Oral Surgery

Presurgical Medical Assessment

• examine pt’s medical status
Management of Routine and • check if treatment modification is necessary
Complicated Exodontia • check if special measures for bleeding control is
needed, antibiotic prophylaxis etc

Prepared by:
Renelie P. San Jose-Dizon

Pain and Anxiety Control A. Local Anesthesia

• remember precise innervations of all teeth and surrounding soft
• dense LA is required tissue
• must be profound to eliminate sensation from • Maxillary teeth - anesthetize the offending tooth and adjacent teeth
pulp, PDL, and adjacent soft tissues • Mandibular teeth - Mandibular Block injection
• (+) pressure • dense LA = loss of pain, temperature, and touch sensations;
(+)proprioception = pressure
• PDL injection - pulpitis, inflammation, infection (15-20mins)
• know the maximum amount of LA that may be used per patient
• consider post operative pain control

Max Amt No. of cartridges for No. of cartridges for

B. Sedation
Drug/Solution
(mg/kg) 70kg adult 20kg child
• already in pain, agitated, fatigued
Lidocaine 2% with 1:100k epinephrine 5.0 10 3.0 • low pain tolerance and threshold
Mepivacaine 2% with 1:20k levonordefrin 5.0 10 3.0 • Diazepam - may help pt to rest well at night prior to
Mepivacaine 3% 5.0 6 2.0
surgery
Prilocaine 4% with 1:200k epinephrine 5.0 6 2.0
• Lorazepam - in the morning of surgery
Articaine 4% with 1:100k epinephrine 7.0 6 1.5
• Nitrous Oxide (inhalation) - mild to moderate
Bupivacaine 0.5% with 1:200k epinephrine 1.5 10 3.0
anxiety
Etidocaine 1.5% with 1:200k epinephrine 8.0 15 5.0 • IV Sedation - moderate to severe anxiety
 1. Caries
• severely carious teeth that CANNOT be restored
Indications for Removal of • complexity and cost required to salvage a severely
Teeth carious tooth makes extraction a choice

2. Pulpal Necrosis
• pulpal necrosis or irreversible pulpitis that is NOT
AMENABLE to endodontics
• root canal is tortuous, calcified, and untreatable by
standard endodontic techniques
• endodontic treatment has been done but has failed to
relieve pain or provide drainage
• pt does not desire treatment

3. Periodontal Disease 4. Orthodontic Reasons

• pt who are about to undergo orthodontic
• severe and extensive correction of crowded dentition with
periodontal disease insufficient arch length
• excessive bone loss • most common : maxillary and mandibular 1st
and irreversible tooth PM
mobility • mandibular incisor
 5. Malposed Teeth
• malposed or malpositioned teeth if:
• they traumatise soft tissue and cannot be
repositioned by orthodontic treatment
• hypererupted teeth that interferes with the
construction of prosthesis
• i.e. Maxillary 3rd Molars in severe Buccal
position that causes ulceration

6. Cracked Teeth 7. Impacted Teeth

• cracked crown or • partially impacted
fractured root tooth that is unable to
erupt into functional
occlusion due to:
• inadequate space,
interference from
adjacent teeth etc.

8. Supernumerary Teeth 9. Teeth associated with Pathologic Lesions

• may interfere with eruption of succeedaneous • odontogenic cysts
• has a potential for causing root resorption and • if maintaining a tooth
root displacement compromises surgical
removal of the lesion,
it should be removed
 10. Radiation Therapy
• teeth along the beam of radiation

11. Teeth involved in Jaw Fractures 12. Financial Issues

• teeth in line of fracture • inability of patient to pay for procedures to
that are : maintain the tooth (periodontal therapy, RCT
• injured etc)
• infected • unwillingness of patient
• severely luxated
• interferes with proper
reduction and fixation
of fracture

Contraindications for
Removal of Teeth
A. Systemic Contraindications
B. Local Contraindications
A. Systemic Contraindications
1. Severe uncontrolled metabolic diseases (Brittle Diabetes,
end-stage Renal Disease with severe Uremia)
2. Uncontrolled Leukemia and Lymphoma
3. Severe uncontrolled cardiac diseases (Myocardial ischemia =
Unstable angina pectoris, recent MI, Malignant HPN, CVA)
4. Severe uncontrolled cardiac dysrhythmias
5. Pregnancy
6. Severe bleeding diathesis (Hemophilia) and severe platelet
disorders
7. Pt with anticoagulants (with caution)
 A. Systemic Contraindications
• Pt taking variety of medications
1. Systemic corticosteroids
2. Immunosuppressive agents
3. Bisphosphonates
4. Cancer chemotherapeutic agents
Clinical Evaluation of
Teeth for Removal
Clinical Evaluation of Teeth for
Removal
Condition of the Crown
• presence of large caries
• presence of large restorations
• endodontically treated teeth
• presence of calcular deposits
• condition of adjacent teeth
A. Local Contraindications
1. History of therapeutic radiation therapy
(Osteoradionecrosis)
2. Teeth located within an area of tumor (esp.
Malignant)
3. Severe pericoronitis* around an impacted
mandibular third molar
4. Acute dentoalveolar abscess**
Clinical Evaluation of Teeth for
Removal
Access to the Tooth
• limitation in mouth opening
• location and position of tooth
Mobility of the Tooth
• hypercementosis
• ankylosis
Radiographic Examination
of the Tooth for Removal
Radiographic Evaluation of Teeth for Removal
Radiographs must meet the following criteria:
• must be properly exposed with adequate penetration and good
contrast
• shows all portions of the crown and roots without distortion
• must be properly processed, with good fixation, drying and
mounting
• mounting should be labeled with patients name, and date when the
film was exposed
• should be mounted as if looking at the patient; raised dot on the
film faces the observer
• should be reasonably current
• should be available during the surgery (mounted on a view box)

Radiographic Evaluation of Teeth for Removal

Relationship of Tooth to adjacent erupted and unerupted
teeth
• Primary tooth = underlying succedaneous tooth
• Root to be removed = root of adjacent tooth
• Bone removal = roots of adjacent tooth
Relationship to Vital Structures
• Maxillary Sinus
• Inferior Alveolar Nerve/Canal
• Mental Foramen/Nerve

Radiographic Evaluation of Teeth for Removal

Configuration of Roots
• Number of roots of the
tooth
• Curvature of the roots
• Degree of Root
Divergence
• Shape of individual
roots
Radiographic Evaluation of Teeth for Removal

• Size of roots (hypercementosis,

bulbous roots)
• Root caries
• Root resorption (Internal/External)
• Endodontically treated (ankylosis)

Radiographic Evaluation of Teeth for Removal

Condition of Surrounding Bone
• Radiolucent bone = Less Dense
= easier Mechanical Principles
• Radiopaque bone = condensing
osteitis, sclerosis = More Dense involved in Tooth Extraction
= harder
• Presence of Apical Pathologic
condition (cysts, granulomas,
etc)

Lever : Elevator
Simple Machines:
1. Lever
2. Wedge
3. Wheel and axle
 Wedge : Forceps and Elevators Wheel and Axle : Elevator

Principles of Elevator and Goal of Forceps Use:

• expansion of the bony socket
Forceps Use • removal of the tooth from the socket

5 Major Forceps Motions

1. Apical Pressure
• tooth socket is expanded by the
insertion of beaks down the PDL
space
• center of rotation of tooth is
displaced apically
2. Buccal Pressure
• expansion of buccal plate, esp 4. Rotational Pressure
crest of the ridge • causes internal expansion of tooth
• also causes lingual apical socket and tearing PDL
pressure • teeth with single, conical roots
• may cause: fx of Bu bone or fx
of apical portion of root
3. Lingual Pressure
• same as Buccal pressure

5. Tractional Forces Maxillary Teeth - Labial/Buccal

• used for delivering the tooth from
the socket Mandibular Incisors to Premolars - Labial/Buccal
• when bone expansion is adequate
• teeth should not be pulled from the
sockets
Mandibular Molars - Lingual

• Closed - Routine Technique

• Open - Surgical or Flap Technique
Procedure for Closed Fundamental Requirements:
Extraction 1. Adequate access and visualization
2. Unimpeded pathway for removal
3. Use of controlled force
 STEP 1: Loosening of the Soft Tissue
• aka Gum separation (Gumsep)
• sharp instrument i.e. Scalpel blade
• Molt #9 (MPE)
Purpose:
• ensure profound anesthesia is achieved
• to allow elevator and forceps to be positioned more
apically
STEP 2: Luxation with a Dental
Elevator
• Expansion and Dilation of alveolar bone
• Tearing of PDL
• Straight elevator is inserted perpendicular to the
tooth into the interdental space

STEP 3: Adaptation of Forceps to the

STEP 2: Luxation with a Dental
tooth
• beaks of the forceps should
Elevator
be shaped to adapt
anatomically to the tooth
root
• beaks of the forceps must
be held parallel to the long
axis of the tooth

STEP 4: Luxation of Tooth with Forceps STEP 5: Removal of Tooth from the Socket
• 4 forcep motions (except Tractional Force)
• force should be directed toward the thinnest and • Tractional Force
weakest bone • unusual direction for malposed teeth
• slow, deliberate pressures must be delivered and NOT
WIGGLES
• force should be held for several seconds to allow the
bone time to expand
 Role of the Opposite Hand
• Reflect soft tissues of the cheeks, lips, and tongue
• Protects teeth from forceps
• Helps stabilize the patient’s head
• Helps in supporting and stabilising the jaw Post Extraction Tooth
• Supports the alveolar process during luxation
• Provides tactile information Socket Care
• Finger guard during luxation using elevator

Post Extraction Tooth Socket Post Extraction Tooth Socket

Care • Expanded Bu-Li plates shouldCare
be compressed with finger pressure
• Debride socket only if necessary • If teeth were removed because of periodontal dse, remove any
• (+) Granuloma on the accumulation of granulation tissue around the gingival cuff with a PA
curette, tissue scissors, or a hemostat
preoperative radiograph, • Bone should be palpated through the overlying mucosa to check for
curette the PA region carefully any sharp, bony projections
• (+) Debris (i.e. calculus, • If any is present, reflect the mucosa and smoothen with a bone file
amalgam, tooth and bone or a rongeur
• Initial control of hemorrhage is achieved by use of a moistened
fragments), gently remove with gauze
a curette or suction tip • Pressure pack

Post Extraction Tooth Socket Care

WRONG!!! CORRECT!!! Principles of More Complex
Exodontia
Source : C8 Contemporary Oral and Maxillofacial Surgery 6th Edition; J.R.Hupp et al
Extraction Techniques Indications for Open Extraction
• Anticipate possible need for excessive force to extract
a tooth (fracture of bone, tooth, or both)
Closed • After initial attempts at forceps extraction have failed
(divide and conquer)
Open/Surgical
• Dense bone
• Hypercementosis

TRIANGULAR
FLAP

ENVELOPE
FLAP

SEMILUNAR FLAP

TRAPEZOIDAL
FLAP
 Indications for Open Extraction
1. Widely divergent roots
2. Severe dilaceration or hooks
3. Pneumatization of Maxillary Sinus
4. Large caries/restoration

Technique for Open Extraction : Single Rooted

Tooth

Technique for Open Extraction :

Single Rooted Tooth
Technique for Open Extraction : Single Rooted Technique for Open Extraction : Single Rooted
Tooth Tooth

Alveolar
Purchase
2. Luxate tooth
1. Flap, Remove Bone on with Straight
elevator
Buccal

Technique for Open Extraction : Single Rooted Technique for Open Extraction : Single Rooted
Tooth Tooth 1. Flap
2. Remove bone to access the
root
3. Make a purchase point for
3. Use forceps to the elevator using a surgical

deliver the tooth bur

4. Elevate the tooth out of the
socket
5. Debride, suture

Technique for Open Extraction :

Multi-Rooted Tooth

1. Envelope Flap 2. Section the tooth Bu-Li (dividing it via the bifurcation) 3. Split the tooth
using an elevator 4. Deliver the individual parts using a forceps. 5. Debride, Suture
 Technique for Open Extraction : Multi
Rooted Tooth
Technique for
Open Extraction :
Multi Rooted
Tooth

Removal of Root Fragments and

Tips
Technique for
Open Extraction :
Multi Rooted
Tooth

Justification for Leaving Root Fragments

• Root fragments should be small, no more than 4 to
5mm in length
• Root must be deeply embedded in bone and not
superficial Multiple Extractions
• Risks outweigh the benefit
 Extraction Sequencing
• Maxillary teeth must be removed first
• infiltration anesthetic has a more rapid onset and also
disappears more rapidly
• debris (amalgams, fx crowns, bone chips) may fall into
empty tooth sockets if MD extraction is done first
• Mx teeth are removed with a major component of Bu
force and no traction force at all
• DA: if hemorrhage is not controlled, bleeding may
interfere visualization on MD extraction site
Extraction Sequencing
•Most Posterior tooth must be removed first
• allows more effective use of elevators to luxate and
mobilise teeth before forceps are used
•Tooth that is most difficult to extract, Canine, should
be extracted last
•Removal of teeth on both sides weakens the bony
socket

Extraction Sequencing
1. Maxillary Posteriors
2. Maxillary Anteriors leaving the Canine
3. Maxillary Canine
4. Mandibular Posteriors
5. Mandibular Anteriors leaving the Canine
6. Mandibular Canine