Surgical Extractions Flashcards
Why are closed extractions not enough sometimes?
Excess force and improper force application
can result in fracture of bone, tooth root, or
both
What are the indications for surgical extractions?
Failure of forceps
extraction
Grossly carious teeth or
brittle teeth (failed root
canal therapy)
Dense or inelastic bone
(bruxism / older patient)
Ankylosed teeth /
hypercementosis
Impacted teeth
Unfavourable roots e.g.
long, curved, dilacerated
Fractured root tip
Proximity of important
anatomy e.g. maxillary
sinus
What are the advantages of using surgical extraction over closed extractions?
Provides greater access to safely remove a
tooth or its remaining roots
Soft tissue flap is reflected and a proper amount of bone removed and/or tooth
sectioned
Achieve mechanical advantage, reduce
resistance and provide an adequate path of
withdrawal
Recontour and smooth bone after multiple
extractions
How are teeth extracted in a surgical extraction?
Access: A mucoperiosteal flap is raised and bone is removed on the way to the tooth.
Mechanical advantage: Bone is removed and tooth is accessed with luxator and leveraged out
Reduce resistance (buccal bone removed and roots elevated)
Recontour bone (Smooth bone after multiple extractions)
How is resistance reduced in a surgical extraction?
Remove buccal bone and tooth is sectioned
Roots are elevated after sectioning
What is the correct path of removal of bone and sectioned teeth and roots?
Elevators are used to elevate the roots separately.
Elevators are used to draw the root down if close to the maxillary sinus
How do elevators work?
They use the lever and fulcrum principle, wedge principle, and wheel and axle principle
The fulcrum is the alveolar bone where the elevator is placed and the long arm is held by practitioner whereas the short arm attaches to the tooth.
How do elevators use the lever and fulcrum principle?
Transmits modest force with the mechanical advantage of long lever arm and short
resistance arm into small movement against great resistance e.g. straight elevators
How do elevators use the wedge principle?
Wedging the elevator between the tooth and socket displaces the tooth occlusally e.g. Coupland’s chisel
How do elevators use the wheel and axle principle?
When handle is rotated, force created on elevator
is multiplied, creating a greater mechanical
advantage to elevate tooth out of its socket e.g. Cryer’s
How does surgical extraction make it easier to perform an extraction?
A few millilitres of bone is removed to expose the root to provide a new point of application for an elevator mesially, distally or buccally,
to provide an unobstructed line of withdrawal
How should hypercementosis be treated during a surgical extraction?
May need to remove bone down to the apex
How should multirooted teeth be surgically extracted?
Same surgical technique used for the single
rooted tooth
For roots of an upper or lower molar, remove buccal bone to bifurcation to be used as application point
If radiograph show unfavourable curvature,
divide the roots and elevate separately
Divide tooth with a bur to convert a multi rooted tooth into several single-rooted tooth
If the crown of the tooth remains intact, the crown portion is sectioned in such a way as to facilitate removal of roots
If the crown portion of the tooth is missing and only roots remain, separate the roots to make them easier to remove with elevators
How should upper molars be surgically extracted?
Extraction of maxillary molars with widely divergent buccal and palatal roots that can be removed by dividing the root into several sections
This three-rooted tooth must be divided in a pattern different from that of the two rooted mandibular molar
The flap is reflected, and a small portion of crestal bone is removed to expose the trifurcation area
The bur is used to section off the mesiobuccal and
distobuccal roots, the forceps delivers the crown and palatal root along the long axis of the root
The entire delivery force should be in the buccal direction
Palatal roots can be approached buccally by
removing buccal alveolar bone and inter-radicular bone. This allows good access but requires remove of a lot of alveolar bone
Intra-alveolar approach may be better. The inter-septal bone between buccal and palatal roots is slowly removed with bur till roots
exposed and then elevator used to draw root down. Upward pressure must NOT be used on roots in close relation to the max sinus
How are lower molars extracted surgically?
Removal of the lower first molar with an intact crown by sectioning the tooth bucco-lingually and dividing the tooth into a mesial half
(with mesial root and half of the crown) and a distal half
An envelope incision is made, and a small amount of crestal bone is removed
Once the tooth is sectioned, it is luxated with straight elevators to begin the mobilization process
The sectioned tooth is treated as a lower premolar tooth and is removed with lower universal forceps
What is the alternative method of surgically extracting lower molars?
An alternative method for removing the lower first molar is to reflect the soft tissue flap and remove sufficient buccal bone
to expose the bifurcation
The bur is used to section the mesial root from the tooth and convert the molar into a single-rooted tooth
The crown with the mesial root intact is extracted with lower molar forceps
The remaining mesial root is elevated from the socket with a Cryer elevator
The elevator is inserted into the empty tooth socket and
rotated, using the wheel and axle principle. The sharp tip of the elevator engages the cementum of the remaining root, which is elevated occlusally from the socket. If the inter-radicular bone is heavy, the first rotation or two of the Cryer
elevator removes the bone, which allows the elevator to
engage the cementum of the tooth on the second or third rotation
How should impacted 3rd molars be assessed prior to extraction?
Classification of the position of impacted molar teeth helps in assessing the best
possible path of removal of the impacted teeth
Prediction of operative difficulty before the
extraction of impacted third molars allows a design of treatment that minimises the risk of complications
Both radiological and clinical information required
What are the classifications of impacted mandibular 3rd molars?
Based on nature of overlying tissues
Winter’s classification
Pell and Gregory’s classification
How are impacted mandibular 3rd molars classified based on nature of overlying tissue?
Soft tissue impaction
Bony impaction
How are impacted mandibular 3rd molars classified based on Winter’s classification?
Based on inclination of the impacted third molar to the long axis of the second molar:
Mesio-Angular
Disto-Angular
Horizontal
Vertical
Buccal / Lingual
Obliquity
Transverse
Inverse.
How are impacted mandibular 3rd molars classified based on Pell and Gregory’s classification?
Based on relationship between impacted lower third molar to ramus
of mandible and second molar:
Impaction depth = A, B, and C
Ramus relationship = Class I, II, and III
How is depth assessed in Pell and Gregory’s classification?
Based on location of mesial cemento-enamel junction relative to the adjacent root
How did Archer modify the Winter’s classification?
Includes the depth of impaction and the angulation
What should be done following surgical extraction?
Once the tooth is removed the flap is repositioned and sharp edges are smoothened with bone file.
Wound is thoroughly irrigated and debrided of loose fragments of tooth, bone, calculus and other
debris.
The flap is then repositioned and sutured in place.
Why is saline irrigation performed following extraction?
Saline irrigation removes debris and has been scientifically shown to shorten healing time post operatively.
