Difficulty of extractions Flashcards
Broadly speaking, what 2 types of features can help you assess the degree of difficulty of an extraction?
clinical features and radiographic features
(patient factors also have a bearing e.g. pt anxiety and PMH)
What effect can age have on extraction?
very young and very old can cause issues
- young pt can be difficult to treat under LA
- older pt have far more brittle teeth, more predisposed to fracture, often more heavily restored which predisposes to fracture, more likely to break alveolus etc
- also likelihood of polypharmacy in older pt
Why is ethnic background a consideration for difficulty of extraction?
relates to quantities/quality of bone in some ethnic backgrounds
e.g. afro-caribbean and asian pts often have very dense alveolar bone which makes extraction more demanding and may require surgical intervention
Why is access to teeth important when assessing difficulty of extraction?
crowing, tilting, rotation, impaction - if can’t get beaks of forceps on the tooth it is challenging
Why is a lone-standing molar important when assessing difficulty of extraction?
particularly upper molars
- subject to occlusal force which makes it more difficult to extract due to thickening of alveolar bone around tooth and thickening of the PDL
- makes it more difficult to remove, more predisposed to alveolar fracture, tuberosity fracture, and formation of OAC particularly in older pt and maxillary antrum tends to become larger
Why are abrasion cavities important when assessing difficulty of extraction?
make tooth more likely to fracture at level of abrasion
Why are endodontically treated teeth/post crowned teeth important when assessing difficulty of extraction?
more fragile, lost elasticity so more likely to break
Why is extensive caries important when assessing difficulty of extraction?
more difficult to engage beaks on the tooth
What is important about retained roots when assessing difficulty of extraction?
can be difficult depending on how much of the root is visible or otherwise
Why are unerupted teeth important when assessing difficulty of extraction?
nearly always require surgery and referral, the same often applies to submerged teeth
What clinical feature can make extraction easier?
periodontal disease - mobile, loss of PDL, visible root surface
Would you manage an impacted tooth in primary care?
no, requires surgery
What does impaction mean?
the tooth is prevented from achieving a functional occlusal position
What are the most commonly impacted teeth?
those that erupt latest
- mandibular third molars (most common)
- maxillary canines
- maxillary incisors
- secondary premolars
What is the flap of gum overlapping a partially erupted tooth?
operculum
What is a soft-tissue impaction?
when the only thing preventing a tooth achieving functional position is soft tissue e.g. an operculum
What effect can crowding have on difficulty of extraction?
can make it much more difficult, can’t engage beaks of forceps on the tooth surfaces they are designed to engage
What is a typical example of a tooth hard to access? Why?
maxillary third molars
- very posterior
- often bucally inclined
- when pt opens mouth the coronoid process rotates downwards into the space you’re trying to engage with forceps
- can be overcome with bayonet forceps
What is one of the main reasons for difficulty of extracting molar teeth?
multiple roots, can be going in different directions etc
Why is it important to assess proximity of the antrum to the tooth being extracted?
extraction can lead to OAC - need to assess the patient’s risk of this happening
- risk can increase when other teeth have already been lost and pneumatisation of the maxillary antrum has occurred, making it bigger
Do you always need to refer for upper molars due to the OAC risk?
no, can extract in primary care and refer if the OAC complication occurs
- key is to properly inform patient of risk, document risk etc
If a crown is grossly carious or in bad condition, what may you need to consider using for extraction?
may need to use elevators etc as may not be able to engage beaks of forceps on the tooth due to inadequate tooth tissue
Do grossly carious teeth always require referral for extraction?
no, can use elevators or specialised forceps in primary care if there is still root above the level of the alveolus
In terms of extraction, why is it important to radiographically assess the extent of the caries?
subgingival caries can be extensive but may be masked by overlying restorations, important to radiographically assess to beaks of forceps can be placed high enough on the root to avoid the carious area
When can retained roots be elevated for extraction, and when would they require surgery to be extracted?
if the root has sound tissue above the alveolus then elevation may be possible, but if the tooth has fractured beneath the level of the alveolus then surgery is required
Why are impacted unerupted teeth removed or uncovered?
- orthodontic reasons
- restorative/aesthetic reasons
- pathology e.g. cysts
What teeth are most commonly submerged?
more commonly affects deciduous molar teeth, often when there is no permanent successor
Why can deciduous teeth be submerged?
surrounding permanent teeth are coming in, alveolus changes shape and the submerged tooth is ‘left behind’
Can submerged teeth be removed in primary care?
no, require surgical removal
Why does periodontal disease lead to easier extraction?
- tooth not as well supported, mobile
- more root surface accessible, can engage forceps further down the root, less force required for removal
What clinical features can affect degree of difficulty of extraction?
- age
- ethnic background
- access - crowding, tilting, rotation, impaction
- lone standing molar
- abrasion cavities
- endodontically treated teeth/post crowed teeth
- extensive caries
- retained roots
- unerupted teeth
- submerged teeth
- periodontal disease
What radiographic features can affect difficulty of extraction?
- bulbous roots
- dilacerated/divergent/convergent roots
- fused roots
- multi-rooted teeth
- hypercementosis
- ankylosis
- lone-standing/last-standing molars
- deeply impacted 3rd molars
What can cause bulbous roots?
- genetics, simply how they have grown
- excess growth of cementum
What does it mean if a tooth has a bulbous root?
end of the tooth wider than neck of the tooth
How are bulbous rooted teeth extracted?
require a surgical approach
Why can multi-rooted molar teeth be difficult to extract?
roots can go in different directions with different paths of withdrawal
What are convergent roots?
roots that come together, move towards eachother
What are divergent roots?
roots that go away from eachother, move in different directions
Why can deciduous molar extractions sometimes be quite challenging?
multi-rooted and often very divergent roots due to underlying tooth bud, can have fragile and thin roots
What teeth in particular may have marked curvatures of the roots?
multi-rooted teeth, particularly mandibular third molars
Why are mandibular third molars more likely to have marked curvature of their roots?
proximity of IAC, roots more likely to form in strange patterns which can make their removal very difficult
Why is a DPT often required when assessing mandibular third molars?
to assess root curvature and proximity to IAC
What pathologies may be present in the jaw?
- osteolytic lesions
- cysts
- odontogenic tumours
- primary cancers
- metastatic cancers
- metabolic bone disorders
- fibro-osseous lesions
What are the kinds of root resorption?
- external
- apical
- coronal
- internal
can also be caused by pathologies
What type of root resorption (ext. or int.) causes a more difficult extraction?
internal - crown more likely to come off
external root resorption may actually lead to an easier extraction
What can cause resorption of the bone around teeth?
infections
- periapical
- periodontal
- osteomyelitis
What is ankylosis?
when tooth fuses to bone
Why does ankylosis cause difficulty of extraction?
tooth fused to bone, can’t mobilise with forceps
What considerations are made when planning a surgical extraction?
plan from radiographs
- path of least resistance
- extrinsic obstacles
- intrinsic obstacles
- bone removal
- sectioning
- point of application
- flap design
What are extrinsic obstacles?
obstacles outwith the tooth e.g. adjacent teeth, proximity to IAC, proximity to maxillary antrum etc.
What are intrinsic obstacles?
obstacles within the tooth e.g. root morphology - bulbous root, marked curvature, dilacerated/convergent/divergent roots
What is an example of when bone needs to be removed?
when roots have been retained below the level of the alveolus, need to remove bone to engage the root
Why can’t high speed handpieces be used to section roots?
introduces air into the soft tissue - surgical emphysema, introduces bacteria and air into the tissue and can lead to cellulitis
What is something you should do before sectioning teeth?
lift a mucoperiostial flap - allows good visual access, can take away bone where needed before sectioning teeth
Where can difficult extraction cases be referred to?
oral surgery department of a dental hospital/school, maxillofacial department in a hospital, oral surgery specialist in practice
What can help when referring a patient?
local and national guidelines
What information must be given when referring a patient to secondary care?
- letter of referral with detailed history
- justification for referral
- up to date radiograph
