Oral Surgery

Complicated Exodontia

Done By : Muad Salahuddin Al-Zoubi

This lecture is about the complicated exodontia (extraction of teeth), not the simple exodontia which we have been acquainted to in this semester and we started to talk about in the summer semester (in fact, all exodontias are surgical though the term simple is widely used).
Synonyms - Simple extraction = Intra-alveolar extraction = Closed extraction = Uncomplicated extraction. - Surgical extraction = Trans-alveolar extraction = Open extraction = Complicated extraction. -

Pain and Anxiety (anesthesia and sedation, respectly):

In general we need to know about the sort of local anesthesia we give to know how long it will be active for, e.g. lidocaine acts for about 2-3 hours, the universally used local anesthetic for outpatient surgical dental management is most of the times lidocaine (xylocaine, lignocaine are other names for lidocaine). Now we need to know how and when do we use lidocaine; in maxillary infiltration anesthesia it takes a shorter time to kick-off (onset of action) and it lasts for a shorter time (shorter duration of action) while in inferior alveolar nerve block ( I.D Nerve Block) it takes more time to kick-off and it wears-off slowly (longer duration of action). When local anesthesia is given, the first tissues to be anesthetized (easily anesthetized) are soft tissues then bone and teeth (take more time to be anesthetized) and vice versa, the first tissues to wear-off are the soft tissues then the bone and teeth. As well as anything complicated, sedation should be considered in complicated extraction of teeth, whenever the patient is thought to be anxious and difficult to manage, something different than anesthesia is needed to be thought about, here we are not talking about pain but about how were going to make the patient relaxed, sedation will never take the place of anesthesia, sedatives are given to deal with something different than pain i.e. anxiety, the sedative which is used most of the times in oral surgery is midazolam (I.V) and its given 1ml per kilogram (this is the maximum that can be given), oral form of benzodiazepines can also be given as well, e.g diazepam (Valium), nitrous oxide (N2O) is also used, mainly with children, its also used in adults but its not as effective, it gives very light sedation . (We need to differentiate between different terms such as sedatives and anesthetics or analgesics, sedatives are not given to control pain, but they are used to reduce stress, and helps to induce sleeping i.e. sedate).

The Indications & Contra-indications for Extraction:

Non- restorable teeth in general are needed to be extracted, carious teeth, remaining roots, severely periodontally-involved teeth (severely mobile teeth), referral for orthodontic treatment or prosthetic rehabilitation, and if there is pathology e.g impacted tooth with associated lesion (pathology is an indication to take any tooth out, not only the impacted teeth, if a tooth is associated with a big pathology, this tooth is needed to be taken out along with the pathology because we never know what sort of pathology is that, to prevent any sort of destruction, it can be sinister or can be benign but causes bone resorption and might lead to pathologic fracture due to the thinning of bone,). The contraindications for taking any tooth out (whether complicated or uncomplicated exodontia) include; radiotherapy (the risk of developing osteoradionecrosis), after some sort of level of radiation dose, not every patient on radiotherapy but after breaching to a degree of radiotherapy dose that makes the bone prone or liable to have osteoradionecrosis, this is the first thing we need to know about radiotherapy i.e. the dose, the second thing we need to know about is where the patient exactly has had the radiotherapy, e.g. a patient has received radiotherapy to treat bone cancer in the lower limb is not contraindicated to have extractions but if a patient has received radiotherapy to treat cancer in the neck or the facial bones or the brain (head and neck region in general) then this patient has had the dose over the area in which we need to extract teeth and that bone in particular might be prone to have osteoradionecrosis, another contraindication is malignancy at the site, if a tooth is to be extracted and there is an associated malignancy, we should make a comprehensive management e.g. not simply extract a carious tooth associated with a big oral cancer, the extraction of such a tooth should be involved in the comprehensive management of the patient ( if the patient will have radiotherapy, resection, where resection should be, etc.) because if the dentist extracted the tooth without being integrated in the comprehensive management of the patient, he would disseminate the cancer, in this case the dentist would open a socket, the cancerous tissues multiply very easily, they can fill in the socket and spread easily, thats why malignancy is something we need to kee p in mind ! Many people and even some dentists have illusions that if there is an infection or abscess the patient is given antibiotic to resolve the problem then the tooth is extracted, and this is never right, rather, if there is an abscess or infection, the tooth should be treated either by extraction or incision and drainage then antibiotics are administered. THE ONLY CASE IN WHICH THE TOOTH (with infection) IS NOT EXTRACTED IS WHEN THE PATIENT HAS MODERATE TO SEVERE PERICORONITIS AROUND THE WISDOM TOOTH (a contraindication

for extraction). So, the moderate to severe pericoronitis is the only indication for giving antibiotics before taking the tooth out. Radiographic evaluation is done; there are vital structures around the mouth, in the mandible, in particular when we do exodontia, we concern about two main structures, these are the lingual nerve and the mental nerve, in the exodontias of the wisdom tooth we also concern about the I.D nerve, in the maxilla, the vital structure we concern about in the complicated exodontia are the maxillary sinus and the greater palatine bundle (neurovascular), especially the greater palatine vessels. Actually, any extraction is considered surgical, but when we use the term simple extraction we mean that its a surgical extraction but its a closed extraction, closed means that we dont need to open a flap, if we need to open a flap and expose the bone, the tooth and the periodontium around the tooth its called open extraction , its also called transalveolar meaning that its not closed and we try to take the tooth out through the alveolus (the socket) by removing bone for example and get the tooth across the alveolus, so , simple extraction is a deceiving term though its used, its better to call it closed extraction . Dont ever think that when you do closed extraction, its always better than doing open extraction, its not more conservative (i.e. the closed extracti on), if the case needs opening a flap it should be done, otherwise, the associating and surrounding tissues will undergo severe trauma e.g. bone fracture by using some instruments, actually when the case needs opening a flap, opening a flap is more conservative!

The indications for open-extraction :

1- Failed closed-extraction, e.g. when a tooth that appears on radiographs to be a simple case, has straight roots and there is nothing impeding taking the tooth out is tried to be extracted by closed-extraction but yet the tooth couldnt be luxated or taken out, then this case is an indication to open a flap to see whats going on in reality (by naked eyes not on radiographs). 2- If theres dense bone surrounding the tooth , this could be racial (e.g. black people usually have denser bone than other races), anatomical (e.g. wisdom tooth surrounded by buccal dense bone) or pathological (e.g. Pagets disease of bone in which there is dense bone and theres hypercementosis, people with this disease need surgical extraction for any tooth). 3- Atrophic mandible, because it might fracture under the force applied for closed-extraction, open-extraction will lessen the amount of the applied force because some bone will be removed and the tooth will be easier to luxate, e.g. an old patient who has one standing tooth

and all other teeth have been extracted long time before, in such a patient the bone (alveolar bone) of the mandible would have been resorbed and the bone surrounding that standing tooth will be dense, so this tooth is anchored strongly in the bone, if closed-extraction is to be used, it would need greater amount of force to take the tooth out, thus, this patient definitely needs an open-extraction. 4- Funny roots, meaning that they are abnormal, examples include ankylosis, hypercementosis (as in Pagets disease or in old people with standing molars especially if theyre not used), and dilacerations. 5- Lose condyles, as in EhlersDanlos syndrome or Marfan syndrome (connective tissue diseases), in general people with connective tissue diseases has lax muscles and lax joints or ligaments, in people with lose condyles, when closed extraction is used it might cause TMJ dislocation.
EhlersDanlos syndrome (EDS) is an inherited connective tissue disorder with different presentations that have been classified into several primary types. EDS is caused by a defect in the synthesis of collagen, specifically mutations in the COL5A and COL3A genes. Marfan syndrome (also called Marfan's syndrome) is a genetic disorder of the connective tissue. People with Marfan tend to be unusually tall, with long limbs and long, thin fingers. The syndrome is carried by the gene FBN1, which encodes the connective protein fibrillin-1. Marfan syndrome is a dominant genetic trait, meaning that people who inherit only one copy of the Marfan FBN1 gene from either parent will develop Marfan syndrome and be able to transmit it to their children. Wikipedia

6- Heavily decayed teeth, which cannot be extracted by closed-extraction because they keep fracturing, so a flap is opened. 7- Pneumatized sinuses, an enlarged sinus, as if the upper first molar has been extracted for a long time, the space of the tooth in the bone will be occupied by the sinus (the sinus would be enlarged), after that if the upper second molar is needed to be extracted, it would be just next door to the bone forming the walls of the sinus, if this tooth is tried to be extracted closely (without opening a flap), the floor of the sinus could be easily fractured resulting in oro-antral communication but if a planned open surgical extraction was done, some bone layers would be removed little by little without applying much force preserving the integrity of the sinus. (The palatal root of the upper first molar is very close to the sinus and can be in the sinus itself, penetrating the sinus floor and covered by the sinus membrane).

Steps for The Surgical (Open) Extraction of Teeth:

All of the following steps are vital and care must be taken of them 1- MPF (muco-periosteal flap). 2- Removing bone. 3- Delivery of the tooth (how to deliver or take the tooth out after doing the flap and bone removal). 4- Debridement. 5- Closure. 6- Post-op. care. The muco-periosteal flaps that can be used in the oral cavity are mainly of three types, the first one is the envelope flap in which the gingiva over the alveolar crest next to the teeth is only incised (from the crevicular side of the gingiva), the second type is the two-sided (or three cornered) flap, the third type is the three-sided (or for cornered) flap. If there is an edentulous ridge, a fourth type of flaps can be used which is called the crestal flap, as if an edentulous patient is seeking for complete denture construction and there is some bone that prevent the denture from being inserted in or removed from the mouth, the crestal flap (on the alveolar crest, like the envelope flap but when there is no teeth) is opened and bone reduction is done.
Synonyms Envelope flap = One-sided flap Triangular flap = Two-sided flap = Three-cornered flap Rhomboid flap = Three-sided flap = Four-cornered flap

One-sided

Envelope Flap

Three-cornered

Two-sided
Triangular Flap

Three-sided Four-cornered

Rhomboid Flap

In the envelope flap the incision is done on the sides of the teeth and there is no releasing or relaxing incision (makes the flap able to be opened wider), so it should be emphasized that a good access is obtained, the good envelope flap incision is two teeth anterior and one tooth posterior to the area to be worked on, e.g. if the first molar is to be extracted using the envelope flap the incision starts from the first premolar and ends at the second molar that is two teeth anterior and one tooth posterior to the tooth being extracted, this is to make sure that the tissues can be retracted easily and nicely without making any tears.

In the triangular flap, the incision is extended one tooth anterior and one tooth posterior to the tooth in question (not two teeth anterior like the envelope flap) because there is a releasing incision, the mucosa will be elevated or retracted away.

Note : the long incision heals just like the short incision as long as its kept clean, so, saying that small incisions are always more conservative than long incision is not right because the small inadequate incision is going to be retracted more to make access and this will cause the incision to be torn and the healing of such an incision is very slow but when the incision is sufficient (not necessarily long) to get good access and visibility, it will heal just as the short incision as long as both are not subjected to any sort of tears, so never think that the small incisions are better, long incisions are good as long as theyre needed and done in the right way. In the four-sided flap its better to go one tooth anterior and one tooth posterior, some argue that its not wrong to make the incision just around the tooth in question, e.g. a canine is needed to be extracted surgically or is associated with abscess around its root and apicoectomy is going to be done (cutting the apex and restoring it), some say that the design of a four-sided flap around the canine only is not wrong but its preferable to go more anterior and posterior to it, and remember always that the base of the flap must be wider than its apex to maintain good blood supply to the flap.

Technique: 1- Doing the incision around the teeth starting from the area which is more difficult to be seen to the area which is easier to be seen (i.e. posterior to anterior), if the incision is started from anterior, the blood will go to posterior making the area posterior (which is already difficult to see) even more difficult to see. 2- Doing the incision parallel to the tooth as much as can be especially in envelope flap or incisions next to the teeth. 3- Doing the incision firmly down to the bone using continuous one stroke (not short intermittent ones) using the tip of the blade (the sharpest part of the blade).

4- If a vertical or releasing incision is going to be done, make sure that the tissues of the alveolar mucosa are a bit tight by retraction (when its tight the incision will be cleaner and the tissues that are cut are less), otherwise its more difficult for the blade to cut through the tissues and the incision will be torn. 5- Reflection then retraction of the flap, by instruments e.g. Woodson elevator for reflection of the flap, and when reflection of the flap is done, make sure to start from the interdental papillae because this area can be easily torn and if its torn, its very difficult to be restored or regenerated, so first the papillae is pried then the rest of the flap is elevated after reflection of the flap, retractors are used to make sure that the flap is away from bone where the operation is going to be done , there are too many retractors that can be used e.g. Austin retractor (refer to the lecture of instrumentation).

6- Removal of bone, this can be done with too many instruments, sometimes reflection of the flap by its merit is enough e.g. clarifying a certain area where the extraction forceps or other instruments such as Coupland's elevator can be applied and no bone is needed to be removed, but most of the times when a flap is opened, there is a need to remove bone, bone can be removed either by a chisel or a bur, the chisel is simply an instrument that can chip bone off but it needs an experienced personnel or practitioner, the chisel has a sharp edge which is applied to the bone needed to be removed and the chisel is hit, if an inexperienced person is using it, the chisel might traumatize tissues which are not needed to be hit, the bur is more conservative and can be used safely by the inexperienced practitioner, because it only removes bone in the area in which it rotates.

There are advantages of bone removal, including exposure (exposing bone then removal of this bone to expose part of the tooth), exposure of a part of the tooth makes it easily elevated, by buying a point of application to the elevator, also bone removal may create a space for a tooth to be displaced, e.g. removing bone distal to a wisdom tooth (no teeth are distal to the wisdom), now the tooth can be simply elevated or moved posteriorly so that the tooth is taken out from posterior, with the chisel or the bur sharp edges and loose fragments of bone can be removed, the socket can be reduced (so that the tooth is taken out easier) and to ensure that there is no prosthetic problem e.g. an edentulous patient with torus mandibularis (bone next to the premolar area lingually), a flap can be opened then the bone (torus) can be removed by the chisel or the bur so that a denture can be set.

There are two methods of taking the bone out, the first one is the postage stamp method and the other method is guttering, in the postage stamp method the site of bone removal is delineated by the bur (making holes around the area) then these holes can be easily matched or connected together making the bone removed in the right amount and the right way (more delicate), the other method which is guttering is done by removing layers of bone until the wanted level is reached so that the instrument that is wanted to be applied can be used well e.g. a lower molar is to be extracted and there is bone buccally that impedes the application of the extraction forceps, this bone can be removed in a way starting from above and going downwards little by little until the level which makes the application of the forceps possible is reached.

The holes in the postage stamps facilitate their separation likewise the postage stamp method of bone removal.

The general rule states that bone can be removed up to two thirds of the root (only leaving the lower third) exposing the root except its lower third but this doesnt mean that this removal (i.e. two thirds of the root) is done whenever bone removal is needed, rather the bone is removed until its thought that the tooth can be taken out, so conservativeness implies always, that is little bone is removed then the tooth is tried to be taken out (using the forceps for example or other instruments) and if its not possible, more bone is removed and so on, not removing the whole amount of bone then trying to take the tooth out. When a tooth is going to be delivered (taken out from the extraction socket), after bone removal the tooth is loose and is ready to be delivered, make sure that there are proper lighting and proper suction (the suction is already there, because bone removal with bur generates heat that can lead to bone necrosis, so proper coolant is used with bone removal by the bur and the suction is there and its a must from the beginning) because its that point ( i.e. tooth delivery) that is most crucial in the surgery since that tooth can be easily dislocated (some practitioner are proud that they extract the tooth using the elevator only and this is never right) whenever a tooth is to be delivered, delivery must be done with the extraction forceps, even if the tooth has been luxated with the elevator, when the tooth is to be delivered out of the patients mouth, it should be done with the extraction forceps to make sure that the tooth is under control, otherwise if it slipped (i.e. the tooth), it can be easily dislocated somewhere, where its not wanted to go to (airways, GIT, enter s the socket and go to the submandibular space or the infratemporal space or the sinus) ----------------------------------------------------------------------------------------------------------------------------" " :] [." ": . . " : . . . " .