertically in the tissues they will

tend to bunch up ahead of the blade and a ragged cut

will result. Where mucoperiosteum is being incised, the

tissues are held steady by the underlying bone and a

clean cut is easily produced. Where soft tissues unsup-

ported by bone are being cut they must be stretched

gently at right angles to the line of incision, for example

on the inner aspect of the lip. Where thick tissues are

to be divided, such as those over the anterior border

of the coronoid process, the incision can be deepened

progressively by a succession of passages of the knife.

This way the direction of the cut can be controlled,

divided vessels identified and picked up with artery

forceps and damage to any important structures avoided.

If an attempt is made to divide the full thickness in one

sweep of the knife the operator will be tempted to plunge

the scalpel blade in at right angles to the surface so

bunching up the tissues as described above or resorting

to a sawing motion, all of which will result in a ragged

incision. \

In order to incise the periosteum cleanly, a degree

of pressure onto the bone must be maintained as the

blade is advanced. After a short while this will blunt the

edge of the blade. Incising over an unerupted tooth will

also damage the scalpel edge and a new blade should

be fitted before further incisions are made.

Loose connective tissue can be broken down by

pushing the ends of the closed blades of a pair of scissors

into the tissue then opening them. Performed with care

this type of blunt dissection will permit vessels and nerves

which are passing through such tissue to be displayed.

The excessive use of blunt dissection, however, is a bad

habit which will cause unnecessary tissue damage, untidy

wounds and imprecise surgery. Scissors can be used as

an alternative to a scalpel to divide sheets of soft tissue,

usually thin muscles and sheets of connective tissue and

mostly in a direction across the fibres. They are also used

to divide loose connective tissue to avoid excessive blunt

dissection.

Periosteum is raised from the bone with periosteal

elevators. These may have a thin rounded edge or a

sharpened edge flush with one surface and the end may

be curved to enable it to be applied closely to curved

bone surfaces. A blade end set at an angle to the handle

like a hockey stick is used in cleft palate surgery and

angled Warwick James' root elevators may be used as

substitutes for such periosteal elevators to raise the edges

of palatal incisions.

Large bi-angled spoon excavators also form excellent

miniature periosteal elevators when it is necessary to raise

soft tissues from bone in a confined space such as a cyst

cavity.

The fibers of most tendinous insertions lie almost

parallel with the surface and a periosteal elevator

advanced from the bone to the edge of the insertion

will slip up over the surface of the tendon. The muscle

insertion should be approached from the side.

FLAP REFLECTION

Flaps are raised by dissecting parallel to the surface at

the junction of tissue layers. Where these have similar

Exodontia Practice

mechanical properties, such as the junction of soft tissue

layers sharp dissection is used. Mostly dental surgeons

are intent upon exposing the mandible and maxilla so

that flaps are raised subperiosteally. This is done by blunt

dissection with a periosteal elevator, making use of the

well-defined plane of mechanical discontinuity between

the soft tissues and the hard bone. The attachment of

the periosteum to bone varies in strength from place to

place. The interdental papillae are firmly attached to the

cribriform surface of the tops of the interdental septa.

In the edentulous jaw this cribriform bone forms a narrow

continuous strip along the crest of the ridge. Connective

tissue fibers and vessels which pass from bone to

periosteum resist separation by the periosteal elevator

and it may be necessary to cut them with a scalpel. The

surface of the bone beyond the alveolar process can be

exposed by further elevation of periosteum and overlying

soft tissues, but a sufficient mesiodistal length of flap

needs to be developed to permit adequate retraction and

comfortable access to the bone at the operation site. On

the outer aspect of the body of the mandible several

structures are encountered which require special

attention. Foremost of these is the mental nerve. As the

periosteum is reflected in the region of the apices of the

mandibular premolar teeth, care should be taken until

the foramen is found. Gentle use of the periosteal elevator

will preserve the mental nerve and vessels inside their

conical sleeve of periosteum.

Special care should be taken where the patient is

edentulous. If the alveolar process is atrophic the mental

foramen will be relatively close to the crest of the ridge.

Indeed where resorption has been extreme the nerve may

emerge on the crest of the residual ridge and can be

seen radiating outwards beneath the mucosa.

Anterior to and below the mental foramen there are

the origins of the depressor labii and depressor anguli

oris muscles and the insertion of the platysma muscle.

These add only a marginally stronger attachment of the

soft tissues to the mandible. In contrast, the origin of

the mentillis muscle below the incisors requires a

substantial effort. Indeed the periosteum is firmly attached

over the whole mental eminence.

The attachment of the buccinator to the mandible

is easily disrupted, but it should not be raised unless the

additional access is definitely required. Once the edge

of the muscle has been separated edema of the buccal

space is facilitated producing a greater degree of facial

swelling postoperatively. As the body of the mandible

is uncovered buccal to the second molar it should be

remembered that the facial artery and vein lie

immediately external to the periosteum at this point.

More posteriorly the insertion of the masseter needs

to be separated to expose the outer aspect of the

mandibular angle. This requires little effort until the

posterior border of the ramus and the lower border of

the angle are reached. However, the tough, inelastic

periosteum may need to be incised by a few gentle strokes

across the inner surface to permit adequate retraction

of the muscle to allow work on the underlying bone.

The shape of the mandible makes surgical access to

its inner aspect awkward and this difficulty is increased

by strong muscle origins. The genial muscles can be

detached only by cutting through their origin, close to

the tubercles and of course if complete detachment is

necessary, they should be reattached. The sublingual

arteries enter the mandible through a single foramen just

above the tubercles and if divided they must be ligated

or the bleeding from them arrested with coagulation

diathermy. The mylohyoid origin extends from the third

molar region to the midline and is not at all easy to

separate from the bone, mainly because the muscle

slopes downwards and the periosteal elevator more easily

perforates the thin lingual periosteum and slips over the

surface of the muscle rather than lifting it from the bone.

It may be detached, if this is necessary, by hooking a

narrow, curved elevator beneath the posterior border

and detaching it from below upwards. This should be

done with care and it may damage the mylohyoid nerve

producing a transient patch of cutaneous anesthesia on

the point of the chin. Naturally in the elevation of the

mucoperiosteum on the lingual aspect of the 3rd molar

region the lingual nerve must be safeguarded. Even the

exposure of no more than the lingual aspect of the

Transalveolar Extraction (Complicated Exodontia)

alveolar process requires care because, except in the 3rd

molar region, the mucoperiosteum is thin and easily torn.

Any tear in the lingual periosteum will permit blood to

spread into the lax tissues of the floor of the mouth

forming a bulky hematoma.

As the outer surface of the maxilla above the alveolar

process is uncovered few obstacles are encountered. The

buccinator attachment is barely noticed and there is only

little resistance from the levator anguli oris. In contrast

the depressor septi muscles form a fleshy zone over the

central Incisors which requires some care during flap

reflection. Once the anterior bony aperture of the nose

is reached the reflection of the periosteum into the nasal

aspect of the maxilla impedes further mobilization of the

soft tissues. Caution should be exercised high on the

anterolateral aspect of the maxilla to identify and preserve

the infraorbital nerve. This is done by elevating the soft

tissues with a swab enclosed finger. Behind the zygomatic

buttress or zygomaticoalveolar crest on the posterolateral

aspect of the rnaxilla again the periosteum should be

raised gently. It is easily stripped from the bone but care

is necessary to avoid unnecessary damage to the

posterior superior dental artery as it enters the bone.

Exploration high up on the back of the maxilla leads

to its disruption and the onset of a brisk ooze. While

the hemorrhage is usually on a small scale. It can be

troublesome in this corner where visibility is bound to

be poor. Also a breach in the periosteum will release

the buccal pad of fat creating an even greater impediment

to vision. The mucoperiosteum of the hard palate is

normally raised by incising the interdental papillae or

by making an incision around the crest of the edentulous

ridge. The palatal mucoperiosteum is tightly attached at

the margin of such a flap so care must be taken not to

use a tooth as a fulcrum for the periosteal elevator when

it is raised. Initial elevation of the margin may be

facilitated by using the spoon-shaped end of a curved

Warwick James elevator. The mucosa is also tightly

attached to the median palatal suture and tethered to

the contents of the incisive fossa. Normally a generous

length of the curvature of the upper dental arch is needed

to form a useful flap. However, redially placed relieving

incisions can be made to limit the amount of mucosa

which is raised to gain access to the surgical site. These

should be short so as not to cut the greater palatine

neurovascular bundle. Division of the palatine artery

leads to a brisk hemorrhage which is best controlled by

elevation of the posterior margin of the cut, the appli-

cation of hemostat and underrunning the vessel with a

resorbable stitch which is then tied to form a ligature.

In order to raise the full width of the palate elevation

is started at a premolar interdental papilla on each side

and separation is carried up to and around the incisive

fossa structures. The nasopalatine nerves and vessels are

divided as they enter the deep surface of the flap and

rarely cause trouble either with hemorrhage or post-

operative loss of sensation. Posteriorly the greater

palatine neurovascular bundles in the adult emerge

opposite the second molars and must be preserved with

care. Damage to both can result in death of the flap.

Damage to one may result in cyanosis of the edge of

the flap.

Access just to the centre of the palate can be made

by a midline incision. The mucosa is thin, as well as tightly

adherent on either side of the midline, but can be raised

with care and retracted to expose the underlying bone.

A V shaped extension about the incisive fossa anteriorly

increases access if this is necessary, but should not extend

so far laterally as to divide the palatine vessels. Further

reflection of the mucosa can be achieved by a V shaped

cut at the posterior end but the thickness of the mucosa

at this site makes such an extension less helpful. In making

a posterior V shaped cut the incisions should not be

carried on to the soft palate nor should they be made

so as to endanger the greater palatine vessels.

TYPES OF FLAPS

• Envelope flop: In this type of flap, only crevicular

incisions are given and mucoperiosteal flap is raised

(Figure 7.10).

• Three cornered/triangular flap: In this type of flap,

in addition to the crevicular incisions, one release

Exodontia Practice

F i g u r e 7.10: Envelop flap

incision usually anteriorly is given, such that the flap

has two edges and three angles (Figure 7.11).

Four cornered flap: In this flap there are two releasing

incisions in addition to the crevicular incision.

Thus this flap has three edges and four angles (Figure

7.12).

The release incisions should lie on the mesio-

buccal or distobuccal line angle of the tooth and on

sound bone (Figure 7.13).

Release incisions on the facial aspect of crown don't

heal properly due to tension and sometimes results

in vertical clefting of bone.

• Incisions that cross gingival papilla damages the

papilla unnecessarily and increased chances of

localized periodontal problems.

INCISIONS (FIGURES 7.14A TO C)

• They play a vital role in health of flap and post-

operative healing.

• They should be made over intact bone.

• They should lie at least 6-8 mm beyond the

anticipated bony defect so that it lies on sound bone.

If incision lies over bony defect—it will tend to collapse

into the defect and result in wound dehiscence and

delayed healing.

F i g u r e 7 . 1 1 : Triangular flap

Transalveolar Extraction (Complicated Exodontia)

F i g u r e 7.12: Four cornered flap

F i g u r e 7.13: Mesiobuccal or distobuccal line angle of tooth

Firm pressure should be applied while placing

incisions.

Periosteum should be incised simultaneously.

A single stroke, without breaking continuity, must be

used to avoid ragged borders. Avoiding ragged

borders affects healing. Smooth borders lead to

primary healing, ragged lead to secondary healing

and scarring.

Blade should be changed if more than one flap is

to be raised because there is blunting of the blade

on contact with the periosteum and bone. Hence,

for clean incisions, while raising a second flap, one

should change the blade.

Reflection of flap begins at papilla with sharp end

of elevator.

Then broad end is used, it is inserted at middle corner

of flap.

F i g u r e 7.14A: Reflection of mucoperiosteal flap

Dissection is carried out with pushing stroke

posteriorly and apically.

This facilitates easy, rapid and atraumatic reflection

of mucoperiosteum.

Exodontia Practice

F i g u r e 7.14B: Lower anterior region with flap reflection

F i g u r e 7.14C: Palatal flap reflection

PREVENTION OF FLAP NECROSIS (BLOOD SUPPLY OF FLAP!
(FIGURE 7.151

1. Flap should be wider at base than apex to provide

unimpeded blood supply to all parts of the flap

Necessary to avoid ischemic necrosis of flap and

dehiscence (Figure 7.15).

2. Releasing incisions should converge at free end.

3. Length should not be more than the width. In

maxillofacial surgery, length of the flap is usually half

the breadth.

4. Base should not be excessively twisted/stretched,

grasped with sharp instruments that might damage

the blood supply of flap.

F i g u r e 7.15: Base at flap broader than open

PREVENTION OF FLAP DEHISCENCE

• Approximate flap margins over sound, healthy

bone.

• Gentle handling of tissues is necessary to maintain

the vitality of the tissues.

• Tensionless suturing to prevent necrosis of the flap

margins and dehiscence___

• Dehiscence causes bone exposure which causes

severe pain, bone loss and increased scarring

AVOID VITAL STRUCTURES

• Mental nerve: In premolar region use envelope flap

as far as possible. As flap is reflected care should be

taken until mental foramen is found. Gentle use of

periosteal elevator will preserve mental nerve in its

conical sleeve of periosteum. In edentulous arch with

ridge resorption- mental foramen will be close to the

ridge crest.

• Lingual nerve comes in mandibular 3rd molar

surgeries. A lingual flap if raised should be subperio-

steal as the nerve lies in the supraperiostael plane.

• Facial artery: releasing incisions at lower 1st molar

site should be curved at its lower edge to avoid the

facial artery.

Transalveolar Extraction (Complicated Exodontia)

• Greater palatine vessels: damage to these vessels is

avoided by avoiding a palatine flap. Controlling

bleeding from greater palatine artery is very difficult.

• If anterior palatine flap is raised, nasopalatine nerves

and vessels can be easily incised at the level of the

foramen. Bleeding can be controlled easily. In

addition nerve can regenerate quickly and the

temporary numbness does not bother the patient.

CLOSURE

• Achieves approximation of flap margins.

• Accurate apposition of flap—primary healing.

• Tensionless sutures: If sutures are tight they might cut

through or compromise blood supply causing necrosis

and dehiscence of flap.

• Suture tightness judged by avoiding tissue blanching

but knot should be tight.

Functions of Sutures

1. Coapt wound margins: If space between margins is

less, primary healing will result which will be rapid

and complete.

2. Hemostasis: Sutures play a role in hemostasis in

oozing socket but not in case of profuse bleeding.

Profuse bleed—chances of hematoma due to conti-

nuity of bleeding in underlying tissues. In Oozing

socket, bleed is controlled due to tamponade.

However, sutures should not be tight.

3. Holding soft tissue flap over bone. Bone that is bare

is very painful. It becomes non-vital and requires

longer time to heal.

ADVANTAGES OF LONG FLAPS

• Adequate visualization.

• Healing by first intention- rest on sound bone.

• Flaps not to overextend in vertical direction to avoid

vital structures.

AVOIDING BUTTON HOLED FLAPS

• In chronic sinus cases sometimes need to include sinus

in the tissue flap to avoid button holing of the flap.

BONE REMOVAL

• "Bone belongs to the patient and tooth to the

surgeon"

• Unnecessary bone removal must be avoided

• Bone removal is divided into removal before tooth

delivery and bone removal after tooth delivery.

• Bone removal before tooth delivery.

1. Removal of buccal cortical plate (l/3rd of retained

root surface to be exposed): Before delivery.

Buccal bone removal done for adequate visuali-

zation of tooth root. It improves access and brings

root in full view which can be removed by hand

instruments or rotory instruments. Rotory

instruments are preferred because hand instru-

ments chisel and mallet may strike root and

fracture root with bone at same level and there

is need for more bone removal. Also the sensation

is unacceptable under local anaesthesia. With bur

avoid cutting into root. Round burs are preferred

over straight fissure for bone removal because

cooling is easier and faster and visualization is

good.

2. Guttering of buccal bone: In this trough created bet-

ween bone and tooth on buccal and/or mesial or

distal aspect and height of alveolus is maintained.

3. Postage stamp method: Buccal cortical bone is

removed upto l/3rd height of root. This technique

is also used for retained apical l/3rd of root (Figure

7.16).

F i g u r e 7.16: Bone removal: Postage stamp method

Exodontia Practice

• Use of coupland chisel for bone removal can be done

under local anesthesia because it involves use of hand

pressure for bone cutting.

• Use of chisel and mallet can be done under general

anesthesia.

• Two vertical cuts, one anterior and one posterior

and one horizontal cut connecting both the vertical

cuts.

• Bevel of chisel should face bone that is to be cut—

faces mesially for distal cut and vice versa and

occlusally for horizontal cut.

• Bone removal after tooth delivery is performed to

achieve the following:

1. To smoothen sharp bone margins.

2. Reduce size of clot by reducing size of socket.

3. Recontour the residual alveolar ridge for prosthetic

rehabilitation.

TOOTH SECTIONING

• Also known as odontectomy. Fragments can be

removed easily one by one, we can section crown

from root, separate cusps, separate roots or perform

a combination.

Advantages:

1. Individual sections with different paths of with-

drawal can be removed easily.

2. Splitting of roots better with burs because of

definite control over splitting, although it is more

time consuming.

3. Creation of space by bur: If space is not created

between divergent roots they will still impact

against each other on elevation.

APPLICATION OF ELEVATORS

• "GIVE ME A LEVER AND A SECURE FULCRUM

AND I WILL MOVE THE WORLD"

• It will depend on configuration of root and direction

in which it must be moved for its delivery (Figure

7.17).

F i g u r e 7.17: Diagrammatic representation showing correct

method of application of elevator in curved root

• Straight roots can be elevated from any side (Figure

7.18)

F i g u r e 7.18: Diagrammatic representation of application

of elevator in straight root

• In curved roots elevator to be applied on convex side.

If applied on concave side root will get forced against

bone- further fracture of root (Figure 7.19).

In multirooted tooth with roots curved in same

direction, elevator applied on convex aspect of whole

root complex.

Multirooted teeth with roots having conflicting lines

of withdrawal:

1. Divergent

recurved root pattern: Roots should be

separated before application of elevator to convex

surface of each. Occasionally elevator can be applied

to unfavorable surface in case of infected root /

resilient bone / bone loss without fracture of root and

if space has been created between the two roots

(Figure 7.20).

Transalveolar Extraction (Complicated Exodontia)

F i g u r e 7.19: Application of elevator on greater curvature

of root

F i g u r e 7.20: Root sectioning and removal of root

2. Convergent root

cprved roots: elevator is applied

to convex surface (Figure 7.21)

• Elevators should be applied with modest and

controlled force.

• Sometimes it is essential to make more secure place

for application of elevators. This is done by drilling

notch in side of root which is more apically at its

depth. This will resist root fracture when elevation

is attempted. Round bur is used at an angle of 45

degrees to long axis of tooth (Figure 7.22).

TECHNIQUE FOR OPEN EXTRACTION OF SINGLE ROOTED TOOTH

1. Provide adequate visualization and access by raising

a flap.

2. Determine need for bone removal

• Reset extraction forceps under direct visua-

lization—extract.

F i g u r e 7 . 2 1 : Root sectioning and application of elevator

in curved roots

F i g u r e 7.22: Preparation of purchase point

• Grasp a bit of buccal/Ungual bone: Iimprove

mechanical advantage—grasp tooth root. Small

amount of buccal/lingual bone is removed. This

is alveolar purchase technique.

• Use straight elevator in a shoehorn pattern forcing

it down the periodontal ligament space with a

wiggling motion to expand the periodontal

ligament space and allow small straight elevator

to enter as a wedge and displace root occlusally.

• Proceed with bone removal over area of the

tooth. Bone removal in mesiodistal direction same

as width of tooth and in vertical direction. Then

extract with elevator or forceps. Heavy elevator

'crane pick' can be used.

Exodontia Practice

• If still difficult to elevate, prepare a purchase point

with bur at most apical portion of area of bone

removal. Notch is 3 mm in diameter and depth

to allow insertion of instrument (Figure 7.22).

TECHNIQUE FOR OPEN EXTRACTION OF

MULTIROOTED TOOTH

Mandibular First Molar

Technique

(Figure

7.23)

• Envelope flap is reflected.

• Tooth is sectioned buccolingually.

• Mesial and distal halves are formed.

• Sectioned tooth is treated as two single rooted teeth.

• Luxated with straight elevators and extracted with

universal forceps.

Technique 2 (Figure 7.24)

• If crown lost previously; reflect flap.

• Remove crestal bone.

• Section the two roots.

• Extract individually.

Technique 3 (Figure 7.25)

• Triangular flap reflected.

• Sufficient buccal bone removed to expose bifurcation.

F i g u r e 7.23: Vertical split of crown and its removal

• Mesial root sectioned with burs.

• Distal root along with crown extracted.

• Mesial root elevated with cryers.

Maxillary Molars with Divergent Roots

If crown is intact (Figure 7.26):

• Reflect mucoperiosteal flap.

• Remove small amount of crestal bone.

• Expose furcation.

• Separate mesiobuccal and distobuccal roots from rest

of the tooth.

• Extract crown with palatal root with bucco-occlusal

pressure.

• Palatal root with crown are delivered along long axis

of palatal root.

• Avoid palatal force to prevent palatal root fracture.

F i g u r e 7.24: Sectioning of mesial and distal roots and its removal

Transalveolar Extraction (Complicated Exodontia)

F i g u r e 7.25: Another method of sectioning and removal of tooth

• Elevate buccal roots one by one using straight / cryer

elevator. Avoid too much apical force to avoid sinus

perforation. Apply maximum force mesiodistally.

Crown is missing/fractured

• Divide the three roots.

• Extract them individually.

• First extract buccal roots, then extract palatal root.

SOCKET TOILET

• Removal of tooth/root does not complete the

procedure.

• Progress of healing and after-pain depends on socket

toilet.

• Irrigate with copious amounts of normal saline in the

socket and apical portion of flap where it joins bone

because it is a common place for debris collection.

If not irrigated may delay healing or cause sub-

periosteal abscess.

• Remove infected granulation tissue using a curette.

SUTURING

Incisions are closed and the tissues held in contact with

one another to permit healing by first intention by the

use of sutures. Hemostasis should be secured always

before the wound is closed. While the act of suturing

the wound will arrest a slight ooze from the surfaces which

the stitches bring together this cannot be relied upon.

If bleeding continues after the wound has been closed

a hematoma will form. This may either take the form

of a clot which creates a dead space in the tissues.

Hematomas increase the volume of the tissues, expand

flaps from the underside impairing their blood supply

and creating tension at the suture line. The tissues within

Exodontia Practice

F i g u r e 7.26: Method of sectioning and removal of maxillary molar

the bite of the sutures are also excessively compressed

and necrose so that the suture cuts out and the wound

opens, the so-called 'burst' suture line. Secondary

infection will follow. Hemostasis therefore must precede

wound closure.

The cheapest sutures are undoubtedly those made

from eyed needles and a suitable length of suture material

cut from a reel. However, most suture materials and

needles are difficult to sterilize, The needles are also

difficult to clean after use and become blunt and work

hardened so that they snap.

Modern sutures are prepared commercially and

sterilized by gamma radiation. The needles are eyeless,

with the end shaped as a tube into which the suture thread

is swaged. These 'atraumatic' sutures pass through the

tissues with minimal effort and damage.

Needles may be either round bodied or cutting.

Cutting needles are flattened on two or more aspects

behind the needle point to raise sharp edges which aid

penetration of tough tissues. Round-bodied needles dilate

a hole for the thread so that delicate tissues are less likely

to tear and the stitches cut out. The thread also fits tightly

in the hole to make a water-tight suture line. Large

needles may be handheld, but small needles such as are

required for suturing in the mouth are held in needle

holders. There should be a portion of the needle shank

which has flattened surfaces which may be held by the

needle holder and which prevent the gripped needle from

rotating. It is a fault of some modern needles that this

necessary flattening of the surface may not be present.

Needles are also either straight or have varying

degrees of curvature. Suturing in a limited space is

Transalveolar Extraction (Complicated Exodontia)

facilitated by a curved needle so that the point can be

readily seen and grasped after rotating it through the

tissues. A half circle needle is usually chosen. These are

22 and 25 mm in length measured around the curve,

and are well suited to relatively thin layers of tissue and

the small 'bites' required to close them. Suture material

of 2 metric (3/0) silk or polyglycolate is usually used

in the mouth.

The sutures may be either absorbable or non-

absorbable and monofilament or braided. The

traditional absorbable suture material is catgut and

despite the appearance of new synthetic materials it is

still widely used. Catgut is prepared from the collagenous

adventitia of lambs intestines and is prepared either plain

and simply stranded, twisted and sterilized with gamma

irradiation or treated with chromate, i.e. chromic gut.

to increase its tensile strength and delay absorption.

However, synthetic polymers the polyglycolate and the

polyglactin suture materials, are stronger and less irritant

to the tissues. Unfortunately if uncoated these sutures

may be difficult to knot securely and will spontaneously

untie unless the surgeon is familiar with their behavior.

Polyglactin sutures are coated with polyglactin 370

and calcium stearate (Vicryl-Ethicon) which reduces

drag.

In general, non-resorbable materials creates little

tissue reaction but because they are not destroyed by

the tissues are only used where they can be removed

or buried deeply in situations where permanent support

from the sutures is required and where subsequent

infection of the foreign material is unlikely. They may

be either monofilament or braided. Braided materials

are generally more flexible and are easy to knot and

so are more suitable for suturing the mucous membrane

of the mouth. Natural fibers, such as silk, with their slightly

roughened surfaces hold knots better than smooth

surfaced artificial fibers. However, a braided thread will

act as a wick for moisture and accumulate debris and

microorganisms which can irritate the wound. To prevent

this, braided sutures are often coated and made water

repellent with wax or silicone.

Monofilament synthetic polyesters such as poly-

propylene or polyamide (nylon) will not absorb and

conduct liquids in this way but are more difficult to knot

as they have an intrinsic springiness. Therefore only

4-0 or finer gauge monofilaments are used in the mouth.

As elsewhere in the body, catgut or other absorbable

material is used for buried sutures although these are

not often required during operations performed through

the mouth. Absorbable sutures are also used for mucosal

flap closure when operating on young children to avoid

the need for suture removal, or in all age groups for

suturing the inside of lips and cheek or the floor of mouth

where postoperative oedema may make the sutures cut

in to a degree that they are difficult to remove. Sizes

3/0 (3 metric) to 6/0 (6 metric) of catgut are chosen,

dependent upon the tissues to be sewn.

Needle holders with narrow beaks are required to

hold small, curved needles without flattening their

curvature. The handles should be sufficiently long that

the holding fingers do not obstruct the surgeon's view.

Modern eyeless needles are difficult to hold without

a ratchet type needle holder and this can be a dis-

advantage in awkward corners of the mouth.

However, they are less highly tempered than the eyed

needles and much less likely to snap if accidently bent.

The needle holder is clamped on to the needle at a

position about two-thirds of the distance from its tip. If

the needle is held correctly in this manner the length

between the jaws of the needle holder and the point

is sufficient to allow the needle to be inserted about

2-3 mm from the wound edge, and rotated through the

tissues so that enough of the pointed end emerges from

the wound to be gripped and drawn through. The flap

is controlled with either toothed dissecting forceps or a

skin hook and the edge everted as the needle is passed.

The needle point enters at right angles to the surface

and it should penetrate completely through a muco-

periosteal flap to obtain the maximum grip, but emerge

near the bottom of the soft tissue incision ensure that

there is no dead space,'left after it has been tied. Eversion

of the first side of the flap enables the curved needle

Exodontia Practice

to travel through the tissue obliquely away from the

incision to enclose a slightly larger bite on the deep aspect

than at the surface.

In general the needle should be drawn out of the

first side of the wound before the point is engaged in

the other. Now the second side is everted with toothed

forceps or a skin hook and the needle inserted from the

underside of the flap. The needle is inserted into this

side of the wound at the same depth that the thread

emerges from the first side. Now, once the needle

has penetrated into the second side the forceps or skin

hook is detached from the edge of the flap and pressed

against the surface of the tissues just beyond the hidden

point of the needle. This action pulls the superficial tissues

over the point so that the needle emerges closer to the

wound edge than it would otherwise. This way again

the needle embraces a greater width of tissue deeper

in.

Now when the stitch is tied the wound edges are

everted slightly. Eversion of the wound edges increase

the area of contact and so improves the early strength

of the healing wound. As the scar contracts a flat surface

results. The distance of the needle punctures from the

edge of the flap should be less than the depth to which

the stitch penetrates into the tissues, particularly with

mucoperiosteal flaps or one edge will overlap the other

as the knot is tied. Overlapping will also result if unequal

depths of flap are embraced by the stitch. Excessive depth

of bite in relation to width, on the other hand. Results

in excessive eversion and gaping of the approximated

wound at the surface.

In the mouth, one side of the wound often constitutes

the flap and has been freely elevated from the bone and

the other side remains attached to the bone almost up

to the incision. The edges of the fixed margin, however,

will have been raised for a sufficient distance to permit

penetration of the full thickness of the flap by the needle.

Suturing from loose to fixed flap usually enables finer

repositioning and reduces the chance of the suture tearing

through the fixed thin tissue layers. However, comfortable

suturing is important to good technique and to this end

it is preferable, where appropriate, to sew from the edge

further from the operator to the nearer one.

A knot is now tied, either by hand or with instruments.

If the knots are tied by hand more thread is wasted than

when instrument tying is employed, particularly where

the knots have to be formed towards the back of the

mouth. The technique of instrument tying therefore will

be described. Furthermore, it is easier to see what is

happening if instruments are used in the confined space

of the mouth.

The needle is drawn out of the second side of the

wound and the thread pulled through until a length of

about 4 cm remains protruding from the entry puncture.

The needle is taken from the needle holder with the index

finger and thumb of the left hand. The excess suture is

taken up into the palm of the left hand, using third and

fourth fingers and the thread grasped again with finger

and thumb about 8 cm from the wound. The beaks of

the needle holder are brought across the front of the

thread and rotated in a circle to pick up two loops of

the thread. The short end is now gripped at its end with

the needle holder and the loops slide off the beaks onto

the thread by rotating the needle holders so that the beaks

point towards the left and by drawing on the long end

with the left hand. The short end is given a short

downwards jerk which tumbles the loops into a slip knot,

which is positioned just beyond the tips of the beaks and

with the short length emerging from under the loops.

By drawing on the long thread the knot may be made

to slide down onto the tissues at the exit puncture. The

short end should not be pulled as if this is done an

unstable knot will result. Tension upon the long end also

results in a short end which needs minimum trimming

subsequently. The short end will emerge between the

loops and the tissues and the knot will not slip while

the long end only is under tension. As this first knot is

tightened the left hand moves away from the operator's

body and across the wound.

To form the second throw of the knot the needle

holder beaks are brought across the long thread from

behind and the points rotated downwards, away and

Transalveolar Extraction (Complicated Exodontia)

to the right to pick up a single loop. The short end is

again clamped but should not be pulled upon. The loop

is drawn off the needle holder beaks and the knot

tightened by traction upon the long end only with the

left hand. Final tightening is accomplished by drawing

the long thread towards the operator and the short end

away, across the wound. A third throw will prevent any

chance of a knot slipping, particularly if a synthetic suture

is being tied, or of the knot untying as it absorbs moisture

from the saliva in the case of catgut. The loop is formed

as for the first throw, but only one loop is picked up.

The left hand travels away from the operator and across

the wound to tighten the knot. The thread ends are held

up and cut off by the assistant.

It is essential to close a wound with the correct suture

tension, sufficient to keep the edges of the wound firmly

together, but no more. Slight edema of the soft tissue

margins can be anticipated postoperatively and

allowance must be made for this, particularly when

suturing the inside of the cheek or lips or the floor of

the mouth. If a suture is too tight it will cut into the tissues

and produce scars at right angles to the healed incision,

or stitch marks. Permanent suture scars depend more

upon the tension of the sutures than upon the length

of time before they are removed. To avoid irritation of

the healing wound the knot should be manipulated so

that it lies over the puncture point to one side of^the

wound. If an angled incision is used the apex between

the two edges is correctly positioned first. Then the next

two sutures are inserted at each mid-point between the

ends of the wound and the first suture. The remaining

sutures are interspaced at regular intervals.

Interrupted sutures are used for most oral surgical

procedures though where long incisions are to be

closed,continuous sutures are used. Where a continuous

suture has been inserted the thread is drawn after the

last penetration of the needle leaving a short loop on

the other side of the wound. The mid point of this loop

is grasped with the needle holder as the knot is tied,

instead of the usual short end.

Mattress sutures, which may be either horizontal or

vertical in design, embrace a greater volume of the tissue

which increases the grip upon the wound margin. In the

case of the former, the needle is introduced through one

wound edge and passed out through the other in the

usual manner. Then the needle is re-inserted about

3 mm further along the wound from the point of its

emergence, carried back through both wound edges and

tied. The vertical mattress suture is made by inserting

the needle 4-5 mm from the wound margin and through

the tissues in a deep bite. The needle is then re-introduced

close to the wound margin and taken through more

superficially in line with the previous direction of insertion,

but of course in the opposite direction. The suture is then

tied on the side of its original insertion. A vertical mattress

will coadapt the wound margins where there is a small

degree of tension and at the same time ensure eversion

of the wound edges.

Absorbable sutures can be inserted to close layers

below the skin surface, to ensure complete closure of

a wound in depth, to reconstitute sheets of muscle or

fascia and to eliminate potential dead spaces. The part

of the suture which will persist longer than the rest and

be likely to form a nidus for infection is the knot. If it

lies under the outer suture line the bulk may affect the

soundness of closure. For both these reasons the knot

should be buried on the deep aspect of the suture line.

The needle is inserted from the deep side of the layer

to be sutured and reinserted from above downwards

on the other side of the wound. When the knot is tied

it will slip through between the approximated tissues.

The removal of sutures should be performed with

care. They should be swabbed gently with chlorhexidine

then each knot gripped in turn with non-toothed forceps.

The external part of the suture is raised and the thread

cut below the knot and flush with its point of emergence.

In order to avoid a strain upon the healing wound the

suture is drawn out across the wound. This draws the

deep part of the suture out of the opposite puncture

creating tension towards the wound rather than away

from it. This prevents dehiscence of the healing wound

Exodontia Practice

F i g u r e s 7.27: Suturing techniques

and also draws only the previously buried part of the

stitch through the wound. Never cut through a stitch in

such a way that part of the contaminated external loop

is drawn through the wound. Above all, avoid cutting

the suture in two places so that part of the suture is left

in the tissues. As the suture is divided some compression

of the tissues is released and the retained segment retreats

into the depths of the tissue. Even if some micro-

organisms have travelled along the suture material they

do not produce a clinical infection in the ordinary way

because a suture creates a wound which is drained at

both ends. Leave a cut segment buried in the suture track

and allow the puncture points to close so that there is

no longer drainage and a stitch abscess will result.

Functions of sutures are:

1. Coapt wound margins.

2. Hemostasis—oozing socket but not in case of

profuse bleeding.

3. Holding soft tissue flap over bone.

4. Maintaining blood clot within socket—use of

gelfoam, oxidized cellulose.

If flaps are snugly in position and bleeding is

controlled, sutures are unnecessary.

AFTER CARE

• Maintenance of oral hygiene, especially at site of

sutures.

• Avoid accumulation of irritants, plaque and food

debris which will lead to infection and breakdown

of flap.

Chapt

2 J

The Root Piece

Removal

(The Fractured

Root)

Exodontia Practice

A decision must be made whether to leave or remove

a residual root. These requires anticipating whether the

root fragment will remain asymptomatic or whether it

will become infected and cause pain, perhaps lead to

an abscess and a discharging sinus, develop a cyst or

interfere with a denture. Occasionally mandibular roots

may even sink towards the lower border creating greater

problems in their removal.

If the root breaks after the tooth has become mobile

the missing piece should be recovered for it is almost

certain to become infected and cause pain. Conversely

when the apex of a tooth with a vital pulp snaps off before

the main body of the tooth has been loosened, the

fragment is likely to be enclosed by the bone of the

healing socket, and remain asymptomatic, and its

removal can be deferred if necessary. Perhaps the only

absolute indication for root removal is for patients for

whom unpredictable local infection may become major

risk such as those who have rheumatic or congenital heart

disease or who are immunosuppressed.

IMPORTANT FACTORS FOR CONSIDERATION

The following factors need to be determined before

decision to be made for removal of root piece.

THE AMOUNT OF ROOT RETAINED

When only apical 3rd or less of the root tip is retained

it may be left. More often the socket heals satisfactorily

and the root remains in the bone. However, sometimes,

as time passes, the alveolus resorbes and eventually the

root comes to the surface and may cause chronic

discomfort or an acute infective episode. Late removal

may be surgically easy, but may result in deficiency in

the edentulous alveolus. Generally, root tips should be

removed in patients below 50 years of age at the time

of fracture, while in older patients, their general condition

and the bone resorption rate should be considered.

THE SITE OF FRACTURED ROOT

i. Roots in the close proximity to anatomical spaces

such as maxillary sinus and inferior dental canal

should be left at the time of fracture and elective

surgical removal can be considered later.

ii. If the root is in close proximity to an adjacent tooth,

as in cases of displaced or dilacerated roots, and

causes damage to the adjacent healthy tooth, then

the root tip is better left alone.

iii. The palatal root of the maxillary 3rd molars,

particularly when the tooth is rotated, may be in

the position where access to it can only be achieved

by removal of the 2nd molar. Hence it is better

-to leave such a root piece.

REASONS FOR EXTRACTION

i. When a tooth is extracted for orthodontic purpose

no root should be left behind as it may prevent

movement of adjacent teeth into this space.

ii. When there is periapical radiolucency present, the

root as well as the periapical granuloma should be

removed, or else it may develop into a cyst.

Radiographic evaluation is mandatory.

AGE AND GENERAL MEDICAL CONDITION OF THE PATIENT

Very young, very elderly and certain nervous individuals

may tolerate extraction of the tooth under local anesthesia

but not the entire procedure of trans alveolar extraction.

It is rather wise to stop the operation and make other

arrangements for root removal than causing distress to

the patient.

CIRCUMSTANCES OF THE FRACTURE

If the tooth has been luxated before the fracture occurred,

the periodontal membrane may have been torn and any

blood supply to the root may have been cut off. Such

root then acts as a foreign body which may give rise

to a septic socket or chronic infection in the bone. Such

roots should therefore be removed.

TECHNIQUE FOR REMOVAL OF

SMALL ROOT TIPS

When the apical 3rd of the root fractures, initial

attempts should be made by the closed technique and

The Root Piece Removal (The Fractured Root)

if unsuccessful, then by open technique. Whatever

technique is chosen 3 basic requirements are of

importance -Excellent light for illumination of field, Good

suction for isolation of area and Good assistance.

THE CLOSED TECHNIQUE

It is a technique that does not require reflection of

mucoperiosteal flap and removal of bone. The technique

is most successful when the tooth has been well luxated

and mobile before the root tip fractured. However, if

the tooth was not well mobilised before fracture, closed

technique is less likely to be successful. It may not be

successful when the roots are hypercemented, dilacerated

or when there is a bony interference.

Forcep Removal

The narrow bladed forceps i.e. root forceps, are

invaluable for the removal of sizeable retained roots if

used with care as follows:

a. Always ensure that the blades are inserted beneath

the gingival which may have to be elevated locally

first.

b. Always obtain a grip on an identified root rather than

just grip the alveolus blindly.

c. Press the forceps well down over the root. In the

mandibular molar region a small amount of alveolar

bone may have to be included.

d. In the maxilla, apply the palatal forcep blade between

the palatal and one buccal root and the outer blade

buccal to the other buccal root where retained molar

roots are being tackled.

e. Apply a firm continuous force with a strong grip to

expand the alveolus, at the same time moving the

root only through a small arc while maintaining an

apically directed pressure. Rapid rocking movements

although popular are likely to fracture the roots.

f. This approach is likely to remove one mandibular

root or in the maxilla two roots, making the removal

of the remaining one easier.

After a root has been recovered, verify that the

removal is complete by fitting the tip to the previously

extracted portion of the tooth. If this precaution is

neglected, the surgeon may discover that he has failed

to retrieve the whole of a missing root. Indeed all teeth

should be inspected carefully after extraction because

some have an extra root and if this is fractured and

retained, its absence may be overlooked by a casual

glance at the tooth.

Endodontic files may help removal of root tips in

certain situations. After proper visualization of the root

canal is achieved, an endodontic file of an appropriate

size is selected and screwed into the root canal at the

fragment, until it firmly engages the root tip. The shank

of the file is gripped with the needle holder, which is

used as a lever to lift the root fragments from the socket.

If the file pulls out of the root canal, a larger size file

should be fitted into the canal and the technique

attempted again. The endodontic files are not useful for

removing root tips with non-visible canals, hypercemen-

ted roots, bony interferences and dilacerated roots that

prevent proper access to the root canal.

A technique that is similar in concept to the

endodontic file technique involves the use of the dental

drill with a small round bur to drill into the tooth root.

There may be sufficient friction between the bur and the

tooth to permit the root to be removed when the drill

is removed from the socket. This technique is more useful

for larger root fragments than for smaller root tips.

Root tips can also be removed with a straight elevator.

This technique is indicated more often for the removal

of larger root tips than for smaller root tips. Straight

elevator is forced into the periodontal ligament space,

where it acts like a wedge to deliver the tooth fragment

towards the occlusal plane. However care should be

taken to avoid strong apical pressure which may force

the root into the underlying tissues. This is more likely

to occur in maxillary premolar and molar area where

the tooth can be displaced into the maxillary sinus.

There are a number of other maneuvers which will

enable the operator to remove a fractured root without

resorting to a surgical procedure. However, too much

time should not be spent in this way and if success is

Exodontia Practice

not soon achieved the attempt should be abandoned

and a flap reflected.

In certain cases one complete root of a multirooted

tooth is fractured off and retained. With care it may be

possible to place a sharp pointed elevator in the empty

socket and rotate it to remove first the inter-radicular

septum and then the root. This is often a successful

method for removing lower molar roots but is less

successful in the maxilla. The distobuccal root from an

upper molar may be extracted in this way provided only

gentle pressure is used with an elevator inserted in the~

mesial socket. Unfortunately the mesial root is difficult

to remove through the distal socket, as the root curvature

is unfavorable for the application of an elevator from

the distal aspect. Mesiobuccal roots can be elevated by

introducing a Coupland chisel or straight Warwick James

elevator up the mesial periodontal membrane in order

to turn the root downwards and backwards.

Elevators should not be used to remove the palatal

root of an upper molar. The buccal wall of the socket

does not form a satisfactory fulcrum and can be crushed

by the elevating force. Furthermore there is always the

danger of forcing the root into the antrum. The palatal

root must be seen clearly, which usually implies the

removal of both the buccal roots and, if necessary,

some surrounding bone which can be done with a bur.

Then gentle dislocation with a narrow Coupland's chisel

or rotation with upper root forceps should deliver the

root.

Sometimes a root apex is heard to fracture after the

tooth has been loosened with forceps and it may be

possible to see the apex clearly with the aid of a sucker.

A probe or a thin root canal reamer or file can be

introduced into the root canal and the loose apex is

withdrawn with its aid.

So-called apical elevators are usually too thick to use

to dislodge the apical third of a tooth root from its socket,

but a stout, bi-angled spoon excavator may enter the

periodontal space and topple it out. However, the

movement will be a tilting one, pushing the sharp

fractured edge on the other side of the root against the

socket wall. This may be sufficient to prevent the operator

dislodging it out of the socket. A narrow groove cut

around the end of the root with a rose-head bur may

be sufficient to overcome this obstruction.

Used with discretion, these maneuvers can neatly

remove a number of small retained fragments but again

it must be emphasized that unless success is achieved

early, further attempts will prove frustrating and time

consuming. It is then much quicker to raise a flap, cut

away some buccal bone and tease out the fragment with

-a^fine elevator. Indeed if socket surgery is performed

without caution, it can lead to roots being forced into

the maxillary sinus or the inferior dental canal.

Where immediate simple measures have failed to

deliver a root, a formal surgical removal is essential. This

should not be undertaken without clinical reappraisal

and adequate radiographs to localize the root fragments

and identify the features which might explain the

problem.

THE OPEN TECHNIQUE

If the closed technique is unsuccessful, the surgeon should

attempt open technique. There are two main open

techniques for removing tooth tips.

1. A soft tissue flap is reflected with a periosteal elevator

and retracted with a right angled retractor. Bone is

then removed with a chisel or bur to expose the buccal

surface of the tooth root. The root is bucally delivered

with a straight elevator. The flap is repositioned and

sutured.

2. Open window technique (a modification of the open

technique without removal of the buccal plate). A

soft tissue flap is reflected in the usual fashion and

the apex area of the tooth fragment is located. A bur

is then use to remove the bone overlying the apex

of the tooth, exposing the root fragment. An

instrument is then inserted into the window, and the

root is displaced out of the socket. This approach

is especially indicated when the buccal crestal bone

must be left intact. An important example is the

removal of premolars root tips for orthodontic

The Root Piece Removal (The Fractured Root)

purposes, especially in adults.There should be no

hesitation to reflect a flap whenever this is necessary

to see the retained root clearly. It is also essential to

remove adequate bone to enable unimpeded

elevation of the fragment along the appropriate line

of withdrawal. This will avoid much frustration from

repeated premature attempts to dislodge the root.

In the edentulous jaw the incision is made along the

crest of the ridge or if adjacent teeth are standing, the

incision is made along their gingival margins. The flap

must be ample in length and vertical depth in order to

provide adequate access for surgical manipulations

without damage to the soft tissues.

BONE REMOVAL

What constitutes adequate bone removal can be learned

only by experience but, within reason, it is better to

remove rather too much bone than too little.

Bone is usually cut away from the buccal aspect of

a root because this not only improves the access but

brings the fragment into full view. The socket wall can

be removed either with a hand chisel or gouge, a mallet

and chisel, or a drill.

In general a bur in a dental drill is preferable to a

chisel or gouge for the removal of bone around a buried

root because if a hammer and chisel are used inexpertly

the edge of the chisel may strike the root it self and

fracture the root. Furthermore, most conscious patients

undergoing surgery under local anesthesia find the

sensation produced by a mallet and chisel objectionable.

When using a bur, care must be taken not to damage

the adjacent teeth or to cut into the root fragment itself

to a degree that fracture when elevation is attempted.

Burs are also used to separate divergent or curved

roots. A tapered fissure bur is best for this purpose.

Separation of roots with a bur may take longer time than

splitting them apart with an osteotome but is more

certain. If the roots are shattered by the splitting blow

their removal may be made more difficult. What is more

important is a space is created between the root ends

by the bur cut permitting curved or divergent roots to

move towards one another as they are elevated. If the

roots are split apart the split surfaces may still impact

against one another as elevation is attempted.

If the operation is performed under a general

anesthesia it may be convenient for the operator to use

chisels and a mallet instead of a hand piece and bur.

Two vertical cuts are made, one on either side or parallel

to the side of the root. For the more mesial cut the bevel

of the chisel should face distally and for the distal one-

mesially. This way the remaining bone edges are not

crushed. A third cut is made horizontally and joining the

other two cuts at a suitable distance from the socket

margin so as to expose at least a third of the length of

the retained root fragment. The cuts should just penetrate

the cortical bone and care should be taken not to damage

the adjacent teeth, nor should the chisel strike the root

as the third cut is made or it will be fractured. A curved

Warwick James elevator is inserted to lever the tooth

from the socket.

Alveolar bone may also be conserved during the

removal of small apical fragments. Instead of removing

the whole length of the lateral wall of the socket to reach

the root tip a window is cut in the bone overlying the

apical part of the socket and access gained to the root

in this way. It may be delivered laterally through the

opening or it can be dislodged into the socket and

retrieved from this aspect if it is a fresh socket.

THE APPLICATION OF AN ELEVATOR

The configuration of the root and direction in which it

must be moved for its delivery will determine the correct

site of application of the elevator. Roots may be straight

or curved and the only way to establish the shape of

a particular root is by radiography. The operator should

always try to identify the reason why the root fractured

during the original extraction. Was the impediment during

the original extraction of the tooth relieved by the fracture

leaving a readily removable root or does the obstruction

still exist.

Theoretically, an elevator can be applied to any side

of a straight root in order to apply the necessary

Exodontia Practice

dislocating force. However, if a root is curved the elevator

must engage its convex aspect. If it is applied incorrectly

to the concave side of the root it will not displace it from

the sockeTbut will produce a further fracture of the

fragment.

When dealing with multistoried teeth the roots of

which all curve in the same general direction, the elevator

may be applied to the convex aspect of the whole root

complex. However if the lines of withdrawal of the apices

conflict, because of a divergent or curved root pattern,

then the roots must be separated before applying an

elevator against the convex surface of each in turn.

Occasionally the application of an extraction force to

unfavorable roots in infected or resilient bone will result

in successful delivery without fracture, but in the vast

majority of cases, the unorthodox approach will lead

to further fragmentation or to crushing of the socket wall

and the formation of a dry socket. Even in the absence

of a suitable preoperative radiograph, an experienced

operator can often feel whether he is applying pressure

to the correct aspect of the root, for on sensing the

slightest resistance he will alter the position of the

instrument so that the edge of the blade engages a more

appropriate side of the root. Nevertheless, it is obviously

more satisfactory to avoid guesswork, and obtain the

relevant information about root pattern from a

radiograph. The elevating force should always be modest

and controlled as the application of excessive force will

result in further fractures of the tooth fragment or even

a fracture of the jaw. A fractured jaw is most likely to

occur during the removal of deeply embedded roots in

a thin mandible. There are times when, after adequate

surgical exposure of the socket, a systematic search for

the root tip proves abortive. Alternative possibilities for

its location should then be considered, namely

dislodgement into the soft tissues, deflection into the

antrum from upper posterior teeth, displacement into

the inferior dental canal or lingual pouch from lower

posterior teeth, loss into the mouth or on to the surgery

floor. Some patients refuse to have a retained root

removed. When this happens the issue should not be

pressed, but an entry should be made in the case notes

to this effect.

POLICY FOR LEAVING ROOT (TIP)

FRAGMENTS

When a root tip has fractured and the closed approach

of removal has been unsuccessful and the open approach

may be extensively traumatic, the surgeon may consider

leaving the root in place. As with any surgical approach,

the surgeon must balance the benefits of surgery against

the risks of surgery.

CONDITIONS FOR LEAVING ROOT TIPS IN THE SOCKET

Three conditions must exist for a tooth root to be left

in the alveolar process.

1. First the root fragment must be small, usually not more

than 4 or 5 mm in length.

2. The root must be deeply embedded in bone and not

superficial. This prevents subsequent bone resorption

from exposing the root and interfering with the

prosthesis that will be constructed over the edentulous

area.

3. The tooth involved must not be infected, and there

must be no radiolucency around the root apex.

The 3 risks involved on removal of root tips: The risk

is considered to be greater than the benefit if one of the

following conditions exists.

1. Removal will cause excessive destruction of the bony

tissue.

2. Removal of the root endangers the vital structures,

most commonly the inferior alveolar nerve, either at

the mental foramen area or along the course of the

canal. If surgical retrieval of a root may result in a

permanent or even a prolonged temporary anesthesia

of the inferior alveolar nerve, the surgeon should

seriously consider leaving the root tip in place.

3. Attempts at recovering the root tip can displace the

root into the tissue spaces or into the maxillary sinus.

The roots most often displaced into the maxillary sinus

are those of the maxillary molars.

The Root Piece Removal (The Fractured Root)

4. If the preoperative radiograph shows that the bone

is thin over the roots of the teeth and that the

separation between the teeth and the sinus is small,

the surgeon will choose to leave a small root fragment

rather than risks displacing it into the maxillary sinus.

Likewise, roots of the mandibular second and third

molars can be displaced into the submandibular space

during attempts to remove them.

ROOTS IN EDENTULOUS JAWS

• Difficult to judge the position of the root piece. There

are no teeth. Hence it is difficult to determine the

location without any guideline

• Insert a short needle in anesthetized gingiva and take

a radiograph just before the operation

• Better to retrieve the root fragment through outer

aspect of jaw, rather than alveolar crest to preserve

the alveolar height.

PROTOCOL WHEN LEAVING REHIND THE ROOTS

If the surgeon decides to leave a root tip in place, a strict-

protocol must be observed. The patient must be informed

that, in the surgeon's judgment, leaving the root in

position will do less harm than surgery. In addition,

radiographic documentation of the root tips presence

and position must be obtained and retained in the

patient's record. The fact that the patient was informed

of the decision to leave the root tip in position must be

recorded in the patient's record. Also the patient must

be recalled for several routine periodic follow-ups over

the year to trace the fate of this root. The patient should

be asked to contact the surgeon immediately if any

problems develop in the area of the retained root.

Chapter

Pediatric

Exodontia

Exodontia Practice

The general principles of exodontias remain the same

whether applied to adults or to children. However, in

the child we are dealing with a developing organism

in both its physical and its psychological aspects.

Techniques, therefore, must be modified to conform to

the needs of this growing patient. Some factors to be

considered in oral surgery for children as compared to

adults are:

1. The oral cavity is small and there is greater difficulty

in gaining access to the field of operation.

2. The jaws are in the process of growth and

development and the dentition is in a continuous state

of change, with the eruption and resorption of primary

teeth and eruption of permanent teeth taking place

simultaneously. Any interference with the growth

centers in the jaw or premature extraction of primary-

teeth may lead to malformations of the jaw, the

permanent teeth or both.

3. The bone structure of a child contains a higher

percentage of organic material, which makes it more

pliable than adult bone and not as likely to fracture.

LOCAL ANESTHESIA

It is unfortunate that many practitioners refer children

to the oral surgeon for extractions under general

anesthesia without first making an effort to perform the

extraction themselves under local anesthesia. The general

practitioner or pedodontist should instruct parents that

general anesthesia is the method of choice.

We have found that many children can be handled

under local anesthesia, provided that parents cooperate

and there are no other contraindications. The child should

be told in simple words what is going to be done. He

should never be told an untruth: a child can be

disappointed only once and his confidence is lost forever.

It is safer to tell the child that he will experience slight

discomfort like a scratch or mosquito bite than to promise

complete painlessness and not be able to abide by our

promise.

If a child complains of pain during an injection or

operation, believe him. reconsider the situation, reinject

if necessary, but never submit him to pain by force. A

great percentage of even the more difficult and frightened

children can be persuaded to take a local anesthetic. When

elective surgery is to be done, it is best to see the patient

at least once prior to the operation. This gives the operator

time to talk to the patient and presents an opportunity

to establish rapport. This visit will permit discussion of

the procedure with the child and parents. By taking time

to explain what needs to be done, the dentist can keep

apprehension and fear to a minimum.

PREPARATORY MEASURES

It is mandatory to obtain permission from a parent or

guardian of a child before any type of anesthesia, local

or general, is to be used. The consent should be in written

form and should include the type of anesthesia to be

used and the operation to be performed. In an

emergency, a telephone call will suffice, but it should be

confirmed by a written statement as soon as possible.

It is a safe precaution to note the number of the telephone

and the name of the person giving the oral consent on

the record of the patient, preferably in the presence of

an assistant who can act as a witness.

Children seem to tolerate local anesthetics better after

a moderate food intake, about two hours prior to the

operation. If it is felt that the child might require a general

anesthetic, the parents should be told not to give the child

food or fluids for at least six hours prior to the procedure.

Appointments for extraction should be made

whenever possible in the early morning when the child

is well rested. The office appointment should be scheduled

so that the child does not have to wait because he tends

to become restless.

The instruments on the tray should be covered

with a towel and out of sight of the patient. We have

found it best to place the instruments on a tray behind

the patient. A display of needles, knives, forceps

and other instruments upsets not only a child but any

patient. There is never a need to load syringes in front

of patients; to do so only loads to further fear and

apprehension.

Pediatric Exodontia

Premedication has proven invaluable and an operator

should not hesitate to use it. Immediately before the

operation, the child should be sent to empty the bladder

and bowels whether local or general anesthesia is used.

Clothing should be loosened and protected with a

gown or a protective apron. We prefer linen aprons, as

rubber or plastic coverings make patients perspire more

freely and this makes any patient, including a child, more

uncomfortable. Relatives and friends should be sent out

of the operating room unless it is felt that their presence

may be of benefit in handling the child. The child's position

should be adjusted for comfort and support and should

be slightly reclining.

ANESTHESIA TECHNIQUE

Some clinicians advise the use of topical anesthetics before

injection. It is difficult to determine how effective they

are. They certainly have a psychological value, but they

do not substitute for a good injection technique. If they

are used at all they should be used properly.

1. The mucous membrane should be dried to avoid

dilution of the topical anesthetic solution,

2. The topical anesthetic should be held in contact with

the surface for at least 2 minutes, allowing at least

another minute for it to act. One of the errors made

in the use of topical anesthetics is the operator's

failure to permit sufficient time for the topical agent

to produce any effect before he injects. It is wise

to wait at least four minutes after the topical

anesthetic is applied before starting the injection.

3. A topical anesthetic should be selected which does

not cause local necrosis at the site of application.

No irritation has been found from the use of

Xylocaine (lidocaine) ointment.

4. A sharp, fine needle with a relatively short bevel

should be used, attached to a smoothly working

syringe. We feel disposable needles should be used,

for they assure both sharpness and sterility. Their

use eliminates the possibility of transferring infection

from one patient to another by means of a

contaminated needle.

5. The tissues should be stretched if loose, as they are

in the mucobuccal fold: they should be compressed

if densely attached, as they are on the hard palate.

The use of tension and pressure helps produce a

certain degree of anesthesia and thus lessens the

pain associated with the introduction of the needle.

If the tissue is loose, we prefer to pull the tissue over

the needle as we are advancing it.

6. When using an infiltration technique the anesthetic

solution should be deposited slowly. Rapid injection

tends to accentuate the pain. If more than one tooth

in the maxilla has to be anesthetized, the operator

can enter the initially anesthetized area and. by

changing the direction of the needle to a more

horizontal position, can gradually advance the

needle and deposit the anesthetic solution. The

palatal side may be anesthetized by injecting a few

drops anterior to the greater palatine foramen,

which can be found on a line connecting the last

erupted upper molars. When anesthesia is necessary

in the incisal region of the maxilla we have found

it best to give the anesthetic on the labial and then

pass the needle from this anesthetized area through

the interdental papilla between the centrals and

gradually deposit the anesthetic solution as the

needle is advanced. This technique seems to

produce less pain than if the needle is inserted in

or around the incisive papilla.

7. The vasoconstrictor should be kept at the lowest

possible concentration e.g.. with 2 per cent

Xylocaine, not more than 1:100,000 epinephrine

should be used.

8. The symptoms of anesthesia should now be

explained to the child. Numbness, tingling, a feeling

of swelling may otherwise frighten a child who has

not been forewarned.

9. Enough time (5 minutes) should be allowed to lapse

before any operation is started. If tingling and

numbness in the lower lip do not occur in 5 minutes

following an inferior dental block, the injection

should be considered a failure and repeated.

Exodontia Practice

10. Aspirating syringes should be used to prevent

intravascular injection of the anesthetic solution to

keep toxic, allergic and hypersensitivity reactions at

a minimum.

TYPES AND LOCATION OF INJECTION

In anesthetizing the maxillary primary molars or

permanent premolars, the needle should penetrate the

mucobuccal fold and be inserted to a depth that

approximates that of the apices of the buccal roots of

the teeth. The solution should be deposited adjacent to

the bone. The maxillary permanent molars may be

anesthetized with a posterior superior alveolar nerve block

or by local infiltration.

Labial infiltration commonly is used to anesthetize the

primary anterior teeth. The needle is inserted in the

mucobuccal fold to a depth that approximates that of

the apices of the buccal roots of the teeth. Rapid deposition

of the solution in this area is conrraindicated because it

produces discomfort during rapid expansion of the tissue.

The innervation of the anterior teeth may arise from the

opposite side of the midline. Thus, it may be necessary

of deposit some solution adjacent to the apex of the

contralateral central incisor.

The infraorbital block injection is an excellent technique

that may be used in place of local infiltration of the anterior

teeth. All ipsilateral anterior maxillary teeth are

anesthetized by this block. The needle is inserted

anywhere in the mucobuccal fold from the lateral incisor

to the first primary molar and is advanced next to bone

to a depth that approximates the infraorbital foramen.

The foramen is readily palpated as a notch on the

infraorbital rim of the bony orbit. The solution is deposited

slowly.

The tissues of the hard palate are innervated by the

anterior palatine and nasal palatine nerves. Surgical

procedures involving palatal tissues usually require a nasal

palatine nerve block or anterior palatine anesthesia. These

nerve blocks are painful, and care should be taken to

prepare the child adequately. These injections are not

usually required for normal restorative procedures. If it

is anticipated that the rubber dam clamp will impinge

on the palatal tissue, however, a drop of anesthetic

solution should be deposited into the marginal tissue adja-

cent to the lingual aspect of the tooth. A blanching of

the tissue will be observed.

MANDIBULAR TOOTH ANESTHESIA

The inferior alveolar nerve innervates the mandibular

primary and permanent teeth. This nerve enters the

mandibular foramen on the lingual aspect of the mandible.

The position of the foramen changes by remodeling more

superiorly from the occlusal plane as the child matures

into adulthood. The foramen is at or slightly above the

occlusal plane during the period of the primary dentition.

In adults, it averages 7 mm above the occlusal plane.

The foramen is approximately midway between the

anterior and posterior borders of the ramus of the

mandible.

For the inferior alveolar nerve block, the child is

requested to open his or her mouth as wide as possible.

Mouth props may aid in maintaining this position for the

child. The ball of the thumb is positioned on the coronoid

notch of the anterior border of the ramus, and the fingers

are placed on the posterior border of the ramus. The

needle is inserted between the internal oblique ridge and

the pterygomandibular raphe. The barrel of the syringe

overlies the two primary mandibular molars on the

opposite side of the arch and parallels the occlusal plane.

The needle is advanced until it contacts bone, aspiration

is completed, and the solution is deposited slowly.

Occasionally, the inferior alveolar nerve block is not

successful. A second try may be attempted: however, the

needle should be inserted at a level higher than that of

the first injection. Care must be taken to prevent an

overdose of anesthetic.

The long buccal nerve supplies the molar buccal

gingiva and may provide accessory innervation to the

teeth. It should be anesthetized along with the inferior

alveolar block. A small quantity of solution is deposited

Pediatric Exodontia

in the mucobuccal fold at a point distal and buccal to

the most posterior molar.

Local anesthesia in children does not differ to a great

extent from that in adults. The lesser density of bone

hastens the diffusion of the local anesthetic through the

compact layers of the bone. On the other hand, the

smaller size of the jaws reduces the depth to which the

needle has to penetrate in certain block anesthesia. One

will find that, with the exception of the inferior dental

block, no other blocks are necessary in children.

The bone density is such, especially in the region

of the tuberosity that anesthetic solutions easily pass

through the cortex without the dentist having to a deeper

injection. Deep injections in this area may be followed

by a hematoma due to injury of the adjacent pterygoid

plexus, or. what is more likely, an injury of the posterior

superior alveolar artery or of its external gingival branch,

which runs downward and forward along the postero-

lateral wall of the maxilla close to the periosteum. This

is an unpleasant accident but it cannot always be avoided.

A hematoma, once noticed, can be controlled by packing

tightly compressed sponges behind and lateral to the

tuberosity intra-orally while applying pressure from the

outside against this pack with ice-cold compresses.

Mental and infraorbital blocks are usually unnecessary.

They often lead to transient nerve injuries

and hematomas which are painful. The block of the

greater palatine foramen often causes a sensation of

choking.

In terminal infiltration the puncture is made in the

mucobuccal (labial) fold, slightly gingival to the deepest

point, and the needle penetrates toward the bone in the

direction of the apex of the particular tooth. One should

consider the length of the root of each particular tooth

as seen on the roentgenogram.

Permanent molars require block injection; so do

multiple extractions or larger operations involving the

lower jaw. In making an inferior nerve block injection,

one has to bear in mind that the ascending ramus in

the child is shorter and narrower anteroposteriorly than

in the adult. The anteroposterior width may be estimated

by palpation through the skin. The lesser height of the

ramus has to be compensated for by inserting the needle

a few millimeters nearer to the occlusal plane than in

adults (Figures 9.1 A and B).

F i g u r e s 9.1 A and B: Difference in inferior alveolar nerve

block techniques

As mentioned earlier, the child should be informed

of the subjective signs such as tingling, numbness and

a feeling of swelling in the lip and tongue, either before

or preferably after the anesthesia has been administered.

Testing for anesthesia should be done carefully with

slowly increasing pressure of an explorer or other in-

strument, keeping in mind that anesthesia in the

superficial tissues does not necessarily mean anesthesia

of the deeper tissues.

The long buccal nerve should not be anesthetized until

definite signs of numbness in the respective side of the

lip appear, as the child might give misleading information

because he is confused by the tingling or numbness of

the mucosa of the lip. The long buccal nerve should be

anesthetized by terminal infiltration in the mucobuccal

fold of the respective tooth.

Exodontia Practice

EXTRACTION OF PRIMARY TEETH

INDICATIONS

In considering the advisability of extraction of primary

teeth, one should always keep in mind that age per se

is not an acceptable criterion in determining whether a

primary tooth should be removed. A primary second

molar, for example, should not be removed just because

a child is 11 or 12 years of age. unless there is a special

indication. For some patients the second premolars are

ready to erupt at 8 or 9 years of age while in other cases

these same teeth do not show sufficient root development

at the age of 12. A primary tooth that is firm and intact

in the arch should never be removed unless a complete

clinical and radiographic evaluation has been made of

the entire mouth and especially of the particular area.

Occlusion, arch development, size of teeth, amount

of root, resorption of the primary tooth involved, the

state of development of the underlying permanent suc-

cessor and adjacent teeth, presence or absence of

infection all of these factors must be considered in

determining when and how a primary tooth should be

removed.

With the above considerations in mind, indications

for extraction of primary teeth are as follows:

1. If the teeth are decayed beyond possible repair; if

decay reaches down into the bifurcation or if a sound

hard gingival margin cannot be established.

2. If infection of the periapical or interradicular area has

occurred and cannot be eradicated by other means.

3. In cases of acute dentoalveolar abscess with cellulitis.

4. If the teeth are interfering with the normal eruption

of the succeeding permanent teeth.

5. In cases of submerged teeth.

CONTRAINDICATIONS

Contraindications to extraction, except for the

considerations mentioned above, are more or less the

same as in adults. Many of these contraindications are

relative and may be overcome with special precaution

and premedication.

1. Acute infectious stomatitis, acute Vincent's infection

or herpetic stomatitis, and similar lesions should be

eliminated before an extraction is contemplated.

Exceptions to this are conditions such as acute

dentoalveolar abscesses with cellulitis, which demand

immediate extraction.

2. Blood dyscrasias render the patient susceptible to

postoperative infection and hemorrhage. Extractions

should be performed only after adequate consultation

with a hematologist and proper preparation of the

patient.

3. Acute or chronic rheumatic heart disease, congenital

heart disease and kidney disease require proper

antibiotic coverage.

4. Acute pericementitis, dentoalveolar abscesses and

cellulitis should be treated as will be explained later,

when and if indicated, with preoperative and

postoperative antibiotic medication.

5. Acute systemic infections of childhood contraindicate

elective extractions for the child because of a lowered

resistance of the body and the possibility of secondary

infection.

6. Malignancy, if suspected, contraindicates dental

extractions. The trauma of extraction tends to enhance

the speed of the growth and spread of tumors. On

the other hand, extractions are strongly indicated if

the jaw or surrounding tissues are to receive radiation

therapy for malignancy: this is done to avoid the risk

of an infection in the bone which has been exposed

to radiation.

7. 7eeth which have remained in irradiated bone should

be extracted only as a last resort and only after the

consequences have been fully explained to the

parents. If the teeth must be removed, consultation

with the radiologist who gave the irradiation might

be wise. Infection of the bone will follow extractions

in most cases even after antibiotic therapy, owing to

the avascularity which follows the radiation. The

infection is followed by a slowly progressing osteo-

myelitis which is very painful and which cannot be

controlled except by wide resection of the whole

Pediatric E x o d o n t i a

irradiated bone. It is. therefore, very dangerous to

remove teeth after exposure to radiation.

Diabetes mellitus

poses a relative contraindication.

Consultation with the physician is a wise precaution

to make certain that the child is under control. In con-

trolled cases of diabetes, one does not observe more

infections than in normal children and there-fore

antibiotics are not a prerequisite to extraction. It is

important that the diabetic child retain his

diet in the same qualitative and quantitative

composition after an operation. Changes in these

respects may change the sugar and fat metabolism

of the child.

INDICATIONS FOR EXTRACTION OF PERMANENT
FIRST MOLARS

When making a decision about the fate of permanent

first molars, the following considerations should be kept

in mind. If a permanent first molar is removed before

the permanent second molar has erupted through the

gingiva, the chances that this second molar will move

mesially and occupy the space of the extracted first molar

are very good. If. on the other hand, the permanent

second molar has erupted through the gingiva at the time

of the loss of the permanent first molar, the second molar

will probably tilt forward into the space of the first molar,

causing conditions favoring periodontal disease and

orthodontic problems such as closing-of the bite.

The procedure in practice, therefore, should follow

the rule that when the second molar has not yet broken

through and one or two first molars are diseased beyond

repair, they should be removed. But if three first molars

are diseased beyond repair, all four first molars should

be removed with the expectation that a more symmetrical

dentition will result.

In cases in which the second molars have broken

through, every attempt should be made to save the first

molars. If extraction is necessary, only the destroyed teeth

should be removed and space maintainers should be

inserted.

EXTRACTION TECHNIQUE FOR PRIMARY TEETH

Armamentarium

Many dentists choose to use the same surgical instruments

for their child patients as they routinely use for their adult

patients. Most pediatric dentists and oral and maxillofacial

surgeons, however, prefer the smaller pediatric extraction

forceps, for the following reasons:

1. Their reduced size more easily allows placement in

the smaller oral cavity of the child patient.

2. The smaller pediatric forceps are more easily concealed

by the operator's hand.

3. The smaller working ends (beaks) more closely adapt

to the anatomy of the primary teeth.

The choice of the proper instrumentation can also

depend on special considerations unique to the child and

the adolescent. The use of cow horn mandibular forcep

is contraindicated for primary teeth, owing to the potential

for injury to the developing premolars. Great care must

also be given to the routine use of elevators and forceps

adjacent to large restorations such as metal crowns and

especially restorations adjacent to erupting single-rooted

teeth that may easily become dislodged with the slightest

force (Figures 9.2A and B).

Figures 9.2A and B: Pediatric extraction forceps

100

Exodontia Practice

General Considerations

The technique used to perform extractions in the child

patient is similar to the manual extraction technique used

in the adult. T h e greatest difference is in patient

management. It is essential that the dentist take the time

to describe the ensuing p r o c e d u r e completely a n d

accurately to the child. A few children require general

anesthesia for the surgical procedure to be accomplished.

The choice of proper local anesthesia-sedation-general

anesthesia technique d e p e n d s on the psychological

constitution of the child and the extent and nature of

the surgical procedure. The appropriate local anesthetic

technique for each type of tooth is described earlier in

this chapter.

A number of aspects of the extraction procedure

should be performed with every extraction. The dentist

should consult with the child and the parents prior to

surgery in order to prepare them for the upcoming

procedure. The dentist should provide any preoperative

needs, such as prescriptions or any dietaiy restrictions,

that might be necessary as a result of the planned sedative

techniques. T h e entire surgical p r o c e d u r e a n d the

expected postoperative recovery course should also be

described. This allows the parents to prepare for any

special postoperative arrangements, such as the need for

a soft diet or child care support. As noted before, the

dentist should perform a thorough review of the patient's

medical history, looking especially for medical conditions

that might complicate treatment.

There is no other type of dental treatment in which

the principles of tell. show, and do are more important

than during extractions. The dentist should be sure to

obtain profound anesthesia because once the patient has

felt pain, it may be difficult to regain the child's confidence

to a level in which he or she will behave in a manner

that allows completion of the procedure.

Just prior to the actual extraction, the dentist should

place the balls of the index finger and thumb in the

area of the extraction and demonstrate to the child the

types of pressures and movements that he or she will

encounter during the extraction. This digital pressure

should be firm enough to rock the child's head from

side to side in the headrest.

The dentist should be placed in the position in which

he or she can easily control the instrumentation, have

good visual access to the surgical site, and control the

child's head. The non-dominant hand of the dentist is

then placed in the patient's mouth. The role of the

nodominant hand is to help control the patient's head:

to support the jaw being treated: to help retract the cheek,

lips, and tongue from the surgical field; and to palpate

the a l v e o l a r process a n d adjacent teeth during the

extraction. Once the proper operator and nondominant

hand positions are established, the actual extraction

technique may begin. Variations in technique for individual

teeth are discussed later in this chapter, but the general

principles apply to all extractions are same.

After the tooth is removed from its socket, the surgical

site is evaluated visually and with the use of a curette.

The curette should be used as an extension of the dentist's

finger to palpate and evaluate the extraction site. No

attempt should be made to scrape the extraction site.

If a p a t h o l o g i c lesion such as a cyst or periapical

granuloma is present at the apex of a permanent tooth

socket, it should be gently e n u c l e a t e d . A g g r e s s i v e

manipulation of a curette in a primary tooth socket is

contraindicated owing to the potential for damage to the

succeeding tooth bud. The operator should palpate both

the facial and palatal or buccal and lingual aspects of the

surgical site to feel for any bone irregularities or alveolar

expansion. Any bone sharpness should be conservatively

removed with the use of either a rongeur or a bone file.

Digital pressure should be able to return the alveolus to

its presurgical configuration if gross e x p a n s i o n has

occurred.

MAXILLARY MOLAR EXTRACTIONS

Primary maxillary molars differ from their permanent

counterparts in that the height of contour is closer to the

cementoenamel junction and their roots tend to be more

divergent and smaller in diameter. Because of the root

structure and potential weakening of the roots during

P e d i a t r i c E x o d o n t i a

101

the eruption of the permanent tooth, root fracture in

primary maxillary molars is not uncommon.

The extraction is completed using a maxillary universal

forceps. Palatal movement is initiated first, followed by

alternating buccal and palatal motions with slow contin-

uous force applied to the forceps. This allows expansion

of the alveolar bone so that the primary molar with its

divergent roots can be extracted without fracture.

EXTRACTION OF MAXILLARY ANTERIOR TEETH

The maxillary primary and permanent central incisors,

lateral incisors, and canines all have single roots that are

usually conical. This makes them much less likely to

fracture and allows for more rotational movement during

extraction than is possible with multirooted teeth.

MANDIBULAR MOLAR EXTRACTIONS

When extracting mandibular molars, the dentist must give

special care to the support of the mandible with the

nonextraction hand so that no injury to the temporo-

mandibular joints is inflicted. The mandibular forceps are

used to extract the tooth with the same alternating buccal

and palatal motions used to extract maxillary primary

molars.

EXTRACTION OF MANDIBULAR

ANTERIOR TEETH

The mandibular incisors, canines, and premolars are all

single-rooted. Because of this fact, one must take great

care that the forceps do not place any force on adjacent

teeth because they can become easily dislodged. This

also enables the dentist to use rotational movements in

the extraction process. Then slow, continuous force applied

in alternating labial and lingual movements enables these

teeth to be removed easily.

MANAGEMENT OF FRACTURED

PRIMARY TOOTH ROOTS

Any dentist who extracts deciduous molars occasionally

has the opportunity to treat root fractures. Once the root

has fractured, the dentist must consider the following

factors. Aggressive surgical removal of all root tips may

cause damage to the permanent tooth buds. On the other

hand, leaving the root may increase the chance for

postoperative infection and may increase the theoretical

potential of delaying permanent tooth eruption, although

most primary root tips will resorb. A common-sense

approach is best. If the tooth root is clearly visible and

can be removed easily with an elevator or root tip pick,

the root should be removed. If several attempts fail or

if the root tip is very small or is situated very deep within

the alveolus, the root is best left to be resorbed, most

probably by the erupting permanent tooth. In some cases,

the root tips do not resorb but are situated mesially and

distally to the succeeding premolar and do not impede

its eruption. The patient and parents should be notified

that a root fragment has been retained, and they should

be assured that the chance of unfavorable sequelae is

remote.

If the preoperative evaluation indicates that a root

fracture is likely or that the developing succedaneous tooth

may be dislodged during the extraction, an alternative

extraction technique should be used. In these cases, the

crown should be sectioned with a fissure bur in a

buccolingual direction so that the detached portions of

the crown and roots can be elevated separately.

If sufficient resorption of the roots has occurred,

extractions may be very simple. On the other hand, if

a tooth, especially a molar, has to be removed prema-

turely, the roots may have undergone little or irregular

resorption, and this situation can make these extractions

difficult. It must be borne in mind that the crown of the

succeeding tooth is situated in close relationship to the

roots of the primary tooth. The widespread roots of the

primary molars surround the crowns of the permanent

teeth, and we may dislodge, if not extract, the forming

tooth if great care is not exercised during the extraction.

The permanent tooth will offer little opposition because

of the lack of development of its roots. Not infrequently

the resorption of a primary molar root occurs halfway

between the apex and the cemento-enamel junction.

Exodontia Practice

This weakens the root considerably and fractures of such

roots are not uncommon. Good radiographs are of great

importance and should be studied carefully before the

extraction is planned. If such a root is broken, the question

arises whether it should be removed immediately or

whether an attitude of watchful waiting should be taken.

The decision hinges upon the skill of the operator and

the accessibility of the root tip. If the tip can be removed

without trauma to the bud of the permanent tooth, it

should be elevated with small spear-point elevators.

Occasionally it is desirable to elevate a mucoperiosteal

flap and remove buccal bone to approach such a tip.

The commercial elevators are usually too heavy and large.

We prefer an instrument which has been ground into

a point from a straight root tip elevator.

If a permanent tooth bud is moved during an

extraction, it should be carefully pushed into its original

position and the socket closed with one or two sutures.

Some operators cover the bud with Gelfoam. Should

a permanent tooth bud be erroneously extracted, it

should be reinserted immediately without disturbing the

tooth follicle or dentinal papilla. Care should be taken

to orient the tooth in the socket in the proper buccolingual

position, and the socket should be closed by sutures. Pulp

tests should be made of the tooth after eruption.

If an already erupted permanent tooth with an

insufficiently formed root has been dislodged during the

removal of a primary tooth, it should be reinserted and

immediately splinted. After healing, pulp tests should be

made, although the radiographic findings of further root

development and of eventual narrowing of the root canal

are proof that the vascular supply has been reestablished.

Chapter

Exodontia Practice

Exodontia is a minor procedure that can be safely

performed in dental office provided the patient is healthy

and the procedure is not dramatically invasive. It might

require some special attention in situation where the

host is compromised either due to underlying systemic

disease or certain prevailing condition like pregnancy,

which render them susceptible to complications.

Knowledge regarding the patient's medical condition is

of utmost importance in patient management. One

should always keep the following words in mind "Dentist

should not be concerned only with the treatment of teeth

in patients but also the treatment of patients who have

teeth". Good pre-operative assessment endeavors to

anticipate and prevent trouble. Hence before any

extraction it is a clever practice to take a thorough medical

history and it is truly said time spent in taking thorough

history is never wasted. Certain systemic conditions needs

special mention like cardiac diseases (e.g. Hypertension),

respiratory disorders (e.g. asthma), endocrine disorders

(e.g. Diabetes mellitus. thyroid dysfunction), disorders

of hemostasis (e.g. hemophilia, thrombocytopenia)

patients on long-term steroids, antiplatelets, anticoagulant

drugs, pregnancy, etc. Exodontia can be relatively or

strictly contraindicated in such systemic conditions.

Criteria of fitness for a procedure are not absolute but

depends on factors such as the. type of procedure,

duration of procedure, degree of trauma and stress,

health of patient, degree of urgency of the procedure,

skill of the operator, etc. Although care of the medically

compromised patient is a complex problem requiring

specialties in the field, its occurrence is so common

that the practitioners and students must be acquainted

with these condition in order to have the competence

necessary to recognize and prevent problems

associated with exodontia. In this chapter the commonly

encountered systemic conditions, preoperative

assessment and relevant investigations to be performed,

special precautions to be taken pertaining to extraction

of teeth, anesthetic considerations, careful use of

drugs and indication, contraindications if any are

disscussed.

List of condition commonly encountered and needs

special mention.

• Diabetes

• Hypertension

• Infective endocarditis

• Heart failure

• Artificial valves/transplants

• Thyroid dysfunction

— Hyperthyroidism

— Hypothyroidism

• Disorders of hemostasis

— Hemophilia.

— Patients on anticoagulants, antiplatelet drugs.

• Patients on long-term steroids.

• Pregnancy

• Epilepsy

• Asthma

• Patients undergoing radiotherapy

DIABETES

Diabetes mellitus is a group of metabolic disorders

characterized by hyperglycemia resulting from defects

in insulin secretion, insulin action or both. There can be

a low output of insulin from the pancreatic beta cells,

or the peripheral tissue may resist insulin. Types of

diabetes includes insulin dependent (type I immune

mediated or idiopathic) and non-insulin dependent

(type II), Gestational diabetes mellitus. Other specific

types include, Genetic defects in beta cell function.

Genetic defect in insulin action, diseases of exocrine

pancreas, endocrinopathies. drug induced infectious

associated with other genetic syndromes.

Type I diabetes is the result of progressive destruction

of the beta cells in the islets of Langerharis. which leads

to severe insulin deficiency. Symptoms of diabetes

become apparent when approximately 80-85% of the

beta cells are destroyed. Develops most often in children

and young adults before the age of 25 years.

The etiology of type II diabetes is not established.

The principle underlying defects are insulin resistance

i.e. the reduction in biological effect of insulin on glucose

Exodontia for Medically Compromised Patients

metabolism, beta cell failure which includes delayed

insulin secretion after nutrient stimulation, inability to

compensate for insulin resistance, metabolic inhibition

of beta cell function by chronic hyperglycemia.

Clinical features of diabetes can be divided into early

and late. Early features usually includes confusion and

behavioral change, constipation, itching, increased thirst

and urination (polydipsia and polyuria), polyphagia,

unexplained weight loss, undue tiredness, tingling or

numbness in the extremities, burning feet. Late features

include abdominal pain, coma, dehydration, hyperven-

tilation, muscle wasting, nausea, paraesthesia, renal

failure, shock, vomiting.

Laboratory diagnosis can give some definite clue, a

person can be said as having diabetes if there are

symptoms of diabetes and random plasma glucose

concentration > / = 200 mg/dl. Fasting plasma glucose

> / = 126 mg/dl, 2 hours plasma glucose > / = 200

mg/dl during glucose tolerance test.

Complications of diabetes can be varied and classified

as acute and chronic. Acute complication include mainly

hypoglycemia and hyperglycemia. Hypoglycemia is seen

usually in patients treated with insulin and is due to

imbalance between food intake and insulin therapy.

Hypoglycemic coma is the main acute complication. It

is usually of rapid onset and is usually a result of failure

to take food, overdose of insulin, alcohol consumption.

Hyperglycemic coma is usually has a slow onset over

many hours with deepening drowsiness, signs of

dehydration, acidosis. Long standing diabetes can lead

to a variety of complication. Chronic complication of

diabetes mainly includes large blood vessel disease, small

vessel disease (microangiopathy) and increased

susceptibility to infection.

Diabetics are considered to be at increased risk of

preoperative morbidity and mortality because of the

involvement of their vital organs the autonomic nervous

system in the natural course of the disease. Poor

metabolic control results in dangerous acute metabolic

complications due to surgical stress. The infection that

develops in them tends to become virulent which further

worsens the metabolic state, thus establishing a vicious

cycle.

Hyperglycemia leads to impaired wound healing,

deficient formation of granulation tissue, with poor tensile

strength of collagen. The fibroblast formation takes longer

time than non-diabetics and there is a deficient capillary-

growth into the wound. The chemotactic, phagocytic and

bactericidal activity of the neutrophil is deficient. There

is impaired humoral host defense mechanism and

abnormal complement function. Hence metabolic

assessment and management of diabetes must begin

early and maintenance of euglycemia (atleast < 200

mg%) during peri-operative period will reduce the

morbidity and mortality to a very large extent.

Surgical procedure causes a considerable metabolic

stress in the non-diabetic and more so in a diabetic. The

stress response to surgery is mediated by neuroendocrine

system essentially by stimulating the adreno-medullary

axis. The neuroendocrine system comes into play to

maintain fuel requirements by glycogenolysis and

gluconeogenesis through stress hormones catecho-

lamines, glucagon. Cortisol, and growth hormone. In a

non-diabetic there is enough insulin secretion to utilize

the fuel produced by the stress hormones and thus

glucose homeostasis is maintained. Whereas this com-

pensatory elaboration of insulin is less possible in Type

II diabetic and cannot occur in Type I diabetic necessita-

ting supplementation of insulin in peri-operative period.

The pre-operative evaluation is necessary to know

the metabolic, nutritional, electrolyte, cardiac, pulmonary

and renal functions as well as the autonomic and

peripheral nervous system status. If the cardiac disease

is suggested by history and physical examination, the

tests to detect the presence of ischemic heart disease can

be helpful in preoperative assessment of the patient.

CARE PERTINENT TO EXODONTIA

Exodontia is a minor surgical procedure and is usually

elective unless performed in emergency depending on

the merit of individual case. It is important to determine

disease status, associated disorders and drug therapy.

Exodontia Practice

Physician consent should be obtained regarding the

planned surgical procedure including drug administra-

tion. Before performing any kind of procedure the dentist

should make use of stress reduction protocol. Stress

increases the amount of secreted Cortisol and endogenous

epinephrine which induces hyperglycemia. So the

procedure should be short, stress free and atraumatic.

Once every measure to reduce the anxiety of patient

is made, other most important concern is avoiding

hypoglycemia. Additional consideration should be given

to maintenance of normal dietary habits. Exodontia can

interfere with normal pattern of food intake and can

interfere with diabetic control, so the insulin dosage must

be adjusted accordingly. It is best to give oral glucose

just before appointment. The essential requirement is to

avoid hypoglycemia but to keep hyperglycemia below

levels that may be harmful because of delayed wound

healing or phagocytic dysfunction.

Appointments should be early to mid-morning after

a normal breakfast and normal antidiabetic treatment

because levels of endogenous corticosteroids are higher

in morning and stressful procedure are tolerated better.

Antibiotic prophylaxis varies depending on the state of

patient's metabolic control. Prophylactic antibiotic

coverage is indicated because of following reasons like

defective leukocyte function, decreased chemotaxis and

phagocytosis secondary to hypoglycemia, decreased

bactericidal activity, cellular immunity and vascular stasis,

higher infection rates and impaired healing. Local

anesthesia can be used safely. Epinephrine level in local

anesthesia has no significant effect on blood sugar but

excessive quantities of epinephrine should be avoided

to prevent elevation of blood glucose levels by stimulation

of sympathetic receptor system. Conscious sedation can

be used safely as well. Autonomic neuropathy in diabetes

can cause orthostatic hypertension hence supine position

should be slowly raised upright in the dental chair.

SYSTEMIC HYPERTENSION

Hypertension is a persistently raised blood pressure

resulting from raised peripheral arteriolar resistance, but

the definition of in terms of blood pressure, of what is

hypertension is arbitrary. In general the blood pressure

rises with age. When either or both systolic or diastolic

pressure are persistently raised and on remeasurement

with systolic pressure over 140 and diastolic over

90 mmHg, it is generally regarded as hypertension. About

one-third of the people with hypertension are unaware

of it, and those under treatment only one-third are fully

compliant. In more than 90% the cause is unknown and

it is then termed essential hypertension which becomes

more frequent as the age advances, and appears to be

related to genetic influence, obesity and various other

factors. About 40% of hypertensive patients have raised

levels of circulating catecholamines, epinephrine or nor-

epinephrine and may therefore have abnormal

sympathetic activity. Hypertension can be secondary to

defined causes such as renal disease, endocrine disorders,

pregnancy, oral contraceptives, certain drugs like cocaine,

amphetamine, immunosuppressives, glucocorticoids,

mineralocorticoids. etc. can raise the blood pressure. Some

nonsteroidal anti-inflammatory drugs like indomethacin

can impair the efficacy of the antihypertensive agents.

CARE PERTINENT TO EXODONTIA

It is important to determine status of hypertension,

associated disorders and physician's consent of any

planned surgical treatment regimen. Knowledge of drugs

administered with their potential to interact with

vasoconstrictors, other drug regimens and associated

systemic disorders. Implement strict stress reduction

protocol. Small, late morning appointments are preferred,

as endogenous epinephrine levels peak during morning

hours and adverse cardiac events are most likely in the

early morning.

Compliance and effectiveness of the medical therapy

should be confirmed by blood pressure recordings

(average of 2 recordings) at several short appointments

prior to and at the time of surgery. Patients with a

sustained blood pressure > 160/95 mm Hg are not

considered well controlled and exodontia should be

delayed until medical control is established.

Exodontia for Medically Compromised Patients

A risk in the administration of local anesthesia for

the hypertensive patient is the inclusion of epinephrine

and its sympathomimetic effect on cardiac beta-2

receptors. The current dosages of a local anesthetic

solution for a patient with poorly controlled hypertension

is two 1.8 ml cartridges (for a total dose of 3.6 ml) with

1:100.000 epinephrine per appointment. If lengthy

procedures are anticipated, the epinephrine should be

diluted to as ratio of 1:200.000. The side effects of

absorbed epinephrine must be weighed against the

benefits. Many clinical situations will contraindicate the

use of epinephrine. The apprehensive sweating, or

nervous patient likely has increased levels of endogenous

epinephrine. Because plasma levels of epinephrine

are dose dependent, administration of epinephrine

would be contraindicated for hypertensive patient.

The type of injection that is administered (block vs.

infiltration) as well as vascularity of the area where the

local anesthetic is being deposited is also an important

factor.

Barbiturates, narcotics and phenylephrine are

contraindicated in patients on mono-amine oxidase

inhibitors.

INFECTIVE ENDOCARDITIS

Infective endocarditis is a rare but dangerous, potentially

lethal infection, predominantly affecting heart valves.

Platelets and fibrin deposits accumulate at sites where

there is turbulent blood flow over damaged valves

(nonbacterial thrombotic endocarditis). These sterile

vegetations can thereafter readily be infected during

bacteremias resulting in infective endocarditis. Infective

endocarditis results from two main predisposing factors—

bacteremia and a cardiac lesion where there is turbulent

blood flow. Viridans streptococci such as Strep, mutans

and Strep, sanguis are most common causative

organisms. Others implicated include particularly

Staphylococcus aureus and enterococci. Viridans

streptococci have complex attachment mechanisms,

which may enable them to adhere to the endocardium.

The most common type of bacteremia implicated in

patients with infective endocarditis involves Viridans

streptococci, which are present in enormous numbers

in the mouth. Viridans streptococci proliferate where

oral hygiene is lacking and proliferate into the blood

stream in large numbers particularly in during tooth

extraction. Oral bacteremia after a tooth extraction are

generally transient and last for less than 15 min. but

may last even for one hour.

The signs and symptoms are highly variable. In the

previously healthy patient who acquires endocarditis due

to Viridans streptococci the picture is likely to be that.

3 or 4 weeks after a dental operation, there is insidious

onset of the low fever and mild malaise pallor or light

pigmentation of the skin, joint pains and hepatospleno-

megaly. The main effect of endocarditis are progressive

heart damage, infection or embolic damage of many

organs, especially the kidneys. Release of emboli can

have effects ranging from loss of a peripheral pulse to

sudden death from stroke. Embolic phenomenon

include hematuria, cerebrovascular occlusion, petechiae.

purpura of skin and mucous membrane, splinter

hemorrhage under the fingernails. Roth spots are small

retinal hemorrhages: Osier's nodes are small tender

vasculitic lesions of the skin.

CARE PERTINENT TO EXTRACTION

Prophylaxis should be given for dental procedures that

disturb the bacteria in periodontal sockets, since this

provides a g o o d chance of precipitating infective

endocarditis in a susceptible patient (Table 10.1). In a

survey of nearly 5000 cases of infective endocarditis

attributable to dental treatment, it was found to have

followed dental extractions in 95%. Role of antibiotic

prophylaxis is a subject of controversy but a word of

caution is that antibiotic prophylaxis is essential, where

appropriate. The current recommendations are,

therefore, that antibiotic prophylaxis is mandatory for

extraction. The surgical procedure should be minimally

invasive and atraumatic as far as possible.

Exodontia Practice

Table 1 0 . 1 : Possible prophylactic antibiotic regimens

against infective endocarditis

Recommending authority

Regimen

U K : B r i t i s h S o c i e t y for 1 9 9 2

A n t i m i c r o b i a l C h e m o t h e r a p y

E u r o p e a n c o n s e n s u s 1 9 9 5

A m e r i c a n H e a r t A s s o c i a t i o n 1 9 9 7

( a ) A m o x i c i l l i n : 3 g 1 h b e f o r e

t r e a t m e n t

( b ) C l i n d a m y c i n : 6 0 0 m g 1 h

b e f o r e t r e a t m e n t

( a ) A m o x i c i l l i n : 3 g 1 h b e f o r e

t r e a t m e n t

( b ) C l i n d a m y c i n : 3 0 0 - 6 0 0 m g

1 h b e f o r e t r e a t m e n t

( a ) A m o x i c i l l i n : 2 g 1 h b e f o r e

t r e a t m e n t

( b ) C l i n d a m y c i n : 6 0 0 m g 1 h

b e f o r e t r e a t m e n t

HEART FAILURE

Heart failure is when the pumping action of the heart

is insufficient to meet body's demands. Lack of tissue

and organ perfusion results. The most common cause

of heart failure is ischemic heart disease. Left-sided heart

failure results in damming of blood back from the left

ventricle to the pulmonary circulation with pulmonary

hypertension and pulmonary edema. Lying down

worsens pulmonary congestion, edema and dyspnea

(orthopnea). It also makes respiration less efficient, and

cyanosis likely, because the abdominal viscera move the

diaphragm higher and reduce the vital capacity of the

lungs. Coughing is another typical consequence. The

sputum is frothy and. in severe cases, pink with blood.

In the more advanced stages of left-sided heart failure

there is inadequate cerebral oxygenation, leading to

symptoms such as loss of concentration, restlessness and

irritability or. in the elderly, disorientation. Right-sided

heart failure causes mainly congestion of the systemic

and portal venous systems, affecting primarily the liver,

gastrointestinal tract, kidneys and subcutaneous tissues.

It thus presents with peripheral (dependent) edema and

fatigue. The liver is usually enlarged due to passive

congestion, causing abdominal discomfort and. in severe

cardiac failure, raised portal venous pressure also leads

to escape of large amounts of fluid into the peritoneal

cavity (ascites). Most patients suffer bi-ventricular failure,

since failure of one side of the heart usually leads to

failure of the other. The pulse may become rapid and

irregular, particularly if there is atrial fibrillation, and. in

extreme cases, patients are cyanotic, polycythemic,

dyspneic at rest and edematous with pulmonary edema

and distension of neck veins -(raised jugular venous

pressure). Heart failure is usually progressive, but may

cause few symptoms until activity becomes limited with

breathlessness (dyspnea), cyanosis and dependent

edema (usually swollen ankles). Sacral or ankle edema

are common dysrhythmias and sudden death may

result.

CARE PERTINENT TO EXTRACTION

It is dangerous to lay any patient with left-sided heart

failure supine. It will severely worsen dyspnea. The dental

chair should be kept in a partially reclining or erect

position. Extraction may precipitate dysrhythmias, angina

or heart failure. Anxiety must be minimized and pain

control must be fully effective. For patients with poorly

controlled or uncontrolled cardiac failure (worsening

dyspnea with minimal exertion, dyspnea at rest, or

nocturnal angina).medical attention should be obtained

before any dental treatment. Appointments should be

short. Patients are best treated in the late morning.

Endogenous epinephrine levels peak during morning

hours and cardiac complications are most likely in the

early morning. Late morning appointments are recom-

mended. An aspirating syringe should be used to give

a local anesthetic. Epinephrine may, theoretically,

increase hypertension and precipitate dysrhythmias.

Blood pressure tends to rise during oral surgery under

local anesthesia, and epinephrine can theoretically

contribute, but this is usually of little 'practical impor-

tance'. Effective analgesia must be p r o v i d e d .

Bupivacaine should be avoided as it is cardiotoxic.

Otherwise, local anesthesia can usually safely be used

providing that consideration is given to the underlying

cause of the cardiac failure. Epinephrine containing local

anesthetics should not be given in large doses to patients

taking beta blockers. Interactions between epinephrine

and the beta blocker may induce hypertension if

excessive doses of the local anesthetic are given.

Exodontia for Medically Compromised Patients

Supplemental oxygen should be readily available.

Cardiac monitoring may be desirable.

Medication such as diuretics may cause orthostatic

hypotension, and therefore patients should be raised

slowly to the upright position. NSAlDs other than aspirin

should be avoided in those patients taking ACE inhibitors

since they increase the risk of renal damage. Patients

being treated with digoxin for atrial fibrillation or congestive

heart failure are more prone to ECG changes such as ST

segment depression during dental extractions under local

anesthesia than other cardiac patients. Erythromycin and

tetracycline should be avoided as they may induce digitalis

toxicity by impairing gut flora metabolism of the digitalis.

Some drugs may complicate treatment, such as digitalis

(vomiting). ACE inhibitors (coughing) or itraconazole

(cardiac failure). Conscious sedation can usually safely

be used. However, consideration must be given to the

underlying cause of the cardiac failure.

ARTIFICIAL HEART VALVES AND TRANSPLANTS

Currently used prosthetic heart valves (synthetic or

porcine) are composed of teflon or teflon like material

to diminish the possibility of adhesions. The danger of

clumps of bacterial colonies collecting on these valves

increases after a bacteremia induced secondary to dental

procedures. So such patients are highly susceptible to

endocarditis, therefore physician's consult for antibiotic

pre-medication is important. The management challenge

is most difficult because of the need to avoid altering

the cardiac output and the physiologic or pharmacologic

compensation mechanisms.

TREATMENT CONSIDERATIONS

Patients who have received a mechanical or bio-pros-

thetic artificial heart valve are at high-risk for endocarditis.

The overall risk for prosthetic valve endocarditis is

1-2% per patient year. Infections due to it are of 2 types

that occurring early within 2 months of valve replacement

which is caused by Staphylococci. Streptococci and

gram negative bacilli. Other occurring late, i.e. 2 months

of v a l v e replacement, caused by Streptococci

predominantly, antimicrobial prophylaxis is mandatory

in these patients. Such patients are maintained on life-

long immunosuppressive therapy which creates an

increased potential for infection. Steroids suppress the

adrenal glands and supplemental corticosteroid therapy

is necessary. When the patient is stable post-operatively.

the condition and recent history must be assessed to

determine if urgent dental care only should be provided

in the first 6 months with necessary antibiotics, monitoring,

concern for coagulopathies and adrenal suppression.

After 6 months, if the patient is stable, the evalua-

tion of the patient's recent history and medical

consultation should reveal what dental extraction is

generally possible with considerations for adrenal

suppression and the potential for infection owing to

immunosuppression.

A significant increase in heart rate is observed in such

patients after administration of 2% lidocaine with

1:80.000 epinephrine, but not after the administration

of 3% mepivacaine with 1:100.000 epinephrine and

prilocaine with felypressin. This suggests that without,

or with, low concentrations of epinephrine should be

used. Such patients should receive antibiotic premedi-

cation orally parenteraly. Local (topical) measures for

hemostasis should be used.

Lab investigation should be carefully evaluated.

PT and aPTT should be adjusted to within 150 % of

the normal/control value, i.e. 11 and 35 sec. respectively.

BT should be under normal range.

HYPERTHYROIDISM

Hyperthyroidism is associated usually, with a diffuse goiter

due to autoimmune disease(graves disease, primary

hyperthyroidism) when there are thyroid-stimulating

autoantibodies against thyroid TSH receptor (TRAbs)

and thyroid microsomal antibodies (TMAbs) sometimes,

with a hyperfunctioning (toxic) multinodular goiter or

nodule due to one or more thyroid adenomas producing

excess thyroxine. 90% of the swellings are benign rarely

with thyroiditis, thyroid hormone overdosage, or ectopic

thyroid tissue.

110

Exodontia Practice

Clinical features include anorexia, vomiting or

diarrhea, weight loss, anxiety and tremor sweating and

heat intolerance cardiac disturbances, particularly in elder

patients. These includes tachycardia, dysrhythmias

(especially atrial fibrillation) or cardiac failure exoph-

thalmos, eyelid lag and eyelid retraction. Thyrotoxic

periodic paralysis comprises attacks of mild to severe

weakness, during which serum potassium levels are

generally low. Myasthenia gravis may occasionally be

associated.

CARE PERTINENT TO EXTRACTION

Patients with untreated hyperthyroidism can be difficult

to deal with as a result of heightened anxiety irritability.

The sympathetic overactivity may lead to fainting. Local

anesthesia is the main means of pain control. The risk

from epinephrine exacerbating symphathetic overactivity

is only theoretical.Conscious sedation is frequently

desirable to control excessive anxiety. Benzodiazepines

may potentiate antithyroid drugs, and therefore nitrous

oxide, which is morerapidly controllable, is probably

safer. Povidone-iodine and similar compounds are best

avoided. Carbimazole occasionally causes agranulo-

cytosis, which may cause oral or oropharyngeal ulceration.

Otherwise the treated thyrotoxic patient presents no

special problems in dental treatment. However, after

treatment of hyperthyroidism the patient is at risk from

hypothyroidism, which may pass unrecognized.

HYPOTHYROIDISM

Hypothyroidism may be primary (due to thyroid

disease)or secondary (to hypothalamic or pituitary

dysfunction).The common causes of hypothyroidism are

thyroid loss from surgical removal of too much thyroid

tissue in a previously hyperthyroid patient or destruction

by irradiation of the neck or thyroid gland autoimmune

disease (Hashimoto's thyroiditis), associated with

autoantibodies to thyroglobulin and thyroid microsomes.

Clinical features includes weight gain, lassitude, dry

skin, myxoedema. loss of hair, cardiac failure or ischemic

heart disease, bradycardia, anemia, neurological or

psychiatric changes, hypotonia, cerebellar signs of ataxia,

tremor, and dysmetria. polyneuropathy, cranial nerve

deficits, entrapment neuropathy (e.g. carpal tunnel

syndrome), myopathic weakness, dementia, apathy,

mental dullness, irritability, sleepiness, hoarseness,

hypothermia and may be complicated by coma.

CARE PERTINENT TO EXTRACTION

The main danger is of precipitating myxoedema coma

by the use of sedatives (including diazepam or

midazolam), opioid analgesics (including codeine), or

tranquilizer. These should, therefore, be either avoided

or given in low dose. Local anesthesia is satisfactory for

pain control. Conscious sedation can be carried out with

nitrous oxide and oxygen. Diazepam or midazolam may

precipitate coma. Associated problems may include

hypoadrenocorticism, anemia, hypotension, diminished

cardiac output and bradycardia. Occasional associations

include hypopituitarism and other autoimmune disorders

such as Sjogren's syndrome. Povidone-iodine and

similar compounds are best avoided.

PATIENT ON EXOGENOUS STERIODS

Corticosteriods are frequently used to suppress inflam-

mation, and for immunosuppression, and occasionally

to replace missing hormones like in Addison's disease

or after adrenalectomy. Corticosteriods act by binding

to cytoplasmic receptors, to produce alterations in

regulatory protein synthesis. One regulatory protein,

lipocortin (macrocortin). a member of the annexin

superfamily of proteins, inhibits phospholipase A2 and

so prevents metabolism of arachidonic acid to leuko-

trienes. prostaglandins and thromboxanes involved in

inflammation. Glucocorticoids also increase beta-

receptor synthesis, reduce microvascular permeability,

reduce cytokine production and mast cells and eosino-

phils. Anti-inflammatory mechanisms involve the

glucocorticoid receptors, the glucocorticoid-responsive

genes, and the release of anti-inflammatory molecules

such as lipocortin-1, IL-IO. IL-1 ra. and nuclear factor-

KB. Corticosteroids induce the transcription of the gene

Exodontia for Medically Compromised Patients

to decreas the pro-inflammatory cytokine secretion. As

a consequence, the immune system is 'blocked'.

Corticosteroids have a negative feedback control on

hypothalamic activity and A C T H production and there

is, thus, suppression of the hypothalamic-pituitary-

adrenocortical axis (HPA) and the adrenals may become

unable to produce a steroid response to stress. Cortico-

steroids are an essential part of the body's response to

stresses such as trauma, infection, general anesthesia or

operation. At such times there is normally an enhanced

adrenal corticosteroid response related to the degree of

stress. In patients given exogenous steroids, the enhanced

adrenal corticosteroid response may not follow. When

the adrenal cortex is unable to produce the necessary

steroid response to stress, acute adrenal insufficiency

(adrenal crisis) can result, with rapidly developing

hypotension, collapse and possibly death. Suppression

of the H P A axis becomes deeper if corticosteroid

treatment has been prolonged and/or the dose of steroids

exceeds physiological levels (more than about 7.5 mg/

day of prednisolone). Adrenal suppression is less when

the exogenous steroid is given on alternate days or as

a single morning dose (rather than as divided doses

through the day). Corticotrophin (ACTH) has been used

in the hope of reducing adrenal suppression, but the

response is variable and unpredictable. However, adrenal

function may even be suppressed for up to 1 week after

cessation of steroid treatment lasting only 5 days. If

steroid treatment is for longer periods, adrenal function

may be suppressed for at least 30 days and perhaps

for 2-24 months after the cessation of treatment. Patients

on. or who have been on. corticosteroid therapy within

the past 30 days may be at risk from adrenal crisis, and

those who have been on them during the previous 24

months may also be at risk, if they are not given

supplementary corticosteroids before and during periods

of stress such as operation, general anesthesia, infection

or trauma. Patients who have used systemic cortico-

steroids should be warned of the danger and should

carry a steroid card indicating the dosage and the

responsible physician. However, the frequency and

extent of the adrenocortical suppression (and the need

for supplementary corticosteroids before and during

periods of stress is unclear and has been questioned.

Although the evidence for the need for steroid cover

may be questionable, medicolegal and other

considerations suggest that one should act on the side

of caution and fully inform and discuss with the patient

take medical advice in any case of doubt give a steroid

cover unless confident that collapse is unlikely.

CARE PERTINENT TO EXTRACTION

Dentoalveolar or maxillofacial surgery may result in stress

and a Cortisol response. Minor operations under local

anesthesia may be covered by giving the usual oral

steroid, dose in morning and giving oral steroids 2-4 h

pre- and postoperatively (25-50 mg hydrocortisone or

20 mg prednisolone or 4 mg dexamethasone) or by

giving IV 25-50 mg hydrocortisone immediately before

operation. Intravenous hydrocortisone must be

immediately available for use if the blood pressure falls

or the patient collapses. Corticosteroids given by

intramuscular injection are more slowly absorbed and

reach lower plasma levels than when given intravenously

or orally. Patients may also require special management

as a result of diabetes, hypertension, poor wound healing,

or infections. Aspirin and other nonsteroidal anti-

inflammatory agents should be avoided as they may

increase the risk of peptic ulceration. Susceptibility to

infection is increased by systemic steroid use. In addition

to careful aseptic surgery, prophylactic antimicrobials may

be indicated.

PATIENTS RECEIVING WARFARIN THERAPY

Warfarin is an anticoagulant which inhibits synthesis of

the vitamin K-dependent coagulation factors II, VII, IX

and X. Indications for anticoagulation are increasing, and

dentists will be consulted by patients taking warfarin .The

activity of warfarin is expressed using the international

normalized ratio (INR). INR = (patient PT/mean normal

P T )

I S I

or log INR = ISI (log observed PT ratio), where

ISI denotes the International Sensitivity Index of the

Exodontia Practice

thromboplastin used at the local laboratory to perform

the PT measurement. The ISI reflects the responsiveness

of a given thromboplastin to reduction of the vitamin

K-dependent coagulation factors. The more responsive

the reagent, the lower the ISI value. A normal

coagulation profile has an INR of 1.0. The desirable

INR range for patients depends on the condition being

treated. Patients receiving treatment for deep vein

thrombosis have a lower target range than those with

prosthetic heart valves. The risk of bleeding increases

exponentially as the INR rises. Gingival bleeding can

indicate a raised INR. Oral surgery can be completed

safely with an INR from 1.5 to 2.5. With appropriate

local measures to reduce bleeding, teeth may be removed

by simple extraction with an INR of 2-4. However dentists

should still be cautious before they remove teeth where

the INR exceeds 3 (Table 10.2). The possibility of

postoperative bleeding in patients taking warfarin

concerns dentists. However, before deciding if warfarin

therapy should be interrupted the risk of perioperative

or postoperative bleeding must be balanced against the

risk of thromboembolism.

CARE PERTINENT TO EXTRACTION

Before extraction a thorough medical history should be

obtained including details of any condition likely to be

treated with warfarin. The dentist should also consider

possible drug interactions with warfarin. Medications

including antibiotics such as metronidazole, herbal

remedies and alcohol may unpredictably alter the INR.

If an interaction is considered likely or if the effect of

any prescribed medication is not known, the dentist

should consult the doctor supervising the patient's

anticoagulant therapy. The INR should be checked

before surgery.

In most cases of dento-alveolar oral surgery, including

simple extraction of teeth, bleeding can be controlled

in a reasonable time by minimizing the extent of surgery

to one site or quadrant, and using firm sutures or firm

postoperative packs over the wound. Preferably surgery

should be performed in the morning to facilitate

postoperative observation.

Where the operative site is infected the use of

antibiotics should be restricted to a preoperative

prophylactic dose and postoperative antibiotics should

be discontinued as soon as reasonable. Prolonged use

of broad spectrum antibiotics should be avoided as it

may change the effectiveness of warfarin by altering gut

microflora compromising availability of vitamin K. Aspirin

and non-steroidal anti-inflammatory drugs may also

increase the risk of bleeding.

Local anesthetics should be given cautiously avoiding

venepuncture. To avoid the needles becoming barbed

and tearing tissues, they should be used once only for

each mucosal or skin puncture. Local vasoconstriction

may be encouraged by infiltrating a small amount of

local anesthetic solution with 1:100 000 or 1:200 000

adrenaline close to the surgery site

PATIENTS TAKING ASPIRIN

Aspirin irreversibly impairs platelet aggregation and is

used long-term in the prevention of cardiovascular events

and stroke in patients at risk. In large doses, aspirin may

also cause hypoprothrombinemia. Even small doses of

Table 10.2: Range of International Normalised Ratio

Type of Suboptimal Suboptimal Normal target Normal target May be normal Out of range

treatment range range INR range INR range target with

mechanical
heart valve

<1.5 1.6-1.9 2.0-2.5 2.5-3.0 3.1-3.5 3.5

Simple extraction Safe Safe Safe Local measures Local measures Not advised

Multiple extraction Safe Safe Local measures Local measures Local measures Not advised
Single bony impaction

Exodontia for Medically Compromised Patients

113

aspirin prolong the bleeding time, impair platelet

adhesiveness. Aspirin may worsen bleeding tendencies

if there are other anticoagulation medications other

bleeding disorders, such as uremia. Patient taking

even one 80 mg aspirin have platelet functions altered

for upto a week until new. unaffected platelets are

produced.

CARE PERTINENT TO EXTRACTION

In patients with no other cause for a bleeding tendency

and receiving up to 100 mg aspirin daily, in general, for

uncomplicated forceps extraction of 1-3 teeth. Suturing

and packing the socket with resorbable gelatin sponge,

oxidized cellulose, or microfibrillar collagen can be

carried out if necessary. In patients with no other cause

for a bleeding tendency and receiving doses of aspirin

higher than 100 mg daily, if there is concern, the current

value of the bleeding time should be established. If it

is over 20 min. surgery should be postponed.

PATIENTS ON HEPARIN

Heparin is a natural product, abundant in granules of

the mast cells that line the vasculature. It is released in

response to injury. Heparin is also used as a parenteral

anticoagulant, given subcutaneously or intravenously for

acute thromboembolic episodes or for hospitalization

protocols that include significant surgical procedures, to

prevent deep venous thrombosis and pulmonary emboli.

Heparin is a sulphated glycosaminoglycan originally

obtained from liver. Heparin acts immediately on blood

coagulation to block the conversion of fibrinogen to fibrin,

mainly by inhibiting the thrombin-fibrinogen reaction via

its binding to and catalysing antithrombin III. which then

inhibits the serine proteases of the coagulation cascade

to inactivate thrombin. Heparin also acts on activated

factors IX-XII and increases platelet aggregation but

inhibits thrombin-induced activation. The anticoagulant

effect of standard or low molecular weight heparin has

an immediate action on blood clotting, which is usually

lost within 6 h of stopping it. The prothrombin, activated

partial thromboplastin (APTT) and thrombin times (TT)

are prolonged. Most patients are monitored with the

APTT and are maintained at 1.5-2.5 times the control

value (the therapeutic range). Large doses of heparin

can prolong the INR. Platelet counts should also be

monitored if heparin is used for more than 5 days, since

it can cause thrombocytopenia. Autoimmune thrombo-

cytopenia is possible within 3-15 days, or sooner if there

has been previous heparin exposure. Heparin is available

as standard or unfractionated heparin, or low-molecular-

weight (LMW) heparins. The latter, such as certoparin.

interact with factor Xa. but do not affect standard blood

test results.

CARE PERTINENT TO EXTRACTION

For uncomplicated forceps extraction of 1-3 teeth, there

is usually no need to interfere with anticoagulant

treatment involving heparin or low-molecular-weight

heparins or antiplatelet drugs. Heparin has an immediate

effect on blood clotting but acts for only 4-6 h and no

specific treatment is therefore needed to reverse its effect.

The effect of heparin is best assessed by the APTT.

Withdrawal of heparin is adequate to reverse anticoagu-

lation where this is necessary. In an emergency, this can

be reversed by intravenous protamine sulphate given in

a dose of 1 mg per 100IU heparin, but a medical opinion

should be sought first. Where heparin has been stopped,

any surgery can safely be carried our after 6-8 h. Low-

molecular-weight heparin may have little effect either

on the APTT or on postoperative bleeding, despite their

longer activity (Up to 24 h). However, the advice of the

hematologist should be sought before surgery.

HEMOPHILIA

Common forms of hereditary bleeding disorders caused

by clotting factor deficiencies of factor VIII, IX. or XI.

Hemophilia A (factor VIII deficiency), which affects about

80% of hemophiliacs, and hemophilia B (factor IX

deficiency) have identical clinical manifestations,

screening test abnormalities, and X-linked genetic

transmission. Specific factor assays are required to

distinguish the two. Hemophilia may result from gene

Exodontia Practice

mutations: point mutations involving a single nucleotide,

deletions of all or parts of the gene, and mutations

affecting gene regulation. About 50% of cases of severe

hemophilia A result from a major inversion of a section

of the tip of the long arm of the X chromosome. Because

factor VIII and factor IX genes are located on the X chro-

mosome, hemophilia affects males almost exclusively.

Daughters of hemophiliacs will be obligatory carriers,

but sons will be normal. Each son of a carrier has a 50%

chance of being a hemophiliac, and each daughter has

a 50% chance of being a carrier. Rarely, random

inactivation of one of the two X chromosomes in early

embryonic life will result in a carrier's having a low factor

VIII or IX level to experience abnormal bleeding.

A patient with a factor VIII or IX level < 1% of normal

has severe bleeding episodes throughout life. Minor

trauma can result in extensive tissue hemorrhages and

hemarthroses, which, if improperly managed, can result

in crippling musculoskeletal deformities. Bleeding into

the base of the tongue, causing airway compression,

may be life threatening and requires prompt, vigorous

replacement therapy. Patients with factor VIII or IX levels

about 5% of normal have mild hemophilia. They rarely

have spontaneous hemorrhages: however, they will bleed

severely (even fatally) after surgery if not managed

correctly. Occasional patients have even milder

hemophilia with a factor VIII or IX level in the 10 to

30% of normal range. Such patients may also bleed

excessively after surgery or dental extraction.

Typical findings in hemophilia are a prolonged PTT.

a normal PT and a normal bleeding time. Factor VIII

and IX assays determine the type and severity of the

hemophilia. Because factor VIII levels may also be

reduced in VWD. VWF antigen should be measured in

patients with newly diagnosed hemophilia A. particularly

if the disease is mild and a family history cannot be

obtained. After transfusion therapy, about 15% of

patients with hemophilia A develop factor VIII antibodies

that inhibit the coagulant activity of further factor VIII

given to the patient. Patients should be screened for

factor VIII anticoagulant activity (e.g. by measuring the

degree of PTT shortening immediately after mixing the

patient's plasma with equal parts of normal plasma and

after incubation for 1 h at room temperature), especially

before an elective procedure that requires replacement

therapy.

CARE PERTINENT TO EXTRACTION

Hemophiliacs should avoid using aspirin. There should

be judicious use of other NSAIDs. which have a lesser,

more transient effect than aspirin on platelet function.

All drugs should be given orally or IV: IM injections can

cause large hematomas. Fresh frozen plasma contains

factors VIII and IX. However, unless plasma exchange

is performed, sufficient whole plasma cannot be given

to patients with severe hemophilia to raise factor VIII

or IX concentrations to levels that effectively prevent or

control bleeding. For hemophilia A. the treatment of

choice is viral inactivated or recombinant factor VIII

concentrate. For hemophilia B. the treatment of choice

is a highly purified viral inactivated factor IX concentrate.

In hemophilia A. the factor VIII level should be raised

transiently to about 0.3 U (30%) to prevent bleeding

after dental extraction.

In hemophilia B. the plasma factor IX level rises to

only half of that expected from the units of factor IX

listed on the bottle. This may reflect binding of infused

factor IX to vascular endothelium.

An antifibrinolytic (-aminocaproic acid 2.5 to 4 g

postoperative qid for 1 week or tranexamic acid 1.0

to 1.5 g postoperative tid or qid for 1 week) should

be given to prevent late bleeding after dental extraction.

Treatment of bleeding in hemophiliacs who develop a

factor VIII inhibitor is difficult, and a specialist should

be consulted. Patients with a low initial antibody titer

may be given a large dose of factor VIII to overcome

the inhibitor and temporarily raise plasma factor VIII

concentration. If this does not control the bleeding, further

factor VIII infusion will usually be futile because of the

rapid rise in antibody titer. The factor VIII antibodies

responsible for inhibitor activity are heterogeneous and

in some patients do not inhibit or only minimally inhibit

Exodontia for Medically Compromised Patients

porcine factor VIII. Thus, a high-purity porcine factor

VIII preparation controls bleeding in such patients.

Prothrombin complex concentrate, which contains factor

IX and variable amounts of an activity that bypasses

the role of factor VIII in coagulation, has also been used

to manage serious bleeding in patients with a high-titer

inhibitor, but it may also induce hypercoagulability and

a paradoxical thrombotic event. The factor VIII inhibitor-

bypassing material in prothrombin complex concentrate

may be factor IXa. Recombinant factor Vila in repeated

high doses (e.g. 90 ugkg) controls bleeding in some

patients with a factor VIII inhibitor without inducing a

hypercoagulable state. Long-term control of inhibitors

in hemophilia A is achieved in most patients by inducing

immune tolerance through continuous exposure to factor

VIII.

PREGNANCY

Pregnancy is a major event in any women's life and

is associated with physiological changes affecting especially

the endocrine, cardiovascular and hematological systems

and often attitude, mood, behavior. Knowledge of

physiologic changes from non-gravid woman to gravid

woman is of utmost importance to dental surgeon. The

hormonal and physiologic changes during gestation

results in alteration of major organ system.

The dental surgeon who treats a gravid woman

should be aware that he she is treating two patient, the

unborn child the second one. In most instances surgery

can be performed safely with proper consultation. Most

experts agree that elective surgical procedures should

be delayed until after delivery. Physiologic changes are

due to hormonal release, anatomic changes or both.

The normal period of pregnancy is approximately

38 weeks - 9 months. For clinical purposes, the gestation

period is usually divided into trimesters (period of 3

months), because each trimester presents different

considerations in medical and dental management.

Trimester approach is safe for mother and child because

it accounts the period of greater risk of harming the

developing fetus or embryo. The embryonic period

spanning weeks 2 through 8 post conception, is the time

of active organogenesis and therefore greater suscepti-

bility to teratogens. The concern of doing procedure

during the first trimester is two-fold. First, the developing

child is at greatest risk posed by teratogens during

organogenesis, and second during the first trimester it

is known that as many as one in five pregnancies undergo

spontaneous abortion. The current recommendation is

that necessary procedures be done during second

trimester. By the second trimester, organogenesis is

completed, and the risk to the fetus is low. The mother

has also had time to adjust to her pregnancy, and the

fetus has not grown to a potentially uncomfortable size

that would make it difficult for the mother to remain

still for long periods. The positioning of the pregnant

patient is important, especially during the third trimester.

As the uterus expands with the growing fetus and

placenta, it comes to lie directly the inferior vena cava,

femoral vessel, and the aorta. If the mother is positioned

supine for a procedure the weight of the gravid uterus

could apply enough pressure to impede blood flow

through the major vessels and cause a condition called

supine hypotension. In this condition, the blood pressure

drops secondary to the impeded blood flow, which

causes a syncopal or near syncopal episode. This situation

is easily remedied by proper positioning of the patient

on her left side and elevating the head of the chair to

avoid compression of major vessels.

CARE PERTINENT TO EXTRACTION

Detailed information of pregnancy state is obtained and

non urgent treatment should be delayed to the post-

partum period. If patient is unsure regarding her preg-

nancy refer to physician. In case of emergency situation

inquire about last menstrual period cycle.The fetus is most

susceptible to harmful effect of teratogens, carcinogens

and maternal stress during first and third trimester.

Certain procedures when clinically indicated may be

defered to 2nd trimester. Important points to be stressed

before doing any extraction procedure is the stress of

Exodontia Practice

surgery, stress of anesthesia, ionizing radiations, drugs.

It is generally accepted that dental radiographs and

minor procedures like exodontia under local anesthesia

expose fetus to minimal risk. Gynecological consultation

should be taken before performing exodontia. Risk

benefit ratio of delaying treatment is made on time of

presentation and progress of disease. Beyond first

trimester, gravid patient should not placed in supine

position because enlarged gravid uterus compress the

vena cava and decrease in cardiac output as low as 30%

results in supine hypotension syndrome of pregnancy.

Compression of vena cava increases venous stasis and

enhances risk of clot formation. Sign and symptoms

includes light headedness. tachycardia, loss of

consciousness. The appropriate and desired position is

left lateral position with right buttock and hip elevated

to approximately 15 degrees. Local anesthesia should

be preferred over general anesthesia.

Procedure like extraction of tooth have the potential

to escalate into bacteremia and sepsis, with resulting

serious fetal complications making antibacterial treatment

and prophylaxis important in pregnant patient.

Obstetrician's consult if doubtful about the teratogenic

effects of a medication.

Drugs which can be safely administered include

Acetaminophen or its combination with oxycodone

(opiod analgesic) for mild to severe pain control.

Beta-lactam antibiotics like Penicillin. Amoxicillin.

Cephalosporin.

Drugs contraindicated are estolate form of erythro-

mycin base because it increases risk of cholestatic

hepatitis.

Tetracyclines have increased effect on developing

tooth and bones. Chloramphenicol. Metronidazole have

carcinogenic effects. Narcotics causes respiratory

depression in fetus and mother.

NSAIDs in 3rd trimester prolongs pregnancy and

labor. It causes anti- and post-partum hemorrhage,

increased chances of oral clefts and other defects,

increased chances of fetal mortality.

EPILEPSY

It is a brain disorder which manifests as chronic, sudden,

often recurrent, paroxysmal, discharge of the cerebral

neurons, resulting in episodic disturbances of conscious-

ness and autonomic nervous system. Convulsive or

involuntary muscle movements called as seizures /fits.

It affects about 1-2% of general population, but more

prevalent in young and handicapped patients. Epilepsy

is characterized by seizures of any type that are chronic

and recurrent. In addition to seizures, there may be other

features, such as headache, changes in mood or energy

level, confusion, and memory loss. The main types of

epilepsy are generalized seizures (grand mal (tonic-clonic)

and petit mal) - when consciousness is typically lost and

petit mal. Partial seizures, which include simple seizures

during which the person remains alert, but there are

abnormal movements or sensations. In complex seizures

abnormal movement or sensation is accompanied by

changes in consciousness. Generalized seizures are the

most dramatic but partial complex seizures are the most

common.

CARE PERTINENT TO EXTRACTION

Epileptics can have good and bad phases, and exodontia

should be carried out in a good phase, when attacks

are infrequent. Various factors can precipitate attacks.

Those who have infrequent seizures, or who depend

on others (such as those with a learning impairment),

may fail to take regular medication and thus be poorly

controlled. Drugs can be epileptogenic or interfere with

anticonvulsants, or can themselves be changed by

anticonvulsant therapy and may. therefore, be contra-

indicated. One should have comprehensive knowledge

of patient's seizure history and medications. Avoidance

of situations likely to provoke a seizure and PAS complex

by strictly implementing stress reduction protocol. In acute

attack-situation following steps should be taken, terminate

dental therapy and position the patient supine on the

floor, if unconscious.

Protect the patient from injury by passive restraint

in the event of a seizure. Remove him/her from any

Exodontia for Medically Compromised Patients

proximity to sharp edges, a fall or other trauma. Loosen

any tight collar or other clothing.

Lightly restrain, if needed. To prevent any injury to

lips, tongue and to establish a patent airway, following

steps are taken immediately - Turn the patient on his

her side in the dental chair with the head extended. A

well padded tongue blade available is kept in between

teeth. Supplemental O2 may be necessary in worse

conditions. Local anesthetics readily cross the blood-

brain barrier. At low (therapeutic/non-toxic) levels, no

CNS effects are clinically significant. At higherjtoxic/

overdose) levels, a generalized tonic-clonic episode is

seen. Patients on valproic acid may have a prolonged

bleeding time, thus bleeding time should determined

prior to surgery.

ASTHMA

Asthma is a chronic inflammatory disease characterized

by reversible airway obstruction. This disorder is typified

by bronchial edema caused by hypersensitivity to either

known or unknown stimuli and which results in airway-

narrowing. This process is also associated with increased

mucin secretion and diminished ciliary action, further

compounding obstruction.

Asthma is broadly classified by the principle stimuli

that incite an acute episode rather than specific etiologic

parameters. Some classification systems divide asthma

into 2 basic groups: allergic, or extrinsic asthma versus

idiosyncratic or intrinsic asthma.

Other proposed classification systems for chronic

asthma are based on disease severity according to the

frequency of acute attacks. This classification system

divides asthma into mild intermittent, mild persistent,

moderate persistent and severe persistent categories.

Furthermore, such classification based on severity lends

itself nicely to specific treatment approaches for each

category,

Regardless of the various classification systems. The

etiology of asthma is both poorly understood and poorly

defined. Asthma is an inflammatory process associated

with bronchial hyper-responsiveness, bronchial lumen

decreases in diameter because of edema, mucus

production, and hypertrophy of the bronchial wall.

Typical symptoms of asthma include wheezing, chest

tightness, cough, and dyspnea. The frequency and the

severity of asthma symptoms vary among patients and

within individual patient episodes. Physical evaluation

of the patient may reveal expiratory wheezing with or

without expiratory phase prolongation or tachypnea.

In acute asthma flares, use of the accessory muscles of

respiration is also characteristic. Pulmonary function tests,

primarily spirometry, are necessary to establish or confirm

a diagnosis of asthma and assess its severity.

CARE PERTINENT TO EXTRACTION

Optimal asthma control is desirable before dental

treatment. The dentist must also remember that some

medications used in dentistry may have specific

implications in the treatment of a patient with asthma.

Aspirin, as well as other nonsteroidal anti-inflammatory

medications, should be avoided in aspirin-sensitive

persons with asthma because they could trigger an acute

asthma attack. In general, nonsteroidal anti-inflammatory

medications, including aspirin, should be used with

caution in all persons with asthma because these

medications inhibit cyclo-oxygenase and preferentially

generate leukotrienes. Opiates, which cause respiratory,

depression and which can induce histamine release,

should also be avoided. Macrolide antibiotics (e.g.

erythromycin), which alter cytochrome P450. may result

in elevated serum methyl xanthine (theophylline) levels.

In addition, sulfite preservatives, as those found in some

local anesthetics (i.e.. those with vasoconstrictors, such

as levonordefrin and epinephrine), can precipitate asthma

attacks. Other concerns for the dentist include the

requirement of steroid supplementation-before stressful

or perceived stressful dental procedures-in patients with

severe asthma who are on a long-term regimen of

systemic corticosteroids. Proper preparation of the

asthmatic patient before dental therapy may enhance

Exodontia Practice

the dentist's ability to emergently manage an acute

asthmatic attack. Patients should be advised to bring

their short-acting beta agonist inhaler medications to

the dental appointment.

PATIENTS RECEIVING RADIOTHERAPY

Radiotherapy is often used to treat oral cancer. It can

be used alone or as adjuvant to surgical procedure aiming

to treat oral cancer. Many oral complications can follow

radiotherapy involving oral cavity and salivary glands.

Radiotherapy to tumors of the mouth, naso and

oropharynx is especially liable to damage the salivary

glands, depress salivary secretion and result in saliva of

a higher viscosity but lower pH. Salivary secretion

diminishes within a week of radiotherapy in virtually all

patients and the saliva becomes thick and tenacious.

Infections are predisposed to by xerostomia. Caries, oral

candidosis and acute ascending sialadenitis are typical

consequences. Some salivary function may return after

many months.

CARE PERTINENT TO EXTRACTION

Before radiotherapy meticulous oral hygiene should be

implemented. Neglected and unsaveable teeth in the

radiation path should be extracted. An interval of at least

2 weeks between extracting the teeth and starting

radiotherapy is desirable but the time interval permitted

between extractions and radiotherapy is invariably a

compromise because of the need to start radiotherapy

as soon as possible. No bone should be left exposed

in the mouth when radiotherapy begins since, once the

blood supply is damaged by radiotherapy, wound healing

is jeopardized.

After radiotherapy oral hygiene and preventive dental

care should be continued. If extractions become

unavoidable, trauma should be kept to a minimum,

raising the periosteum as little as possible, ensuring that

sharp bone edges are removed, suturing carefully and

giving prophylactic antibiotics in adequate doses from

48 h preoperatively and continued for 4 weeks at least.

Clindamycin 600 mg tds is an appropriate antibiotic since

it penetrates bone well.

Exodontia Practice

General anesthesia (GA) has been one of the far-reaching

inventions of medical science. The use of general

anesthesia in dentistry began in 1844 when Connecticut

dentist Horace Wells first used the chemical compound

nitrous oxide, commonly known as laughing gas. to

relieve pain during a dental procedure. Two years later,

his former partner. William Thomas Morton, introduced

the use of ether as a general anesthetic at a public

demonstration.

Though general anesthesia is an expensive

component of a surgical procedure, recent economic

development in India has widened the scope for

extraction of teeth under general anesthesia. Various

anesthetic agents are available and readers are advised

to refer to appropriate general anesthesia textbook.

It is imperative to understand that though dental

extraction is classified as a minor surgical procedure,

the morbidity and mortality from general anesthesia

still remains same to a large extent. Any complication

from the procedure is there for not well tolerated by

patient. Fortunately most complications are minor but

occasionally respiratory and cardiac arrests will occur.

Proper case selection and precautions can only reduce

these complications but cannot eliminate it from

happening.

INDICATIONS FOR GENERAL ANESTHESIA

1. Anxious patient.

2. Difficult procedure (e.g. very low lying third molar).

3. Pediatric dental extraction in a non-cooperative child.

4. Extraction in people with special needs, e.g. cerebral

palsy, learning difficulties.

CONTRAINDICATIONS FOR GENERAL

ANESTHESIA

Cardiovascular and respiratory diseases are the most

common limiting factors for GA. A detailed questionnaire

is provided to go through when a patient is planned for

G A . Any significant medical problem needs to be

investigated and discussed with the anesthetist. Amount

of exercise tolerance gives a good indication of fitness

for general anesthesia. Finally it is the individual

anesthetist's skill and acute care facilities, which

determines the patient selection.

One of the common reasons for cancellation in day

case procedure is due to non-fasted patients. Patient

needs to be nil by mouth for eight hours. All regular

medication needs to be checked by the anesthetist to

advise on taking them on the day of the operation. Use

of chewing gums or drinking tea/coffee with milk will

stimulate gastric secretion which can regurgitate leading

to aspiration pneumonia which can be fatal.

Dental extractions under GA are routinely carried out

in developed countries. The assessment of these patients

is mainly carried out using American Society of

Anesthesiologists (ASA) grading. Medical co-morbidity

increases the risk associated with anesthesia and surgery.

ASA accurately predicts morbidity and mortality (Table

11.1). In general fifty percent of patients presenting for

elective surgery are ASA grade 1. This number is very

likely to be large in maxillofacial surgery as the age group

of people who have wisdom teeth removed are in a

younger age group and are generally fit and healthy.

Operative mortality for these patients is less than 1 in

10,000.

Table 1 1 . 1 : ASA predicts mortality and morbidity

Any contraindication for extraction under local

anesthesia (apart from those which indicates GA) will

also apply to GA for. e.g. bleeding disorders unless

corrected.

ASA Definition Mortality

Grade (%)

I Normal healthy individual 0.05

II Mild systemic disease that does

not limit activity 0.4

III Severe systemic disease that limits

activity but is not incapacitating 4.5

IV Incapacitating systemic disease

which is constantly life-threatening 25

V Moribund, not expected to survive

24 hours with or without surgery 50

CONSENT

Obtaining an informed consent is an important and

recommended practice of modern day surgery. Though

it is not something routinely carried out in Indian

circumstances due to difference in practice of surgery.

With the increasing health awareness and publicity of

medicolegal issues, informed consent should be incor-

porated in routine practice by explaining the importance

of it to patients.

The extent of warning should involve routine

complications like numbness of tongue and lip following

third molar removal. It is advisable to cover the risks

of GA either separately by the anesthetist or as a team.

It is always advisable to discuss the possible outcomes

and change of plans intraoperatively. for example, it is

advisable to include the adjacent tooth on the extraction

list if it is radiographically carious and found to be beyond

restoration clinically once adjacent tooth is extracted. It

is not a good idea to wake the patient to inform the

changes.

GENENRAL ANESTHESIA AND

CONSIDERATIONS FOR INTRAORAL

PROCEDURE

All intraoral procedures have limited access and presence

of endotracheal tube can only make it more difficult.

The two clinical exercise which should be part of a clinical

assessment for GA are mouth opening and neck exten-

sion. Poor mouth opening is not only a surgical difficulty

but also anesthetic. When there is trismus secondary to

infection and suspected airway compromise as well, the

team should be ready to carry out emergency tracheo-

stomy if needed. The use of fiberoptic guided intubation

technique is more safe and can avoid emergency

tracheostomy. Patients with reduced neck extension

should be discussed with anesthetist before hand.

Technically, blind nasal intubation is more difficult

than placing oro-endotracheal tube. Where good access

is needed, surgeon needs to inform the anesthetist the

requirement of nasoendotracheal intubation. Where

simple extractions are planned, oral intubation using

Portex

cuffed oral endotracheal tube-PDT which are soft

and specially engineered for maxillofacial surgery can

be used. They provide enough maneuvering for retraction

using tongue retractors. It is always a good idea to inform

the anesthetist when their position is changed for access.

Laryngeal mask airways are alternative airway

devices which are successfully used in short general

anesthesia. They can be used when there is adequate

access is available and the procedure is short and patient

does not have any contraindication for laryngeal mask

airway like morbidly obese patients or procedures close

to oropharynx.

POSITIONING FOR GENERAL ANESTHESIA

The patient needs to be kept comfortable and any soft

tissue damage by pressure needs to be avoided. These

injuries will be severe as most often they go unnoticed

till patient is awake. Soft cushioning jelly pads are

routinely used. This has a major significance especially

when the routine short procedure is prolonged due to

any complication. Catheterization is not routinely

required.

The layout for anesthetist and his equipment,

operating lights, scrub nurse, operator and assistant needs

to be planned before hand as moving anesthetic machine

or operating table is cumbersome and will delay the

procedure. It is important to move the operating light

whenever patient or operator's position is changed.

POSITIONING OF THE OPERATOR

The positioning of the operator varies individually but

in general it is better to stand on the side of the operation

to enhance access and visibility. Most of the extraction

forceps are designed for patients sitting in a dental chair:

therefore operators need to use non-conventional use

of forceps for patients in supine position during general

anesthesia. For example, the author finds lower anteriors

are some times better accessed from 12 O' clock position

with an upper anterior forceps.

Exodontia Practice

IDENTIFYING THE RIGHT TOOTH

Marking the site of surgery is an integral part of preparing

the patient for theater. Though it is not widely used,

marking the tooth is suggested by some. It is imperative

for the actual surgeon to do an oral examination just

before the surgery. The assistant has to be equally vigilant

to avoid any wrong tooth extraction. Charting the whole

mouth before extraction is a very useful safety technique,

especially when multiple extractions are planned. Marking

the tooth to be extracted on the OPG (which should have

patients name and date of exposure and sides correctly

oriented) and writing it on the board is a safe practice

and reduces the intraoperative confusion, delays and

medicolegal issues. Before applying the forceps or

elevator, the surgeon must re-check the notes. The

importance of preoperative examination cannot be

emphasized enough as symptoms cannot be elicited once

the patient is anesthetized. This also gives an opportunity

to check if the symptoms have resolved or changed

warranting change of treatment plan.

In certain situations where complete clinical

examination is not possible, examination needs to be

carried out along with whole mouth charting. There

should be low threshold for extracting teeth in these

patients as restoration on a later date may not be possible

and further GA may be needed to complete the

extractions. It is important to plan restoration at the same

time where possible to avoid unnecessary distress to

patient.

SURGICAL CONSIDERATIONS FOR GENERAL ANESTHESIA

Surgical procedures under GA need to be planned to

avoid any unnecessary delay or cancellation of

procedures. All equipment needs to be checked and

availability of instruments should be confirmed. Any

special need or equipment should be informed prior hand

to theatre staff. The most important thing is the skill of

the surgeon. He should be skilled enough not only to

carry out the procedure but also to handle any

complications like fractured roots, root in the antrum or

an oro-antral fistula.

Extraction under GA is usually complicated by the

fact that area of airway maintenance by anesthetist and

operating site are very close to each other and co-

ordination between the two is crucial. Standard two towel

draping is recommended. Many surgeons prefer not to

prepare the skin or oral cavity prior to surgery but using

a mouthwash on the ward preoperatively is recom-

mended.

Local anesthesia ( L A ) is mainly used to obtain

adequate postoperative pain control and long acting

agents like bupivacaine is preferred. They usually contain

adrenaline for its hemostatic property. Local anesthesia

is also shown to avoid any tachycardia due to stimulation

of nerve fibers but presence of adrenaline can cause

immediate tachycardia and therefore should be told to

anesthetist prior to injection. Care should be taken not

to dislodge the anesthetic tube while operating especially

where advanced anesthetic machines, which have

sensitive alarms, are not available.

The airway must be protected from any copious

irrigation, fractured tooth, filling and any other debris.

Relying on the endotracheal cuff is not sufficient and

the anesthetist routinely places a throat pack. At the end

of the procedure all extracted teeth and fractured crowns

and fillings, roots, instruments, swabs and needles must

be accounted for. If it is not. immediate bronchoscopy

should be arranged where facilities available or an urgent

chest and abdominal X-ray should be arranged. It is the

surgeon's duty at the end of the procedure to remove

the throat pack and the team needs to record it. You

forget to take it out only once.

Obtaining good access to carry out the procedure

is very prudent. It is advisable to use a mouth prop on

the non-operating side to keep the mouth open. The

tongue needs to be retracted with out damaging the floor

of the mouth mucosa. They should also retract the throat

pack which should be placed beyond oropharynx to

avoid entanglement to high speed burs leading to soft

tissue injury. Cheek retractors need to be in place and

should be held by hand rather than the surgeons gown

to avoid any accidental injury to cheek.

Extraction Under General Anesthesia

It is recommended that surgeon informs the

anesthetist about the proceedings of the surgery so that

they can plan the anesthesia. This will avoid unnecessary

prolongation of the anesthetic time due to muscle

relaxants and other drugs given for longer periods than

needed.

Placing immediate dentures and loose intraoral packs

can be difficult especially if they are ill fitting. They are

potential to obstruct the airway. It is advisable to place

them in when patient is more alert in the recovery when

local anesthetic is still working and tissues haven't swollen.

Small pressure packs used to press on the extraction

socket can come off and obstruct the airway. A long pack

sufficiently hanging outside the mouth which is easily

retrievable should be used and removed once bleeding

has stopped.

Most of the time extraction under general anesthesia

is carried out due to some special needs and stopping

bleeding from their extraction sockets when they are

awake can be very difficult and some times may need

another anesthesia. It is ideal to put sutures and obtain

good homeostasis to avoid an unpleasant complication

of post extraction hemorrhage in a non co-operative

patient. When in doubt, place surgicel in the socket

and horizonthal mattress suture to compress the

socket.

POSTOPERATIVE INSTRUCTION

It is important to provide postoperative instructions

prior to surgery so that patient can make necessary

arrangement and also he will not be in a state to receive

any instruction after a GA in the initial hours. The

language of choice should be the one patient is comfor-

table with.

COMPLICATIONS OF EXTRACTION UNDER
GENERAL ANESTHESIA

Complications of extraction in general are covered in

a different chapter but specific complications arising

mainly under GA are covered here.

Inadvertent force while carrying out extraction under

GA is not uncommon and can result in various compli-

cations. Fractured mandibles are mainly associated

following removal of third molars. Should this happen

the surgeon should proceed directly to fixing the fracture

and fully explain the situation to the patient post-

operatively. It is easy to forget the traction on temporo-

mandibular joint while applying the force. This is only

felt after patient has recovered from anesthesia and can

be very uncomfortable, some times more than the pain

at the surgical site. Supporting the mandible, applying

mouth prop and applying controlled, guided force

reduces the risk of such damage. On completion of treat-

ment, before taking the throat pack out the operator must

ensure that mandible can come to centric occlusion to

rule out TMJ dislocation unless patient is intubated orally.

Soft tissue injury is not uncommon under GA. Most

commonly the angle of the mouth is injured due to

injudicious retraction or friction from the instruments.

Poor access and visibility contributes to the problem.

Copious amounts of skin lubricants/ moisturizing cream

should be applied to lips preoperatively and also

postoperatively. Care should be taken as instruments can

get very slippery due to lubricant coat.

It is important to make sure that autoclave instruments

are cool before being used. Surgical gloves do not

conduct heat well and can give false low temperature

leading to tissue trauma. Eyes should be covered at all

the time as they are exposed to sharp material and high

velocity rotary instruments. Use of cautery for dental

extraction is rare but if needed bipolar cautery is more

advisable to prevent soft tissue injury.

POSTOPERATIVE INSTRUCTIONS

Patient information for removal of teeth under

1. You may not have anything to eat or drink (including

water) for eight (8) hours prior to the appointment.

2. A responsible adult must accompany the patient to

the office, remain in the office during the procedure,

and drive the patient home.

Exodontia Practice

3. The patient should not drive a vehicle or operate any

machinery for 24 hours following the anesthesia

experience.

4. Contact lenses, jewelry, and dentures must be

removed.

POSTOPERATIVE INFORMATION

1. The surgical area will swell and will be more swollen

on the 2nd or 3rd postoperative day.

2. Stiffness of the muscles may cause difficulty in opening

your mouth for a few days

3. You may develop sore throat and ear ache which

are temporary.

4. The corners of the mouth may become dry and crack.

Your lips should be kept moist with cream or ointment.

5. There may be a slight elevation of temperature for

24 to 48 hours. If temperature continues, notify us.

Further information may be added as per- post-

operative instruction following extraction under LA.

Exodontia Practice

The healing of wounds is one of the most interesting

of the many phenomena which characterize the living

organism. The ability of damaged tissue to repair itself

is a response of life itself, and within this very process

may lie the final understanding of nature. It is said that

an unhealed wound will eventually result in the death

of the organism. Therefore, wound healing must be

considered one of the primary survival mechanisms from

birth onward. It should be clearly understood that the

healing of a wound is not an isolated, solitary phenom-

enon but actually a very complex series of biologic events.

Classic reviews of this dynamic process are those of Arey

in 1936 and of Schilling in 1968.

Repair of tissue is generally considered to be a phase

of the inflammatory reaction, since it cannot be separated

from the preceding vascular and cellular phenomena

occurring in response to an injury. Healing of all tissues

after injury has an essentially identical pattern, but this

healing may be modified considerably, depending upon

numerous intrinsic and extrinsic factors.

Oral wounds are common, some being sustained

accidentally and others being inflicted by the dentist for

a specific purpose. The unusual anatomic situation of

the oral cavity, the teeth protruding from the bone, the

constant inflammation present in the gingival tissues, the

presence of countless microorganisms in a warm, moist

medium of saliva contribute to modify the healing reac-

tion of the various wounds. It is. these reparative

phenomena and their alterations from the basic pattern

which are discussed in this chapter.

HEALING OF THE EXTRACTION WOUND

A thorough understanding of the phenomenon of

healing of extraction wounds is imperative to the dentist,

since vast numbers of teeth are extracted because of pulp

and periapical infection as well as various forms of

periodontal disease, and there is an ever-present

possibility of complications in the healing process.

A number of careful scientific studies have been carried

out, both on the experimental animal and in the human

being, dealing with undisturbed as well as complicated

extraction wound healing. The healing of an extraction

wound does not differ from the healing of other wounds

of the body, except as it is modified by the peculiar

anatomic situation, which exists after the removal of a

tooth. The healing process to be described here is a

composite of the various studies reported in the literature

and. while minor variations in the time sequence have

been described, the uncomplicated healing of an

extraction wound in the human may be expected to parallel

that described later. Normal human biologic variation

precludes the establishment of a day-to-day timetable

for such healing wounds, the healing process can only

be described as an "average" sequence of events.

IMMEDIATE REACTION FOLLOWING EXTRACTION

After the removal of a tooth, the blood which fills the

socket coagulates, red blood cells being entrapped in

the fibrin meshwork. and the ends of the torn blood

vessels in the periodontal ligament become sealed off.

The hours after tooth extraction are critical, for if the

blood clot is dislodged, healing may be greatly delayed

and may be extremely painful.

Within the first 24 to 48 hours after extraction, a

variety of phenomena occur which consist principally

of alterations in the vascular bed. There are vasodilatation

and engorgement of the blood vessels in the remnants

of the periodontal ligament and the mobilization of

leukocytes to the immediate area around the clot. The

surface of the blood clot is covered by a thick layer of

fibrin, but at this early period visible evidence of reactivity

on the part of the body in the form of a layering of

leukocytes here is not particularly prominent. The clot

itself shows areas of contraction. It is important to

recognize that the collapse of the unsupported gingival

tissue into the opening of a fresh extraction wound is

of great aid in maintaining the clot in position (Figures

12.1A and B).

FIRST-WEEK WOUND

Within the first week after tooth extraction, proliferation

of fibroblasts from connective tissue cells in the remnants

of the periodontal ligament is evident, and fibroblasts

Healing of Extraction Socket

F i g u r e s 12.1 A and B: Tooth socket immediately after

extraction

have begun to grow into the clot around the entire

periphery. This clot forms an actual scaffold upon which

cells associated with the healing process may migrate.

It is only a temporary structure, however, and is

gradually replaced by granulation tissue. The epithelium

at the periphery of the wound exhibits evidence of

proliferation in the form of mild mitotic activity even

at this time. The crest of the alveolar bone which makes

up the margin or neck of the socket exhibits beginning

osteoclastic activity. Endothelial cell proliferation signaling

the beginning of capillary in growth may be seen in the

periodontal ligament area.

During this period, the blood clot begins to undergo

organization by the in growth around the periphery of

fibroblasts and occasional small capillaries from the

residual periodontal ligament. Remnants of this perio-

dontal ligament are still visible, but as yet there is no

evidence of significant new osteoid formation, although

in some cases it may have just commenced. An extremely

thick layer of leukocytes has gathered over the surface

of the clot, and the edge of the wound continues to exhibit

epithelial proliferation (Figure 12.2).

SECOND-WEEK WOUND

During the second week after extraction of the tooth,

the blood clot is becoming organized by fibroblasts

Figure 12.2: First week extraction wound

growing into the clot on the fibrinous meshwork. At this

stage, new delicate capillaries have penetrated to the

center of the clot. The remnants of the periodontal

ligament have been gradually undergoing degeneration

and are no longer recognizable as such. Instead, the

wall of the bony socket now appears slightly frayed. In

some instances, trabeculae of osteoid can be seen

extending outward from the wall of the alveolus.

Epithelial proliferation over the surface of the wound

has been extensive, although the wound is usually not

covered, particularly in the case of large posterior teeth.

In smaller sockets, epithelialization may be completed.

The margin of the alveolar socket exhibits prominent

osteoclastic resorption. Fragments of necrotic bone

which may have been fractured from the rim of the

socket during the extraction are seen in the process of

resorption or sequestration (Figure 12.3).

THIRD-WEEK WOUND

As the healing process continues into the third week,

the original clot appears almost completely organized

by maturing granulation tissue. Very young trabeculae

of osteoid or uncalcified bone are forming around the

entire periphery of the wound from the socket wall. This

Exodontia Practice

F i g u r e 12.3: Third week extraction wound

early bone is formed by osteoblasts derived from

pluripotential cells of the original periodontal ligament

which assume an osteogenic function. The original

cortical bone of the alveolar socket undergoes remodeling

so that it no longer consists of such a dense layer. The

crest of the alveolar bone has been rounded off by

osteoclastic resorption. By this time the surface of the

wound may have become completely epithelized (Figure

12.4).

FOURTH-WEEK WOUND

During the fourth week after the extraction, the wound

begins the final stage of healing, in which there is contin-

ued deposition and remodeling resorption of the bone

filling the alveolar socket. However, this maturative

remodeling will continue for several more weeks. Much

of this early bone is poorly calcified, as is evident from

its general radiolucency on the roentgenogram.

Roentgenographic evidence of bone formation does not

become prominent until the sixth or eighth week after

tooth extraction. There is still roentgenographic evidence

of differences in the new bone of the alveolar socket

and the adjacent bone for as long as four to six months

after extraction in some cases. Because the crest of

alveolar bone undergoes a considerable amount of

F i g u r e 12.5: Healed extraction socket

osteoclastic resorption during the healing process and

because the bone filling the socket does not extend above

the alveolar crest, it is obvious that the crest of the healed

socket is below that of the adjacent teeth. Surgical

removal of teeth, during which the outer plate of bone

is removed, nearly always results in loss of bone from

the crest and buccal aspects, producing in turn a smaller

alveolar ridge than that after simple forceps removal of

teeth. This may be of considerable significance in the

preparation of a prosthetic appliance (Figure 12.5).

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Exodontia Practice

No surgical procedure is guaranteed to be free of

complications and tooth extraction is no exception.

Whilst the risk of certain adverse events can be minimized

with forethought at the assessment stage and careful

execution of the surgery, some of the problems that

arise are totally unpredictable.

Any deviation from the normal procedure is called

as complication. Complication at the time of exodontias

can occur at the time of giving anesthesia (anesthetic

complications), at the time of removal of tooth (intra-

operative complication) or after removal of tooth

(postoperative complications). In this chapter we will

discuss intraoperative and postoperative complications.

LOCAL COMPLICATIONS

IMMEDIATE

• Failure of local anesthesia

• Failure to move the tooth

• Fracture of the tooth or root being extracted

• Fracture of the alveolus (including maxillary

tuberosity)

• Oro-antral communication

• Displacement of the tooth or a root into the tissues.

Loss of a tooth or part of a tooth into the pharynx

and then to the lung

• Fracture or subluxation of an adjacent tooth

• Collateral damage to surrounding soft tissues

• Hemorrhage

• Dislocation of the temporomandibular joint

• Fracture of the mandible

• Damage to branches of the trigeminal nerve.

DELAYED

• Excessive pain

• Swelling

• Trismus

• Hemorrhage

• Localized osteitis (dry socket)

• Acute osteomyelitis

• Infection of soft tissues

• Oro-antral fistula

• Failure of the socket to heal

• Nerve damage

• Osteomyelitis

• Osteoradionecrosis.

LOCAL COMPLICATIONS

IMMEDIATE COMPLICATIONS

Failure of Local Anesthesia

Failure of local anesthesia is usually the result of either

inaccurate placement of the anesthetic solution, too small

a dosage, or not waiting long enough for the anesthesia

to act before commencing surgery. Both patient and

operator need to know that the anesthetic is working

satisfactorily before the extraction can proceed procedure

starts. A simple test of adequate numbness is to push

a blunt probe firmly into the gingival crevice around

the tooth for extraction. Whilst the patient will feel the

transmitted pressure from the probe there should be

no sensation of sharpness or pain. An additional caution

is to tap the tooth with a mirror handle as occasionally

there is possibility of periodontitis, and therefore would

be painful to extract, is not detected using the probe

test. If anesthesia cannot be secured by using

conventional techniques of infiltration or regional block,

intraligamental, intraraosseous or intrapulpal injections

may be indicated, provided that the cause of the failure

is not local infection around the tooth. Local anesthetic

should not be injected to infected tissues because of the

risk of spreading the infection.

Failure to Move Tooth

If the tooth does not yield to reasonable displacing forces

applied with forceps or elevators, this normally indicates

that either the bone texture is dense and inelastic, or that

the root shape is obstructing its path of withdrawal. To

apply forceps using even greater force is likely to result

in fracture of the tooth or exhaustion of both the operator

and the patient. The cause of the obstruction should be

findout by taking a radiograph before proceeding to lift

131

Complications of Tooth Extraction

a mucoperiosteal flap and remove bone and/or divide

the tooth as indicated.

Fracture of Tooth

The causes of crown or root fracture are:

• Excessive force applied to the tooth

• A tooth weakened by caries or large restorations.

• Inappropriate application of force resulting from

failure to grasp enough of the root mass or using

forceps with blades too wide to make two point

contacts on the root

• Haste due to impatience or frustration

• Unfavorable root anatomy.

Tooth fracture is an inconvenience, but need not be

a disaster, and it happens to even the most experienced

dentists. The key to managing this potential problem

is to reassess the situation and decide whether to

proceed, or abort the extraction attempt and refer the

patient for oral surgical advice. Inspection of the

fractured tooth shows the likely size and position of the

retained root. If there is no pre-operative radiograph

that shows the whole of the root structure then one

should be taken at this stage. When only the crown has

been removed, it may be possible to reapply root forceps,

but this is unlikely to be productive unless there is a

reasonable amount of root accessible above alveolar

bone level, and the root has already shown signs of

loosening. When the root itself has fractured, retrieval

of the retained portion normally requires a surgical

approach. The operator must assess whether this surgical

task is feasible cooperation of the patient, the facilities

available and his or her level of experience.

Ideally all roots should be removed but some apical

fragments may be difficult or hazardous to pursue

because of the proximity of the inferior dental nerve

or the antral floor. Such small apices are best left in situ

and rarely cause symptoms. In general, a root fragment

of a vital tooth, less than 5 mm in length, can normally

be safely left in the jaws of healthy patients. Larger root

fragments and those with necrotic pulps or periapical

radiolucent areas should be removed, unless the risk of

so doing outweighs the potential gain. If it is decided that

the root can be safely retained, then the patient must

be informed of this eventuality along with a suitable

explanation, and both the retention of the root apex and

the information given to the patient should be recorded

in the clinical notes.

Fracture of Alveolar Bone

Fracture of alveolar bone is a common complication

of tooth extraction, and examination of extracted teeth

reveals alveolar fragments adhering to a number of

tooth. This may be due to the accidental inclusion of

alveolar bone within the forceps blades or to the

configuration of roots, the shape of the alveolus, or to

pathological changes in the bone itself. The extraction

of canines is frequently complicated by fracture of the

labial plate, especially if the alveolar bone has been

weakened by extraction of the lateral incisor-and/or the

first premolar prior to the removal of the canine. If these

three teeth are to be extracted at one visit, the incidence

of fracture of the labial plate will be reduced if the canine

is removed first.

It is advisable to remove any alveolar fragment which

has lost over one-half of its periosteal attachment, by

gripping it with hemostatic forceps and dissecting off

the soft tissues with a periosteal elevator.

Fracture of Maxillary Tuberocity

Fracture of maxillary tuberocity occasionally, during the

extraction of an upper molar, the supporting bone and

maxillary tuberocity is felt to move with the tooth. This

accident is usually due to the invasion of the tuberocity

by the antrum, which is common when an isolated

maxillary molar is present, especially if the tooth is

overerupted. Pathological germination between an

erupted maxillary second molar and an unerupted

maxillary third molar is a rare predisposing cause. When

fracture occurs the forceps should be discarded and a

large buccal mucoperiosteal flap raised. The fractured

tuberosity and the tooth should then be freed from the

palatal soft tissues by blunt dissection and lifted from

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Exodontia Practice

the wound. The soft-tissue flaps are then approximated

with mattress sutures which evert the edges and are left

in situ for at least 10 days.

If this complication occurs in one maxilla the patient

should be warned that it is liable to complicate a similar

extraction performed on the other side of the mouth.

Only if a preoperative radiograph reveals the possibility,

it is possible to reduce the risk of fracture of the tuberosity

by extracting the tooth by careful dissection.

Fracture of an adjacent or opposing tooth during

extraction can be avoided. Careful preoperative

examination will reveal whether a tooth adjacent to that

to be extracted is either carious, heavily restored, or

in the line of withdrawal. If the tooth to be extracted

is an abutment tooth, the bridge should be divided with

a diamond disk before extraction. Caries and loose or

overhanging fillings should be removed from an adjacent

tooth and a temporary dressing inserted before the

extraction. No force should be applied to any adjacent

tooth during an extraction, and other teeth should not

be used as a fulcrum for an elevator unless they are

to be extracted at the same visit.

Opposing teeth may be either chipped or fractured

if the tooth being extracted yields suddenly to

uncontrolled force and the forceps strike them. Careful

controlled extraction technique prevents this accident.

Under general anesthesia, teeth other than the one

being extracted may be damaged by the injudicious use

of gags and props. The presence of heavily restored

or loose teeth, crowns or bridges should be noted and

brought to the attention of the anesthetist. Such teeth

should be avoided when props or gags are inserted.

If possible mouth gags should not be used. Gags and

props must either be placed under direct vision, or, if

inserted by an anesthetist standing behind the patient,

should be guided into place by the operator.

Fracture of the Mandible

Fracture of the mandible may complicate tooth extraction

if excessive or incorrectly applied force is used, or

pathological changes have weakened the jaw. Excessive

force should never be used to extract teeth.

The mandible may be weakened by senile osteo-

porosis and atrophy, osteomyelitis, previous therapeutic

irradiation, or such osteodystrophies as osteitis defor-

mans, fibrous dysplasia. Unerupted teeth, cysts,

hyperparathyroidism, or tumors may also predispose

to fracture. In the presence of one of these conditions,

extraction should be attempted only after careful clinical

and radiographic assessment and the construction of

splints preoperatively. The patient should be informed

before operation of the possibility of mandibular fracture,

and should this complication occur treatment must

be instituted at once. If a fracture occurs in the dental

surgery, extra-oral support should be applied and the

patient referred immediately to a hospital where facilities

for treatment exist.

Dislocation of an Adjacent Tooth

Dislocation of an adjacent tooth during extraction is an

avoidable accident. Improper application of elevator

may lead to this type of complication. During elevation

a finger should be placed upon the adjacent tooth to

support it and enable any force transmitted to it to be

detected.

Dislocation of the Temporomandibular Joint

Dislocation of the temporomandibular joint occurs

readily in some patients and a history of recurrent

dislocation should never be disregarded. This

complication of mandibular extractions can usually be

prevented if the lower jaw is supported during extraction.

The support given to the jaw by the left hand of the

operator should be supplemented by that given by the

anesthetist or an assistant pressing upwards with both

hands beneath the angles of the mandible.

Dislocation may also be caused by the injudicious

use of gags. If dislocation occurs it should be reduced

immediately. The operator stands in front of the patient

and places his thumbs intra-orally on the external oblique

ridges lateral to any mandibular molars which are

Complications of Tooth Extraction

133

present and his fingers extra-orally under the lower border

of the mandible. Downward pressure with the thumbs

and upward pressure with the fingers reduce the

dislocation. If treatment is delayed muscle-spasm may

make reduction impossible, except under general

anesthesia. The patient should be warned not to open

his mouth too widely or to yawn for a few days

postoperatively, and an extra-oral support to the joint

should be applied and worn until tenderness in the

affected joint subsides.

OROANTRAL PENETRATION

The incidence of oroantral communication after tooth

extraction is probably high but as the number of patients

with residual fistulae is small, the ability of the alveolar

tissues to heal spontaneously is marked.

Predisposing causes of oroantral communications are:

1. The relationship of unerupted teeth and of the roots

of standing teeth to the maxillary sinus. Submerged

premolars or upper first molars at extraction are likely

to produce communication with the antral cavity Tooth

shape anomalies which may produce their own

physical problems of surgical removal. Excessive

deposition of cementum around the roots of the

upper premolar and molar teeth often leads to root

fracture at the time of extraction. Hypercementosis

occurs in relation to lone standing teeth or when teeth

have chronic excessive occlusal loads. Generalized

hypercementosis may be idiopathic in origin, but that

accompanying Paget's disease or even acromegaly

may give insight to the underlying generalized bone

disease. In advanced disease the increase in root size

can be gross and must produce surgical difficulties on

extraction. In a patient with previously undiagnosed

established Paget's disease the writer has

seen excessive extraction force subluxate all the molar

teeth in one quadrant together with their grossly

hypercementosed roots and supporting alveolar bone.

Encroachment of such roots and the altered bone

on the maxillary sinus may distort the anatomical cavity

but produce no other special features.

2. Where the sinus has extended into the alveolus

especially each side of a longstanding molar tooth or

posteriorly enlarged tuberosities.

3. Bulbous or curved roots or bony sclerosis leading to

excessive force being used for an extraction.

4. Loss of periapical bone due to the presence of a

granuloma or an apical periodontal cyst.

5. Dental elevators incorrectly applied either 'blind' or

using vertical instead of transalveolar forces.

6. Surgical procedures performed for the removal of

lesions such as cysts or neoplasm lying in the maxillary

sinus.

Healing of Oroantral Penetrations

An oroantral penetration does not necessarily become

a permanent fistula as a small perforation will often heal

spontaneously. The main factor favoring healing is an

adequate thickness of bone between the sinus and the

mouth, ensuring that the socket is of sufficient depth

to encourage fibrous repair to take place and so keep

antral or oral epithelium separate. Similarly, the smaller

the diameter of the bony deficiency the better is healing.

Infection in or around the socket, or raised air pressures

on one or other side of the wound are detrimental.

When these conditions are satisfactory it can be expected

that granulation tissue, then callus, will seal the wound

and allow it to epithelialize on both the sides.

On occasions the extraction of a maxillary molar will

be accompanied by a fragment of the smooth concave

antral floor, attached between its roots, which may retain

some antral lining confirming the presence of an

oroantral communication. A mouthwash or later a drink

may come down the nose, a free-flow of air and bubbling

between the mouth and nose may be noticed, or

difficulty experienced in smoking or blowing against

resistance. No attempt to prove the presence of a fistula

by probing or other means should be made.

The following measures will assist healing:

Socket Edge Reduction and Simple Suturing

Reflection of the buccal mucosa and reduction of the

bony outer wall of the socket with rongeurs to eliminate

134

Exodontia Practice

part of the buccal root spaces will allow the mucoperios-

teum to fall medially. It may then be sutured to the

palatal side of the socket with horizontal mattress sutures.

This technique does not close the socket opening but

reduces it and helps support clot formation.

Use of a Supporting Pack or Protective Dental Palate

Placing any non-resorbable dressing into the socket

means that healing must occur by secondary intention.

Hemostatic substances such as oxidized cellulose

'Surgical' (Ethicon) or 'Oxycell' (Parke-Davis) are

similarly to be avoided if possible. However, where

support of the clot is required, a short length of 1.5

cm ribbon gauze is folded and soaked in an antiseptic

agent such as Whitehead's varnish or bismuth-iodoform-

paraffin paste (BIPP). It is suspended across ^the socket,

and held in place by prepared loops of sutures crossing

from the palatal buccal mucosa. All packs should be

sutured to the wound edge to prevent their loss. They

are kept in position for 2 weeks and then removed.

A protective dental plate worn for a limited period

may partly prevent food particles being forced into the

socket. When taking impressions for the appliance, the

socket must be adequately protected by a layer of gauze

to prevent impression material being forced into the

sinus. These supportive measures are no substitute for

a good surgical technique but may be sufficient to

prevent a permanent communication.

Nose Blowing and Mouth Washing

Restriction of nose-blowing to avoid raising the air

pressure in the antrum and of mouth-washing to protect

the clot is advised until healing is complete. A suitable

prophylactic antibiotic cover will help to prevent infection.

TREATMENT OF THE ESTABLISHED

OROANTRAL FISTULA

Exposure of the antral cavity to the mouth for any length

of time will expose the sinus to salivary secretions and

contamination with food debris. This will induce chronic

irritative changes in its lining and hence infection, which

will disturb the normal ciliary action and mucous flow

which transfers foreign bodies to the medial antral wall.

Early closure of such a communication is vital, but there

are contraindications to immediate surgery.

The first is the degree of soft tissue damage that has

accompanied the extraction. Macerated and edematous

oral tissue prevents early closure and a decision to leave

the fistula for 3 or 4 weeks may have to be taken,

whereas with minimal trauma to the mucoperiosteum

closure can be performed in the first 48 hours.

The second is infection of the antrum. The success

of all surgical attempts to close an oroantral fistula

depends largely on having a clean sinus with a healthy

mucosa. Wherever there is a history of a previous

chronic sinus infection, the antrum must be radiographed

to assess the state of the lining, including chronic mucosal

thickening or cavity obliteration. Where there is a history

of longstanding disease with chronic mucopurulent nasal

discharge, closure of the fistula must be combined with

an intranasal antrostomy to provide drainage in the

postoperative period.

Where the sinusitis is related to the creation of the

defect and is of shorter duration it may be treated

conservatively, unless widespread polypoidal changes

in the mucosa make it unlikely that it can be improved

by simple measures. Indeed polyps may make irrigation

impossible or uncomfortable.

Fistulae that have been open for weeks will frequently

show a localized hyperplastic polypoidal change imme-

diately surrounding the defect, and metaplastic change

to squamous epithelium may have occurred. This can

be treated by local removal of the affected sinus mucosa

at the time of attempted surgical closure.

Conservative treatment consists of daily antral lavage

through the socket, enlarged if necessary to give suffi-

cient access to allow the patient to perform the irrigation

with warm saline using a bulb syringe. Over 4-6 weeks

the infection should resolve and the communication may

even have closed spontaneously. After this time

epithelialization of the tract will have occurred. Any

attempt at permanent closure must be delayed until the

infection is settled.

135

Complications of Tooth Extraction

Buccal Mucoperiosteal Flap

This surgical approach was first described by Von

Rehrmann (1936).

Most patients will prefer the surgery to be completed

under general anesthesia, though it can be performed

satisfactorily under local anesthesia. Nasotracheal in-

tubation through the nostril of the opposite side gives

an unimpeded intraoral approach and permits a nasal

antrostomy to be performed where necessary. Alternati-

vely, an oral tube taped to the opposite angle of the

mouth is acceptable. Hemostasis and visibility are much

improved by the use of a local vasoconstrictor subject

to agreement with the anesthetist. This is introduced

along the anterolateral wall of the sinus and behind the

zygomatic buttress, being infiltrated freely to separate

fascial planes. A further reduction in bleeding can be

produced by tipping the table to raise the head.

As in all procedures for closure of an established fistula,

the excision of the partially or wholly epithelialized fistulous

tract is imperative. An incision is made with a no. 11 blade.

2 mm outside and encircling the fistulous tract. This should

pass either down to underlying bone or through the bony

defect and into the sinus cavity. The excised tubular tract

is then grasped with fine curved artery forceps and

removed, and as a precautionary measure sent for

histopathological examination. This procedure must lay

bare bone and connective tissue to which the advanced

cheek mucosa and periosteum can unite. It is vital that

where necessary further mucosa is removed palatally to

expose about 3 mm of the bony edge so that the line

of repair will be supported on bone.

From the anterior and the posterior limit of the

excised fistula two divergent buccal incisions pass up

into the vestibule. They are made with the scalpel blade

pressed hard on to bone, to cut through mucosa,

connective tissue and periosteum to a level well above

the attached gingiva. The funnel shape allows the flap

to be advanced palatally between the standing teeth.

The posterior limb is the shorter of the two, and can

be quite short when placed further back in the buccal

sulcus, particularly in elderly patients who have alveolar

resorption. A longer posterior limb will not only make

control of hemorrhage more difficult by involving the

branches of the maxillary artery as they pass forward on

the outside of the lateral antral wall, but the scalpel will

leave the bone surface, and therefore the periosteum,

as it passes into the soft tissues above. Where it is not

possible to make the divergent limbs of equal length,

sufficient laxity is obtained by extending the anterior

incision in a curve forward and upward over the apices

of the teeth. The mucoperiosteal pedicle flap may then

be advanced down and back to meet the palatal mucosa.

A coronal view of the maxilla and the oral soft tissue

shows that the mucosal and periosteal layers separate

at the vestibular fornix so that the mucosa descends to

the cheek while the periosteum continues upwards,

following the anterolateral and buccal aspects of the

maxillary bone above. The flap cannot be advanced

in a palatal direction without sectioning the rigid fibrous

periosteum and so freeing the more elastic mucosa and

submucosal connective tissues to be drawn across the

ridge. To do this the incisions must extend beyond the

vestibular height to allow the flap to be everted and

so expose the periosteum beyond the reflection of the

mucosa. A horizontal cut through the periosteal layer

alone, made in one stroke high up and adjacent to the

maxilla enables the flap to be advanced easily mainly

from its anterior edge over the crest of the alveolar ridge

to a point well palatal to the fistula. IrTits final position

it must lie without tension with the suture line resting

on bone. Sufficient laxity may be provided by digital

stretching after it has been undercut.

The leading alveolar edges of the buccal flap are

trimmed to fit accurately into the area already provided

by excision of the fistula. The advanced pedicle must

also closely contact the adjacent teeth as it passes across

the arch. The edge of the palatal mucosa may be slightly

elevated to allow eversion of the raw edges of the wound

with horizontal mattress sutures. To complete the

procedure the entire incision is repaired with interrupted

sutures and the buccal vertical limbs of the incision are

also loosely closed. All sutures are, unless resorbable,

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Exodontia Practice

removed after 10 days. As there is a hematoma within

the sinus cavity over the mucoperiosteum that has been

advanced, every effort should be made to prevent

infection. This is done by prescribing the antral regime.

A disadvantage of this repair is the local reduction

in sulcus depth caused by drawing the cheek across the

sulcus. It is most marked in the first week following

surgery. Some 40% of oroantral communications closed

using this method still had sulcus reduction at about

6-8 weeks, but had minimized at 6 months.

Palatal Mucoperiosteal Flap

When the oro antral fistula is related to the palatal side

of the ridge or where buccal procedures have failed

usually because of considerable ridge resorption, a

palatal pedicle flap based on the greater palatine artery

may be lifted and rotated across the arch perhaps to

be attached to the buccal tissues.

The palatal mucosa is firmly fused to periosteum from

which separation is difficult. This makes the palatal flap

thick and inelastic so that it must be made longer than

would appear necessary. Even so, only limited rotation

can be safely performed without twisting the palatine artery

and thus devitalizing the flap. Rotation posterior to the

second molar is not recommended though it may be

used for closing an oro antral or oronasal communication

on the contralateral side of the mouth in this position.

The fistula is dissected out and the mucosa cut back to

expose 4 mm of bone all round the defect. The palatal

margin of the excised fistula is made to coincide with the

lateral edge of the palatal flap. An incision is made along

the mid palatal line from just anterior to the junction of

hard and soft palate and curved laterally toward the

affected side, when it has reached the canine and lateral

incisor region. It then passes back about 4 mm palatal

to the crest of the edentulous ridge or the gingival margin

of the fistula when excised.

The flap is lifted and detached from the palate

anteroposteriorly until it can be rotated laterally to lie

without tension over the fistula. This maneuver can be

helped by removing a small notch bucally. After it has

been trimmed to fit the defect accurately it is sutured

to the recipient area with horizontal mattress sutures

and interrupted sutures secure the line of closure

supported on bone.

The denuded bone anteriorly is then covered by

ribbon gauze soaked in an antiseptic solution. The sutures

are retained for 10 days and the pack for 3 weeks. The

uneven palatal surface regains a very nearly normal

appearance in about 2 months.

The Palatal Island Flap

This plastic procedure dissects out an island of palatal

mucosa but retains its connection to the greater palatine

artery (Brosch 1950). Variations of this technique have

been described by Millard (1962) and Moore and Chong

(1967). By dissecting the greater palatine neurovascular

bundle back to the palatal foramen, some extension can

be provided and the flap can be transferred as a well-

nourished full thickness flap to a palatal or buccal site.

Twisting of the exposed artery is reduced by virtue of

its length but care with manipulation of the vascular

supply is imperative.

Bridge Flap

Other forms of local flap have been used but offer no

greater degree of certainty or ease of procedure than

those already discussed. In the edentulous maxilla a local

bridge of tissue in an area adjacent to a fistula may be

mobilized and moved back to cover it (Kazanjian 1949;

Schuchardt 1953). After excision of the fistulous tract

incisions are placed transversely across the line of the

arch. The length of the bridge of mucoperiosteum is

somewhat limited at its palatal end by the palatine artery

which may not be preserved. It can however be extended

buccally sufficiently to elevate and lift it over the fistula

without tension. It is then sutured to the undisturbed edge

of the mucoperiosteum on the distal edge of the defect.

The bridge must be wider than the bony defect and broad

enough for its margins to be well seated on bone. It

follows therefore that the size of the fistula must be

accurately measured before the incisions for the bridge

137

Complications of Tooth Extraction

are made. The denuded bone of the donor area will

granulate under a pack and later epithelialize.

Gold Foil Technique

It is an attractive conservative measure because it requires

the minimal surgical intervention, can be completed easily

under local anesthesia, and preserves the full depth of

the sulcus. It is advocated primarily for the manage-

ment of very large fistula or those repaired by one of

the other techniques described which have failed

subsequently, and where an immediate, simple, trouble-

free protection for the sinus is required. As for all other

methods it can only be used when the maxillary sinus

is free of infection.

The fistulous tract is excised, or curetted to take away

the epithelial lining and bring the underlying defect into

view when any diseased bone is removed. A linear incision

along the crest of the ridge is extended 1.5 cm anterior

and; posterior to the defect and the oral mucoperiosteum

reflected from around the area for about 5 mm

surrounding the defect. A small oblong piece of gold foil

(24 ct) 35 gauges is placed on the bone to cover the

hole completely, with an overlap of 3 millimeters that

can be tucked under the edges of the mucosal wound

to prevent displacement. The incision is then closed with

interrupted sutures, no attempt being made to oppose

the tissues but leaving an elliptical defect which exposes

the underside of the gold throughout the healing period.

Granulation tissue grows from the wound edges on the

superior antral surface of the inert gold foil and crosses

it to form a bridge. This is said to be complete in most

patients in 3-6 months.

The sutures are removed after 10 days. As healing

progresses the edges of the oral wound recede progressi-

vely to expose the gold foil which in time can be removed

with little difficulty. The oral surface then gradually

epithelializes. The obvious problems are that healing

above the foil cannot be seen and that conventional

repair by one of the other methods may be needed

later.

SUPPORTIVE MEASURES

The postoperative regime will depend on the state of

the antrum found at the surgery and the nature of the

procedure. In general the patient should be advised to

follow the antral regime for the first 10 days after

operation.

DISPLACEMENT OF THE TOOTH OR A ROOT INTO THE TISSDES

This is a rare but potentially serious complication. The

tooth or part of it may be lost under a mucoperiosteal

flap into the lingual pouch through the thin lingual cortex

of bone in the lower third molar region, or into the

infratemporal fossa around the back of the maxillary

tuberosity from the upper molar region. Improper

application of forceps to a tooth or elevating a root

with inadequate access may cause such displacement.

Any root or part of the tooth that is unaccounted for

during extraction should be pursued by taking a further

radiograph of the socket and, if possible, the surrounding

area. The patient should then be referred for further

investigation and management by an oral surgeon.

If a tooth or root is lost from view during the course

of an extraction, it may be in one of the following sites:

• Swallowed into the stomach or inhaled into the lung.

If either of these is suspected the patient should be

sent to hospital for abdominal and chest radiographs.

• Pushed into the antrum.

• Displaced into a soft tissue space.

• Collected inadvertently by the suction apparatus.

• Still in the socket.

COLLATERAL DAMAGE TO SDRROUNDING SOFT TISSUES

A certain amount of disruption to the gingival tissues

around an extracted tooth is to be expected. Some

attached gingiva may need to be dissected free of small

fragments of alveolar bone but such displaced tissues,

like flaps of mucoperiosteum can be replaced with

sutures. However, the incidence of the following modes

of soft tissue injury can be reduced with care and

forethought:

Exodontia Practice

• Gingival tissue lacerated by the forceps blades. Be sure

to place the blades inside the gingival crevice and not

trap the soft tissue against the tooth. This is a particular

danger on the lingual aspect of lower teeth.

• Lower lip crushed against the lower teeth while

extracting resistant upper molars. This is due to

incorrect angulations of the forceps and is more likely

to happen under general anesthesia or when the

patient's lower lip is also anesthetized. Awareness of

this problem is usually enough to prevent it.

• An elevator that slips off the intended point of

application and stabs the tongue, floor of mouth or

the palate. Elevators should always be held with the

index finger down the shank of the handle towards

the tip to act as a 'stop' in case the instrument slips.

HEMORRHAGE

Tooth extraction is a stringent test of hemostasis and

excessive bleeding from the socket occurs not

infrequently even in patients who have no pathological

hemorrhagic tendency. The bleeding may be at the time

of surgery— primary hemorrhage within a few hours

after surgery when the vasoconstriction of damaged

blood vessels ceases-reactionary hemorrhage, or present

up to 14 days post-operatively as a result of infection—

secondary hemorrhage.

All patients should be asked whether they or any

blood relative have a history of excessive bleeding and

full details obtained about relevant previous incidents

particularly following tooth extraction. If a hemorrhagic

diathesis is suspected then the patient should be referred

for investigation by a hematologist. Diseases causing

excessive bleeding may involve abnormalities of:

• Blood clotting, e.g. hemophilia, or more commonly

the acquired complication of anticoagulant therapy.

• Platelet deficiency (thrombocytopenia). Either

because to rapid destruction or failure of production

of platelet.

• Blood vessels.

Precautions to minimize the risk of hemorrhage

include careful handling of the tissues to avoid

unnecessary trauma. Placing a gauze pack over the

socket for at least 10 minutes with the patient applying

steady pressure by biting gently to encourage a blood

clot to form in the socket, and then instructing the patient

not to disturb the clot by avoiding vigorous mouth rinsing

or chewing.

If hemorrhage becomes a problem at the time of

extraction it is essential to have good suction apparatus

available so that clear vision of the operative field is

possible. Injecting further local anesthetic solution

containing a vasoconstrictor can help substantially to

control soft tissue bleeding whilst a horizontal matters

suture is placed across the margins of the socket. A small

oxidized cellulose gauze (Surgicel-Ethicon) placed into

the superficial part of the socket further stabilizes the

forming blood clot at this site. When persistent oozing

is coming from the cancellous bone, this can be stopped

by smearing bone wax into the relevant spaces in the

bone marrow. If all else fails then packing the socket

with gauze soaked in Whitehead's varnish (compound

iodoform paint) is a reliable solution to the problem

but the pack must be removed 10 days later.

When patients return with post-operative hemor-

rhage it is often amidst a flurry of high anxiety and blood

stained dribbling. Sitting the patient down quietly,

cleaning away the blood clots that have formed in the

mouth but evidently not in the socket, and giving

reassurance while the patient bites on a pack placed

accurately over the bleeding area will do much to tackle

the situation. In some cases this may be enough to stop

the hemorrhage. Normally it is helpful to inject local

anesthetic around the socket and then suture its margins

with or without the placement of a pack. The medical

history should be checked along with any drugs that

are being taken, notably any anticoagulant such as

warfarin, although aspirin and non-steroidal anti-

inflammatory drugs have an anti-platelet action and may

sometimes be the cause of significant hemorrhage. If

it is thought that there could be a systemic rather than

a local reason for the bleeding, it may be appropriate

to refer the patient for further investigation. In the case

Complications of Tooth Extraction

139

of hemorrhage that is not controllable by the above

measures, the patient should be sent directly to hospital

for surgical management which in severe cases requires

blood transfusion.

Most patients who return complaining of post-

operative hemorrhage is accompanied by anxious

relatives or friends and it is essential to separate the

patient from these well-intentioned, but unhelpful,

companions. Until the patient has been taken to the dental

surgery and the persons accompanying him asked to

remain in the waiting room, it will be quite impossible

either to reassure or treat him satisfactorily. After seating

the patient comfortably in the dental chair and covering

his clothes with a protective waterproof apron, the dental

surgeon should examine the mouth in order to determine

the site and amount of hemorrhage. Almost invariably

an excess of blood-clot will be seen in the bleeding area

and this should be grasped in a piece of gauze and

removed. A firm gauze pack should then be placed upon

the socket and the patient instructed to bite upon it. If

tannic acid powder is placed upon the portion of the

pack adjacent to the bleeding socket it will help to arrest

the hemorrhage. In most instances it will be advisable

to insert a suture into the mucoperiosteum, under local

anesthesia, to control the hemorrhage. An interrupted

horizontal mattress suture is best suited to this purpose

and should be inserted across the socket as soon as

possible. The object of suturing is not to close the socket

by approximating the soft tissues over it, but to tense

the mucoperiosteum over the underlying bone so that

it becomes ischemic. In the vast majority of cases, the

bleeding arises not in the bony socket but from the soft

tissues surrounding it and is stopped by the procedure

described above. The patient should be instructed to bite

upon a gauze pack for 5 minutes following the insertion

of a suture. Should these measures fail to control the

hemorrhage, either gelatin or fibrin foam may be tucked

into the socket. After the pack has been placed in situ

and an extra-oral support provided, the patient should

be referred to the nearest hospital for further treatment.

The mouth tastes unpleasant after a dental hemorrhage,

but repeated rinsing promotes bleeding and should be

avoided. The oral cavity should be cleaned carefully with

gauze soaked in cold water, special attention being

paid to the tongue. This simple procedure adds greatly

to the patient's comfort.

DRY SOCKET

Dry socket has "plagued oral surgeons since the practice

of exodontia began". It is one of the most perplexing

post extraction complications.

The term 'Dry socket' was first introduced by

Crawford in the year 1896. Other terms describing the

condition include alveolitis sicca dolorosa, fibrinolytic

osteomyelitis, alveolalgia, osteomyelitis syndrome.

Dry socket is a term generally understood to refer

to the delayed onset of severe pain associated with

breakdown of clot. This has been satisfactorily established

in a normal extraction wound.

Etiopathogenesis

It is the subject of debate with the opinions being divided

into two main schools of thought.

The first opinion, i.e. inability to form the clot based

on the presumption that there is an absolute absence

of blood clot or improper blood clot formation.

Second opinion i.e. dislodgement of clot, assumes

initial formation of blood clot which however, is

subsequently lysed and lost, leaving behind the empty

socket. The loss of blood clot from the extraction socket

is probably the most accepted factor because of various

reasons which lead to dry socket.

In most of the cases the clot is lost from the socket

due to patient's carelessness in following postoperative

instructions particularly vigorous and constant mouth

rinsing, constant drink which have bubbling effect

destroys the clot or weaken the adherence of clot to the

socket wall, making it more vulnerable for dislodgement.

Breakdown of the clot due to fibrinolytic mechanism

should be given due consideration. According to Brin's

hypothesis, the fibrin is lysed by plasmin which is an

140

Exodontia Practice

enzyme, acting at neutral pH. A proenzyme plasminogen

is converted to plasmin by the action of activators or

kinases like bradykinin and kininogens, released from

traumatized mucosa, periosteum, bone marrow, and

concentrate in the endothelial cells of blood vessel. Its

release is promoted by variety of stimuli. It may also

come from body fluid or arises in plasma precursors

which are proactivators. Thus this plasmin breaks down

the fibrin network of clot, making the socket dry.

The recent study has shown that the oral anaerobic

bacteria 'Treponema denticola' which is a normal

habitant of oral cavity has fibrinolytic activity. The

enzymes produced by this microorganism have a

plasmin like activity leading to breakdown of clot and

dry socket even in the absence of mentioned firbrinolytic

mechanism. This organism doesn't produce pus,

swelling or redness, since it is an anaerobic infection.

It explains the foetid odor and bad taste associated with

dry socket.

The degree of fibrinolytic activity of common oral

bacteria such as streptococcus hemolytics, staphylococ-

cus, and bacteroides is probably not sufficient to be the

cause of dry socket.

PREDISPOSING FACTORS

Difficulty during Extraction

If more force is used than average to extract the tooth,

it may damage and devitalize the bone of socket wall,

reducing its resistance to infection from Treponema

denticola like organism and increasing the local release

of plasminogen activators.

Site of Extraction

Mandibular extractions are complicated by dry socket

more frequently than maxillary extractions. The

mandible has much dense bone and is less vascular as

compare to maxilla.

Also lower teeth are more difficult to extract and

gravity ensures the mandibular sockets to become

contaminated with food debris.

Sclerotic Jaw Bones

In sclerotic jaw bones and irradiated jaws blood supply

is reduced leading to improper clot formation which is

vulnerable to lysis leading to dry socket.

Vasoconstrictors

Reduced vascularity due to the action of vasoconstrictors

inhibits the vascular component of the inflammatory

reaction and tends to favor the establishment of

infection.

Patient on Oral Contraceptives

The use of oral contraceptives has a significant role in

increasing the probability of dry socket after tooth

extraction. Increased fibrinolytic activity is suspected as

a causative mechanism.

Diagnosis: The diagnosis of dry socket can be confirmed

by gently passing a small probe in the extracted wound,

a bare bone is felt which is extremely sensitive.

Signs and symptoms: Following signs and symptoms

helps for the correct diagnosis of dry socket.

PAIN

After two to five days patient comes with the complaint

of severe pain which is closely localized to the socket,

it may radiate to the ear of the same side or other parts

of the face, but with or without signs and symptoms

of infection such as fever, swelling and erythema. Pain

is exaggerated by contact with food during mastication

and also by air blow or fluids. The pain becomes dull

after some days due to necrosis of tissue in the socket,

which covers the bare bone.

HALITOSIS

The food debris may have accumulated in the socket

which, with the disintegrating clot, produces a foul taste

and smell. Anaerobic micro-organisms Treponema

denticola could be a etiologic agent that produce foetid

odor.

Complications of Tooth Extraction

141

GINGIVAL MARGIN

It is usually swollen and becomes dusky red. The socket

itself is either devoid of clot or contains a brown, friable,

foamy clot which is easily washed out.

After a period of 7 to 14 days granulation tissue lines

the socket and gradually fills it up, often there is no

frank sequestrum of the bone but from time to time

exuberant granulation forms and small pieces of socket

wall or part of the interradicular space separate and are

discharged with the formation of small amount of pus,

due to superimposition.

Treatment

The treatment of dry socket is directed primarily towards

the relief of pain as well as healing of wound and is

divided into following ways:

Local Therapy

When patient reports within first 48 hours after

extraction, the dry socket should be treated as simple

extraction wound in which the necrotic blood clot is

removed gently and after irrigation, fresh bleeding is

induced under local anesthesia and pressure pack is given

with antibiotic cover.

When patient reports after 48 hours, all necrotic

debris should be removed and the socket irrigated with

a warm sterile isotonic saline solution and diluted solution

of antiseptic like Betadine. After irrigation of wound the

socket is gently packed with ribbon gauze painted with

zinc oxide eugenol paste (with minimum eugenol

contents). The ribbon should not be packed forcefully

or tightly to form and cover the base of bone. The pack

should completely obliterate and isolate the socket from

the oral cavity. Dressing can be changed depending upon

the severity of the pain but generally the second dressing

is not required, as initial healing takes place to cover

the raw bone.

Zinc oxide- eugenol dressing protects the bare bone

from irritants like food, saliva etc. and prevents food

debris from accumulating in the socket. Eugenol being

an obtundent relieves the pain by destroying superficial

nerve ending. It also acts as a mild irritant which

stimulates the healing and doesn't cause bone necrosis.

Bone necrosis chances are more if eugenol is more. ZnO

itself works as an antiseptic agent.

Systemic Therapy

Systemic therapy consists of use of systemic antibiotics

and antianaerobic agent like metronidazole for rapid

recovery with local wound care. Analgesics and anti-

inflammatory drugs should be given for relief of pain

and to minimize the inflammatory response.

CONCLUSION

Thus it should be noted that dry socket can be taken

care like local wound care with a suitable material like

ZnO—eugenol dressing. The role of systemic antibiotics

is very limited or only to the extent of preventing the

superinfection. It should never be considered curative

and the patient should not be put on heavy antibiotic

or multiple drugs which are not required.

NERVE DAMAGE

The following branches of the nerve may be at risk during

tooth extraction.The mental nerve can be damaged by

over-extension of releasing incisions in the depth of the

buccal sulcus in the lower premolar region, or by bone

removal encroaching on the mental foramen just below

and between the premolar apices. The affected area of

sensory loss extends over the ipsilateral lower lip and chin.

If the tooth or root is in an intimate relationship with

the inferior dental nerve, damage can be prevented or

minimized only by preoperative radio-graphic diagnosis

and careful dissection. The mental nerve may be

damaged either during the removal of lower premolar

roots or by acute inflammation in the tissues around

it. If the nerve is protected by a metal retractor during

operation, and bone removal is maximal mesially to a

first premolar root and distally to a second premolar

root, impairment of labial sensation will be avoided

altogether or be minimal and transient.

142

Exodontia Practice

The lingual nerve may be damaged either by a

traumatic extraction of a lower molar in which the lingual

soft tissues are trapped in the forceps, or by being caught

up with the bur during the removal of bone. A metal

retractor should be used to protect adjacent soft tissues

from harm whenever a bur is in use.

EXCESSIVE PAIN, SWELLING AND TRISMUS

Some degrees of swelling and discomfort is to be

expected after any surgical procedure: tooth extraction

is no exception. Suitable analgesic medication prescribed

for the patient before the expected onset of pain,

combined with appropriate post-operative instructions

and reassurance, is normally adequate management of

these symptoms. Careful instrumentation and handling

of the tissues during surgery minimizes post-operative

edema by avoiding unnecessary trauma, but other

causes of swelling, such as hematoma formation or

infection, cannot always be prevented.

TRISMUS

Trismus is an inability to open the mouth to a normal

and is commonly seen following extractions, particularly

lower molars. Inflammation and edema may spread

from this region to affect the powerful jaw closing

muscles, masseter and medial pterygoid, which are then

painful when stretched. Severe and progressive trismus

occasionally follows a few days after an inferior dental

nerve block as the result of the development of a

hematoma in the medial pterygoid muscle. The passage

of the local anesthetic needle through this muscle may

unavoidably pierce a small blood vessel and cause some

bleeding between the muscle fibres. Fibrosis of the

hematoma may result in prolonged limitation of mouth

opening unless active stretching exercises are employed.

Trismus due to edema normally resolves spontaneously

with the inflammation but the patient can be made more

comfortable meanwhile by the application of heat to

the affected area.

One of the common complications of an inferior

alveolar block is post injection trismus. This may be

caused by (1) needle track infection, (2) trauma to the

medial pterygoid muscle, or (3) the development of

myofacial pain dysfunction syndrome.

Occasionally there will be a persistent trismus which

has certain characteristics that differentiate it from the

three conditions referred to above.This condition is not

frequently mentioned in the literature, and to suggest

that a conservative approach to therapy may be as

effective as the more radical procedures that have been

advocated by some clinicians.

Campbell, in describing his personal experience with

the condition, expressed his opinion that forced opening

was unnecessary and harmful and that even stretching

exercises should not be used, as spontaneous remission

would occur after several months.

Brown believed that such delay in treatment was

usually not acceptable to patients and that gentle

stretching exercises supplemented by a forced opening

under an anesthetic in some cases was the treatment

of choice.

Berry quoted some unpublished studies in these

patients which led him to believe that the trismus might

be a form of guarding of a damaged structure.

Therefore, he did not advocate forced opening.

The use of reassurance together with jaw-opening

exercises and physiotherapy, in the form of ultrasound,

as an initial measure in all cases. Complete failure to

respond after a period of 3 or 4 weeks from the

commencement of treatment would appear to indicate

that forcible opening might be necessary, but this should

be undertaken only if the patient is unable to persist

with the more conservative method of therapy.

Etiology

Various views exist as to the cause of this condition.

Campbell believed that the problem was due to a

hematoma in the medial pterygoid muscle. As mentioned

earlier, Berry thought that the condition was a form of

"guarding" of a damaged structure. It is true that this

type of phenomenon may occur in the muscles of mas-

tication. The argument against this is the fact that the

trismus does not disappear even if the patient is paralyzed

Complications of Tooth Extraction

143

under general anesthesia. This condition is the result of

a needle piercing a small artery with resultant hematoma

formation, followed by its organization into a band of

tissue in the vicinity the medial pterygoid, is the most

feasible one.

(1) onset of the condition is usually a few days

following the injection (average time, 3 days); (2) once

the trismus begins, it becomes established in about 24

hours; (3) spontaneous pain is unusual, but forced

opening of the jaw causes discomfort; (4) there appears

to be a "mechanical restriction" of opening. (5) in most

with correct conservative management, the condition

will resolve in less than 4 months.

The application of intra-oral heat by means of short-

wave diathermy or the use of hot saline mouth-baths

gives relief in mild cases, but other patients require the

administration of antibiotics or specialist treatment to

relieve their symptoms.

OSTEOMYELITIS

Osteomyelitis is an established infection within bone

tissue. All tooth sockets are bony wounds open to the

contaminated environment of the mouth, it is surprising

that infections of the jaws are not seen more often

following tooth extraction. The excellent blood supply

of the facial bones as well as the immunological and

anti-bacterial activity of saliva is largely responsible for

this effect.

Intense penetrating bone pain, prolonged healing

of the socket, anesthesia of the lower lip and general

malaise are the symptoms of osteomyelitis which, in the

acute phase, may show signs of spreading infection and

fever. If the infection becomes chronic the main features

are suppuration, an indurated swelling, and patchy

radiolucency seen on radiographs of the affected bone.

Treatment of acute osteomyelitis requires a high dose

of an appropriate antibiotic for an extended period,

normally several weeks. In addition to this, chronic

suppurative osteomyelitis demands surgical debridement

of the affected area to remove any sequestra of dead

bone.

OSTEORADIONECROSIS

Osteoradionecrosis is an extremely serious complication

of radiotherapy to the jaws that can be triggered by

tooth extraction. The effect of radiation on the tissues,

especially bone, is to reduce dramatically their blood

supply, and therefore to increase vulnerability

infection and failure of normal healing. All teeth in the

anticipated radiation field that may require extraction

should ideally be removed before the patient has

radiotherapy treatment or within a few weeks of it (the

ischemic post-irradiation effects on bone are slowly

progressive over a period of months). If the opportunity

for this preradiation management has been missed and

a patient who has had radiotherapy needs a dental

extraction in an affected part of the jaws, then this should

be undertaken in hospital by an oral surgeon.

TRAUMATIC ARTHRITIS OF THE TEMPOROMANDIBULAR JOINT

Traumatic arthritis of the temporomandibular joint may

complicate difficult extractions if the lower jaw is not

supported. The risk of this unpleasant condition

occurring can be minimized if the operator uses his left

hand correctly and the anesthetist or an assistant steadies

the mandible by holding it under the angtes. If it is known

that the patient has a history of a previous dislocation

of the temporomandibular joint it is a wise precaution

to get him to hold a dental prop tightly between his

teeth on the contralateral side during a dental extraction.

SWELLING

If the soft tissues are not handled carefully during an

extraction traumatic edema may delay healing. The use

of blunt instruments, the excessive retraction of badly

designed flaps, or a bur becoming entangled in the soft

tissues predispose to this condition. If sutures are tied

too tightly postoperative swelling due to edema or

hematoma formation may cause sloughing of the soft

tissues and breakdown of the suture line. Usually both

conditions regress if the patient uses hot saline mouth-

baths frequently for 2 or 3 days.

144

Exodontia Practice

A more serious cause of postoperative swelling is

infection of the wound. No effort should be spared to

prevent the introduction of pathogenic microorganisms

into the wound. If the infection is mild it will often respond

to the application of heat intra-orally by the use of

frequent hot saline mouth-baths. The patient should be

cautioned against applying heat extra-orally because this

increases the size of the facial swelling. A hot-water bottle

applied to the cheek in an effort to relieve pain is a

common cause of gross swelling of the face. If fluctuation

is present the pus should be evacuated before beginning

antibiotic therapy. Any patient with a postoperative

infection severe enough to warrant antibiotic therapy

is best treated at a hospital with oral surgery facilities,

especially if the swelling involves the submandibular and

sublingual tissues.

Collapse in the dental chair may occur suddenly

and may or may not be accompanied by loss of

consciousness. In most instances these episodes are

syncopal attacks or 'faints' and spontaneous recovery

is usual. The patient often complains of feeling dizzy,

weak, and nauseated, and the skin is seen to be pale,

cold, and sweating. First-aid treatment should be

instituted at once and at no time should such a patient

be left unattended. The head should be lowered by

lowering the back of the dental chair. With some designs

of chair the use of this method may be considerable

delay and in these circumstances the patient's head

should be put between his knees after ensuring that his

collar has been loosened. Care should be taken to

maintain the airway and to ensure that the patient cannot

fall out of the chair. No fluids must be given by mouth

until the patient is fully conscious.

If recovery does not occur within a few minutes of

first-aid measures being instituted, the collapse is

probably not of syncopal origin and oxygen should be

administered and medical aid summoned. Careful note

should be taken of both the type and rate of respirations,

and the rate, volume, and character of the pulse. If

circumstances permit, the blood-pressure should be

recorded at intervals.

If respiratory arrest occurs the skeletal muscles

become flaccid and the pupils are widely dilated. The

patient should be laid flat on the floor and his airway

should be cleared by the removal of any appliances or

foreign bodies and by pulling the mandible upwards and

forwards to extend the head fully. The patient's nostrils

should be compressed between the operator's finger and

thumb, and mouth-to-mouth resuscitation should be

performed so that the chest is seen to rise every 3 or

4 seconds. The efficiency of this form of resuscitation is

greatly enhanced if a airway is available and can be

inserted over the tongue. Whilst he is attempting to

remedy respiratory arrest the dental surgeon must check

the carotid pulse and apex beat at regular intervals, for

cessation of breathing may be quickly followed by cardiac

arrest, which is a more serious emergency.

Unless the circulation can be restored and maintained

within 3 minutes of cardiac arrest occurring, irreversible

brain damage may occur due to cerebral anoxia. The

patient exhibits a pallor and greyness, and his skin is

covered with a cold sweat. The pulse and apex beat

cannot be felt and the heart-sounds cannot be heard.

If the patient is a child, the heart will often start beating

again if the sternum is tapped sharply. When an adult

is being treated the patient should be laid flat on his

back on the floor. The dental surgeon places the

heel of his left hand on the lower third of the patient's

sternum. The operator then places his right hand on

the back of the heel of his left hand and presses

downwards rhythmically at second intervals, with

sufficient force to compress the heart between the

sternum and the vertebral column. If an assistant is

present she should simultaneously treat the respiratory

arrest in the manner described a b o v e . When no

assistance is available the dental surgeon should perform

respiratory and cardiac resuscitation alternately for

periods of 20 seconds.

Index

A d v a n t a g e s of long flaps 75

A l v e o l a r process of the mandible 26

A l v e o l a r process of the maxilla 22

A v o i d vital structures 74

facial artery 74

lingual nerve 74

mental nerve 74

B o n e removal: postage stamp m e t h o d

C o m p l e t e e x o d o n t i a 62

Complications of tooth extraction 129

fracture of alveolar b o n e 131

fracture of maxillary tuberocity 131

fracture of the mandible 132

dislocation of an adjacent tooth

132

dislocation of the

temporomandibular joint

132

oroantral penetration 133

fracture of tooth 131

local complications 130

failure of local anesthesia 130

failure to m o v e tooth 130

nose b l o w i n g and mouth washing

134

socket e d g e reduction and simple

suturing 133

use of a supporting pack or

protective dental palate 134

Contraindications of exodontia 34

active infections 35

b l e e d i n g disorders 35

diabetes and hypertension 34

medically c o m p r o m i s e d patients 35

patients on steroid therapy 35

pregnancy 35

Dental extraction 2

Directions to m o v e teeth for extraction

5 2

mandibular anterior teeth 57

mandibular molars 58

mandibular premolars 58

mandibular teeth 57

maxillary canine 54

maxillary first premolar 54

maxillary second premolar 55

maxillary molar 55

maxillary teeth 52, 53

Stobie's technique 57

Exodontia for medically compromised

patients 103

artificial heart valves and transplants

1 0 9

treatment considerations 109

asthma 117

care pertinent to extraction 117

diabetes 104

care pertinent to exodontia 105

epilepsy 116

care pertinent to extraction 116

heart failure 108

care pertinent to extraction 108

hemophilia 113

care pertinent to extraction 114

hyperthyroidism 109

care pertinent to extraction 110

hypothyroidism 110

care pertinent to extraction 110

infective endocarditis 107

care pertinent to extraction 107

patient on e x o g e n o u s steroids 110

care pertinent to extraction 111

patients on heparin 113

patients receiving radiotherapy 118

care pertinent to extraction 118

patients receiving warfarin therapy

111

care pertinent to extraction 112

patients taking aspirin 112

care pertinent to extraction 113

pregnancy 115

care pertinent of extraction 115

systemic hypertension 106

care pertinent to exodontia 106

Extraction of primary teeth 98

contraindications 98

extraction technique for primary

teeth 99

armamentarium 99

general considerations 100

indications 98

indications for extraction of

permanent first molars 99

Extraction under general anesthesia

119

consent 121

contraindications for general

anesthesia 120

indications 120

Factors that complicate the extraction

procedure 62

adjacent teeth 65

b o n e 6 4

increased b o n e bulk 65

increased b o n e density 64

periodontal health 64

crown 62

diminished access 65

prosthetic concerns 66

proximity to vital structures 65

roots 62

ankylosis 63

bulbous roots 62

dilacerated roots 64

divergent root 64

hypercementosis 63

multiple roots 62

root canal treatment 63

Functions of sutures 75

coapt w o u n d margins 75

hemostasis 75

holding soft tissue flap o v e r b o n e

General anesthesia and considerations

for intraoral procedure 121

146

Exodontia Practice

complications of extraction under

general anesthesia 123

postoperative information 124

postoperative instructions 123

identifying the right tooth 122

positioning for general anesthesia

121

positioning of the operator 121

postoperative instruction 123

surgical considerations for general

anesthesia 122

General principles in exodontia 38

basic requirements 38

a g o o d radiograph 38

adequate anesthesia 38

adequate illumination 38

efficient assistance 38

instruments 38

suction apparatus 38

chair position for forceps extraction

3 9

for a mandibular extraction 40

for a maxillary extraction 39

clinical evaluation 38

interpretation of a preoperative

radiograph 39

patient and surgeon preparation 39

placement of fingers during extraction

of mandibular teeth 42

role of assistant during the

extraction procedure 43

role of opposite hand 42

Healing of the extraction w o u n d 126

first-week w o u n d 126

fourth-week w o u n d 128

immediate reaction following

extraction 126

s e c o n d - w e e k w o u n d 127

third-week w o u n d 127

Important factors for removal of root

p i e c e 86

a g e and general medical condition

of the patient 86

amount of root retained 86

circumstances of the fracture 86

reasons for extraction 86

site of fractured root 86

Indications of exodontia 32

apical p a t h o l o g y 32

dental caries 32

e c o n o m i c considerations 34

esthetics 34

focal sepsis 34

impactions 33

orthodontic reasons 32

m a l p o s e d teeth 32

serial extraction 32

therapeutic extractions 32

periodontal disturbances 32

prosthetic considerations 32

pulp p a t h o l o g y 32

root fragments 33

supernumerary teeth 33

teeth in relation to bony pathology 33

teeth prior to irradiation 33

tooth in the line of fracture 33

Instrument for providing suction 19

Instrument to hold the mouth open 19

Instrument to hold towels and drapes

in position 19

Instruments for controlling hemorrhage

Instruments for elevating

mucoperiosteum 13

Instruments for irrigation 19

Instruments for r e m o v i n g b o n e 15

b o n e file 15

bur and handpiece 16

chisel and mallet 15

R o n g e u r forceps 15

Instruments for suturing mucosa 16

n e e d l e 17

n e e d l e holder 16

suture cutting scissor 17

suture material 18

Instruments to grasp tissue 14

Instruments to incise tissue 12

Instruments to r e m o v e soft tissue from

b o n y defects 16

Instruments used for tooth luxation

(elevators) 10

types 10

a p e x o elevator 11

axio elevator 11

cross bar elevator 11

straight elevator 11

winter cryer elevator 11

Instruments used to extract tooth

(dental forceps) 6

mandibular forceps 9

mandibular anterior forcep 9

mandibular c o w horn forceps

mandibular molar forcep 9

mandibular premolar forcep 9

universal forcep 10

maxillary forceps 7

maxillary anterior forcep 7

maxillary Bayonet forcep 9

maxillary c o w horn forcep 8

maxillary molar forcep 8

maxillary premolar forcep 7

maxillary third molar forcep 9

Management of fractured primary tooth

roots 101

Maxillary molar extractions 100

extraction of mandibular anterior

teeth 101

extraction of maxillary anterior teeth

101

mandibular molar extractions 101

Mechanical principles of elevators 43

lever principle 43

w e d g e 4 3

w h e e l and axle principle 44

Pediatric exodontia 93

anesthesia technique 95

local anesthesia 94

mandibular tooth anesthesia 96

preparatory measures 94

types and location of injection 96

Policy for leaving root ( T I P ) fragments

9 0

conditions for leaving root tips in

the socket 90

protocol w h e n leaving behind the

roots 91

roots in edentulous j a w s 91

Postextraction care 44

Prevention of flap dehiscence 74

Prevention of flap necrosis ( b l o o d

supply of flap) 74

Principles of flap design 66

flap reflection 69

incision 66

instrumentation 69

types of flaps 71

e n v e l o p e flap 71

four cornered flap 72

release incisions on the facial

aspect of crown 72

three cornered/triangular flap 71

Procedure for closed extraction 46

general steps 46

adaptation of the forceps to the

tooth 47

application of forces to the tooth

with the forceps 49

I n d e x

147

loosening of soft tissue

attachment from the tooth 46

luxation of the tooth with a

dental elevator 47

removal of the tooth from the

socket 51

R o l e of assistant during extraction 52

R o l e of the opposite hand 51

Socket toilet 79

Technique for o p e n extraction of

multirooted tooth 78

mandibular first molar 78

maxillary molars with divergent

roots 78

Technique for o p e n extraction of

single rooted tooth 77

Technique for removal of small root

tips 86

application of an elevator 89

b o n e r e m o v a l 8 9

closed technique 87

forcep r e m o v a l 87

o p e n technique 8 8

Tooth sectioning 76

Treatment of the established oroantral

fistula 134

bridge flap 136

buccal mucoperiosteal flap 135

collateral d a m a g e to surrounding

soft tissues 137

dry socket 139

etiopathogenesis 139

excessive pain, swelling and trismus

142

gingival margin 141

treatment 141

g o l d foil technique 137

h e m o r r h a g e 138

nerve d a m a g e 141

osteomyelitis 143

osteoradionecrosis 143

palatal island flap 136

palatal mucoperiosteal flap 136

predisposing factors 140

difficulty during extraction

140

patient on oral contraceptives

140

sclerotic j a w b o n e s 140

site of extraction 140

vasoconstrictors 140

supportive measures 137

swelling 143

traumatic arthritis of the

temporomandibular joint

143

trismus 142

etiology 142

Exodontia Practice

Dr Abhay N Datarkar earned his BDS and MDS degree at Govt.
Dental College and Hospital Rashtra Sant Tukdoji Maharaj Nagpur

University. He also has an honour of being the First Diplomat of
National Board in Central India.

A meritorious student throughout his career, a recipient of Gold

Medal award of Nagpur University and Best student of Nagpur
University award in 1996. He has various scientific presentations and publications

to his credit in various national and international conferences and journals.

He is a natural teacher, excellent academician and a surgeon par excellence.

He is known amongst his colleagues and students for his inestimable calm,
professional competence, unalloyed guidance, elucidatory suggestions and
ineffable surgical wisdom.

Rs. 795.00

JAYPEE BROTHERS

MEDICAL PUBLISHERS (P) LTD.

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