Difficulty of Extraction Flashcards
4 clinical features that make extractions in elderly patients more difficult.
- Teeth become more brittle (predisposed to fracture).
- Heavily restored (increase risk of fracture).
- Loss of tissue elasticity (teeth, alveolus, tuberosities).
- Polypharmacy.
Which populations tend to have thicken alveolar bone?
Afrocaribbean and asian.
Why do lone standing molars increase the difficulty of extraction (2).
- Subject to occlusal force, there is THICKENING OF THE ALVEOLAR BONE AROUND THE TOOTH + THICKENING OF THE PDL + PNEUMATIZATION OF THE MAXILLARY ANTRUM.
- Increases risk of alveolar fracture, tuberosity fracture, oro-antral communication.
What is a characteristic that can make a tooth EASIER to remove?
Periodontal disease
10 clinical features that increase the difficulty of extraction?
- Age.
- Ethnic background (quality/quantity of bone).
- Access (crowding, tilting, rotation, impaction).
- Lone standing molar.
- Abrasion cavities.
- Endodontically treated/ post crowned teeth.
- Extensive caries.
- Retained roots.
- Unerupted teeth.
- Submerged teeth.
Define Impaction
The tooth is prevented from achieving a functional occlusal position
4 commonest impacted teeth?
- Manidbular molars.
- Maxillary canines.
- Maxillary incisors.
- Second premolars.
As a general rule, which teeth are the ones to be most likely impacted?
The ones that erupt LATEST
Flap of gum overlying a partially erupted tooth?
operculum
What special forceps can be used to extract a maxillary 3rd molar when there is limited space available?
Bayonets.
Why do large abrasion cavities increase the difficulty of extraction?
Predisposes the crown to fracture so if the beaks of the forceps are not firmly on solid root then the crown will fracture off.
Why is removal of canine roots difficult?
Long and oval shaped roots.
When can luxators and elevator be used?
When enough of the root is fractured ABOVE the level of the alveolus so that a POINT OF APPLICATION can be created.
What happens when a root fractures BELOW the level of the alveolus?
Commits you to SURGICAL extraction.
3 reasons impacted teeth would be removed?
- Orthodontic reasons (ex. orthodontic realigning aka uncover impacted tooth and bond to impacted tooth to realign it).
- Restorative/ aesthetic reasons (ex. implant placement).
- Pathology (ex. cysts).
2 causes of submerged teeth?
- Deciduous molar teeth that are retained, often when there is no permanent successor OR due to ankylosis (less common).
- Growth and eruption of adjacent teeth causes the alveolus to change position, leaving the submerged deciduous tooth behind.
8 radiographic features of difficulty of extraction?
- bulbous roots.
- dilacerated/ divergent/ convergent roots.
- fused roots.
- multi-rooted teeth.
- hypercementosis.
- ankylosis.
- lone standing/ last standing molar.
- deeply impacted 3rd molars.
What are bulbous roots? How are they caused?
How can these be extracted?
- The apical portion/end of the tooth is wider than the neck of the tooth.
- Genetic or due to hypercementosis.
- Require SURGICAL removal.
Is it easier to take out a more “challenging” multi-rooted tooth with divergent roots on a younger or older patient?
- on a YOUNGER patient as their bone is more ELASTIC.
- Older patients have more brittle teeth and bones –> risk of fracturing the tooth or alveolus or tuberosity.
What condition causes an opaque cloud-like appearance in the mandible/maxilla?
cemento-osseous dysplasia
How is cemento-osseous dysplasia managed?
SURGICAL removal of tooth + associated displastic tissue in maxilla/mandible.
6 types of osteolytic lesions?
- Cysts.
- Odontogenic tumors.
- Primary cancers.
- Metastatic cancers.
- Metabolic bone disorders.
- Fibro-osseous lesions.
How to differentiate radiographically between a benign or malignant osteolytic lesion?
Benign lesions are unlikely to cause extensive osteolytic lesions or extensive resorption of nearby teeth.
3 extrinsic obstacles to extraction?
Proximity to:
- Adjacent teeth (ex. if tooth displaced, ectopic, tilted or rotated).
- IAN/ ID canal
- Maxillary antrum.
3 intrinsic obstacles to extraction?
- Bulbous root.
- Multirooted & convergent/divergent/fused.
- Marked curvature
- Dilacerated.
What is the 7 step plan made from the radiograph for a surgical extraction?
- Determine path of least resistance.
- Extrinsic obstacles.
- Intrinsic obstacles.
- Bone removal.
- Sectioning.
- Point of application.
- Flap design.
5 things to include in a referral letter to a specialist oral surgeon?
- Complaint and HPC
- Past medical history
- Past dental history
- Justification for referral.
- Up to date radiograph
You attempted an extraction in general practice but part of the root broke off when attempting to extract. What must you do prior to sending a referral letter to a specialist?
- Take a peri-operative/ post-operative radiograph detailing what is left in situ.
Why is access for XLA of maxillary 3rd molars difficult (2)?
- Because mouth opening brings the CORONOID PROCESS into the space lateral to the maxillary 3rd molar.
- Teeth are often slightly buccally inclined.
Why do endodontically treated teeth increase the difficulty of extraction?
- Teeth are more BRITTLE and thus more likely to FRACTURE.
How do caries/ condition of the crown increase the difficulty of extraction?
Inadequate tooth tissue to engage the beaks of the forceps.
What can be used to extract carious teeth?
Cowhorns.
Elevators.
How do we use elevators?
Point of application between the root surface and the alveolus.
Do NOT use adjacent teeth.
3 cases where application of forceps may cause the crown to come off.
- Caries of the crown
- Grossly fracture teeth
- Postcrown
Why may we wish to refer for XLA of teeth with postcrowns?
Postcrowns often also have caries down the length of the post, thus coronal part of the root retaining post may also be carious.
What is the most common pathology impacted teeth develop?
Cysts
How are submerged teeth treated?
Requires SURGICAL REMOVAL, would not be undertaken in primary care.
How are unerupted teeth removed?
All unerupted teeth require SURGICAL MANAGEMENT.
What determines the path of withdrawal of a tooth?
The shape of the root determines the path of withdrawal of that root. Thus if 2 roots have different POW, need sectioning and removal.
Cause and effect of internal root resorption on difficulty of extraction?
- Inflammatory aetiology.
- More CHALLENGING XLA as the tooth structure is compromised. Forcep XLA would lead to crown fracture, leaving crown behind.
Cause and effect of external root resorption on difficulty of extraction?
- Inflammatory aetiology.
- Less challenging XLA.
3 types of periradicular infections and their effect on degree of difficulty of XLA?
- Periapical.
- Periodontal
- Osteomyelitis.
Cause OSTEOCLASTIC BONE RESORPTION, making XLA EASIER.
What is ankylosis?
Tooth fuses to bone and cannot be mobilized using forceps.
How is XLA of ankylosed teeth done?
- Cannot be XLA using forceps.
- Will have to be done in SECONDARY CARE.
3 reasons to take radiograph of lone standing maxillary molar if going to XLA?
- Assess proximity to antrum
- Root morphology (convergent, bulbous, divergent, fused).
- Assess risk of OAC or fractured tuberosity.
What is the path of least resistance?
Natural path of extraction/ natural path of eruption of the tooth.
What is good practice to do before sectioning teeth?
Lift a MUCOPERIOSTEAL FLAP.
- Gives GOOD VISUAL ACCESS and can take away bone where needed before sectioning teeth.
What is used to section teeth? Why?
- Never use a high speed handpiece to section roots as it causes surgical emphysema and introduces air in to the tissue and can lead to cellulitis
- There are surgical handpieces that do not introduce air into the tissues
Where can difficult extractions be reffered to? (3)
- Oral surgery specialist.
- Maxillofacial department.
- Oral surgery department
