Tolabar Pie chart showing exodohtia comparison of complications occurring with a medium frequency Click here to view. Evaluation of trismus, bite force, and pressure algometry after third molar surgery: If the perforation does occur then the patient should follow certain instructions: Report of a case in the lateral cervical position. Excluded and included patients Click here to view. Anatomic distribution of teeth extracted Click here to view. Any patient taking anticoagulants like Heparin or Coumadin, or patients who have bleeding disorders, like hemophilia, should give this medical compkications to the dentist so that they may be aware to help prevent further complications. It is a rare dental condition which mostly occurs after dental extraction, implant surgery or other invasive dental procedures.
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However, when the time does come to extract these teeth it can be far from straightforward. Tips and techniques for dealing with failed or stubborn extractions are also discussed, as well as how to manage some of the more common complications of dental extractions. He qualified in from the University of Manchester and after completing his PhD in Glasgow undertook academic oral and maxillofacial surgery training to become a senior lecturer and honorary consultant in oral surgery in Manchester until At present, he holds an honorary senior lecturership at the University of Cardiff.
Introduction Advances in techniques and materials have resulted in patients keeping many teeth for longer. However, when these teeth eventually fail they can be more challenging to extract. Additionally, patients may opt to have these missing teeth replaced by dental implants so preservation of as much bone as possible when extracting teeth should be one of the objectives.
Careful assessment, correct choice of instruments and knowledge of techniques to achieve successful removal of teeth and roots are essential. Secondary and tertiary specialist referral services are under great pressure and thus can result in a delay for patients getting treated.
So, successful removal of teeth by the general dental practitioner GDP in a timely manner is going to be preferable. Reserving the use of the specialist providers for the more complex treatment or severely medically compromised patients is more efficient and beneficial to all. However, remember the consent process for such patients begins with the referring practitioner, so knowledge of the risks and potential complications by the GDP is essential.
None of the information provided here relies on advanced techniques or materials unlike much dentistry today. It is not rocket science more a back-to-basics approach.
Assessment A complete assessment of a patient including clinical and radiographic examination does not take long but really is the key to successful exodontia and anticipating difficulties and potential complications.
Clinically, teeth requiring removal will range from having completely intact crowns to just retained roots so the initial approach to removing these teeth will vary. Patients with limited mouth opening may pose a challenge especially for the removal of posterior teeth. Adjacent teeth that are heavily restored must be noted and the greatest care must be taken not to cause iatrogenic damage during the procedure.
Although some have argued that a preoperative radiograph is not essential before all dental extractions, such a simple investigation with low radiation exposure may readily alert the dentist to potential difficulties or complications.
Common examples of these are listed in Table 1. Even mobile periodontally involved teeth can be a challenge, especially in the mandible. Table 1 Radiographic signs of potential problems with extraction Full size table Instruments Having appropriate instruments for the procedure and knowing how to use them correctly will greatly facilitate a successful extraction. The most useful instruments are without doubt the luxators; equally, they can be one of the most dangerous if not used correctly with appropriate precautions.
The luxator does exactly as its name implies and luxates the tooth or root from within the socket. It requires careful application following the long axis of the root in the periodontal ligament space between the alveolar bone and root. Controlled force is applied in an apical direction and rotational movements applied to dilate the socket and move the root coronally. The operators index finger should always be placed close to the tip of the instrument in case it slips Fig.
Figure 1: Illustrating the application of a luxator in relation to the long axis of the tooth. Note the position of the index finger close to the working end of the luxator blade to prevent deep penetration into adjacent tissues if the instrument slips off the tooth.
A surgical handpiece is another essential instrument used for division of teeth or roots of multi-rooted teeth to facilitate the removal of each root separately. Techniques Whether an implant is being considered or not, preservation of bone should always be one of the objectives whenever possible. Always remember the successful removal is going to require breakage of the periodontal ligament and dilation of the socket.
Some would advocate the use of periotomes only to remove teeth before implant placement, which is more achievable for anterior single rooted teeth than it is for posterior multi-rooted teeth. Rotational forces can be applied to any tooth and should always be slow and sustained to allow dilatation of the bone.
When the crown crumbles or fractures off a multi-rooted tooth, look on this as an opportunity rather than a threat. Knowing the root morphology which would be confirmed after viewing the preoperative radiograph , the remainder of the tooth can be drilled to separate the roots Fig.
Figure 2: A periapical radiograph of a lower right first molar that was to be extracted. The tooth is root filled and the coronal portion heavily restored. One would anticipate the crown would readily fracture off during attempted removal. Also, be mindful of generating an oroantral communication 2 Lone-standing posterior maxillary teeth and upper third molars: In both of these instances beware of non-functional teeth that may have become ankylosed. Such teeth which are anchored to the bone may cause fractures of the tuberosity 3 Lower third molars: The mandibular bone in this region where the body meets the ramus is dense and relatively inelastic, and so frequently the usual forces and techniques for tooth removal will not work here.
The path of withdrawal of the tooth will often be difficult and impacted by bone or the second molar. The root morphology is extremely variable and the proximity of the inferior dental nerve should always be fully assessed.
Generally, lower third molars should only be attempted by those with sufficient experience and competence 4 Retained deciduous molars: Especially when infra-occluded, they are often ankylosed. Conclusion With careful assessment, being equipped with appropriate instruments and knowing how to use them, most teeth can be successfully removed in the general practice setting. Richard will also be providing a suturing masterclass at the conference on the same Friday at am.
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Prevention and management of oral surgery complications in general dental practice
The patient should be asked about their chief complaint and history of present illness describing onset, quality, intensity, duration, location, radiation, exacerbating or relieving factors, medications prescribed or over the counter being taken including any allergies and the type of allergic response. A ROS should be completed and it might reveal undiagnosed medical conditions. Questionnaires are used for this purpose Appendix 1. The common medical conditions and their management are discussed below: Cardiorespiratory: Angina, myocardial infarction, hypertension and asthma are most common. Symptoms are crushing chest pain, dyspnoea, oedema and palpitations. Minor treatment can be performed in case of stable angina, but elective dental care deferred in unstable or recent angina. Elective dental care can be normally performed safely in asymptomatic patients with more than 12 months MI.
Complications of Exodontia