Oral and Maxillofacial Surgery

Fig. 15.1

Panoramic radiographs are an excellent screening tool to determine anatomic landmarks and the degree of difficulty of the extraction
  • Complex extractions of third molars

    • Indications to extract impacted dentition include pericoronitis, cystic formation from a retained follicle (e.g., dentigerous cyst or keratocyst), facilitating orthodontic treatment and arch length, dentition in the line of a fracture, tumors, caries, and periodontal disease of adjacent teeth (Sakar et al. 2008; Rafetto 2012).
    • Factors determining complexity in order of increasing degree of difficulty include mesioangular impaction, vertical impaction and horizontal impaction, and distoangular impaction (Ness and Peterson 2004; Juodzbalys and Daugela 2013).
    • In addition, the level of complexity is compounded by soft tissue impaction, partial bony impaction, or complete bony impaction (Ness and Peterson 2004).
    • Impacted third molars buried in the ramus of the mandible are more difficult to remove (Pell and Gregory Classification) (Ness and Peterson 2004; Juodzbalys and Daugela 2013).
    • Conical roots are easier to extract than divergent roots. Roots that are only 1/3–2/3 formed are much less difficult to extract, at an average age of 16–18 years old (Ness and Peterson 2004).
    • Palatally or lingually positioned teeth are more difficult to extract (Ness and Peterson 2004).
    • A large follicular sac around the crown makes the tooth easier to extract (Ness and Peterson 2004).
    • Extracting teeth prior to 20 years of age makes the surgery less difficult (Ness and Peterson 2004).

      15.1.2 Armamentarium

      • Practice universal precautions; every patient should be treated as though they have a communicable disease.
      • Place a gauze throat screen at all times to prevent accidental aspiration.
      • Use a bite block for access and to decrease temporomandibular joint (TMJ) pain from rotational torquing forces.
      • Position the patient nearly upright in the dental chair to extract mandibular teeth, and position the dental chair in a supine position to extract maxillary teeth (Sakar et al. 2008).
      • Small and large elevators are used as a wedge and a rotational force. Elevators separate alveolar bone from the tooth surface, in addition to rotating the tooth out of the socket (Sakar et al. 2008).
      • A #9 Periosteal elevator or Woodson instrument expands the periodontal ligament (PDL) space to facilitate extraction without excessive bony or soft tissue destruction.
      • Forceps can be used in multiple vectors, to remove the tooth: apical, buccal, lingual, rotational, and tractional vectors. The tooth is usually delivered buccally and coronally (Sakar et al. 2008).
      • Rongeurs are useful to extract root tips and to remove minimal surrounding bone.
      • East-West elevators are used for leverage against bone, often through the radicular bone, to extract root tips.
      • A surgical drill and bur with irrigation is crucial for surgical extractions and pre-prosthetic surgery.

      15.1.3 Simple Exodontia

      • Local anesthesia

        • Profound anesthesia must be administered to the tooth as well as the adjacent tissues. Although analgesia is achieved, pressure sensation persists. Be cognizant of the amount of local anesthetic needed in the presence of a local infection.
        • Be aware of the maximum recommended dosing levels of local anesthetic in an adult (Table 15.1).

          Table 15.1

          Maximum dosage of local anesthetic (Cummings et al. 2011; Massoomi 2008)
          Local anesthetic
          Maximum recommended dosage (mg/lb)
          2 % lidocaine
          1:100,000 epinephrine
          2 % mepivacaine
          1:20,000 levonordefrin
          3 % mepivacaine
          4 % articaine
          1:100,000 epinephrine
          • Cardiac patients: limit the amount of epinephrine to 0.04 mg which is equivalent to two cartridges of local anesthetic with 1:100,000 epinephrine (Malamed 1997).
          • Pregnant patients: note that lidocaine is a Category B drug (Massoomi 2008).
        • Have a thorough knowledge of anatomical innervations when providing local anesthetic. Periodontal ligament (PDL) and intraosseous injections can help in difficult situations.
      • Utilize the small straight elevator in the PDL space as a means of alveolar bone expansion and separation, in addition to luxation of the tooth. Luxating the tooth with an elevator will prevent root fracture at the time of extraction (be cognizant of inadvertent adjacent tooth luxation).
      • Forceps use

        • Excessive force is a poor substitute for proper technique.
        • #150 maxillary forceps are used for extraction of maxillary anterior and posterior teeth (Sakar et al. 2008).
        • Asch forceps are used for extraction of mandibular anterior teeth (Sakar et al. 2008).
        • Seat the forceps as apically as possible. Apply careful buccal and lingual forces slowly to expand the alveolar bone. Conical roots can be rotated in screwdriver or figure-eight motions (Sakar et al. 2008).
        • #151 mandibular forceps or #23 cowhorn forceps are used for extraction of mandibular posterior teeth (Sakar et al. 2008).
        • Cowhorn forceps placed in the interradicular furca will luxate the tooth coronally. If the tooth is grossly decayed and consequently fractures at the furca, each root can be delivered separately (Sakar et al. 2008).
        • Placing the operator’s opposing hand over the alveolus surrounding the tooth being luxated allows the operator to protect adjacent teeth, while gauging the amount of force placed on the surgical site (Sakar et al. 2008).
      • Surgical extraction of a complex tooth is often less invasive than nonsurgical techniques.

      15.1.4 Bone and Site Preservation

      • Maximize the use of elevators, such as a #9 Periosteal elevator, Woodson instrument, or surgical osteotome, to expand the periodontal ligament (PDL) space. Use apical pressure to further expand the alveolar bone prior to any forceps use. Preserving a four-wall socket prevents collapse of the alveolar ridge (Moy 2004; Bartee and Lignelli 2008).
      • Ensure adequate mobility of the tooth prior to the extraction in order to prevent root and alveolar wall fracture. Minimize twisting motions when extracting the roots to reduce the propensity for alveolar wall fracture (Moy 2004).
      • If a surgical bur is needed, remove periradicular and interradicular bone by troughing around the perimeter of the tooth and between the roots and apply forceps to facilitate removal of the tooth. If this is not successful, use the surgical bur to section the tooth, and an East-West elevator as a rotational force to remove each root separately. Another useful technique is to create a purchase point in the tooth with a surgical bur to aid elevation and extraction. #702 crosscut tapered or straight fissure burs work well for surgical extractions, as do #6 or #8 round burs. Copious irrigation while using the surgical hand piece lessens the incidence of thermal trauma and bone necrosis (Sakar et al. 2008).
      • Bone augmentation may be necessary after extraction in anticipation of future implant or bridge placement or for other aesthetic, functional, and structural reasons. A less traumatic extraction process, coupled with socket augmentation, significantly reduces alveolar ridge dimensional changes (Moy 2004; McAllister and Haghighat 2007; Camargo et al. 2004).

        • The treatment modality will vary according to the morphology of each defect; the defect may be horizontal, vertical, or both. Bone resorption also varies between the maxilla and the mandible (Moy 2004; McAllister and Haghighat 2007).
        • The number of resulting walls in the defect may determine the type of graft (e.g., particulate socket graft vs. block grafting and augmentation) (Bartee and Lignelli 2008; Block 2006).
        • Careful consideration of the soft tissue volume and quality is necessary to improve aesthetic and functional results. A wide band of keratinized mucosa ameliorates the overall health of the tissue and results in fewer complications (Geurs et al. 2010).
        • Bone augmentation modalities include the use of biologic growth factors (e.g., platelet-rich plasma (PRP), bone morphogenetic protein (BMP), leukocyte- and platelet-rich fibrin (L-PRF)), particulate and block grafting, distraction osteogenesis, and guided bone regeneration (GBR), with and without membrane barriers (McAllister and Haghighat 2007; Wikesjo et al. 2007). Several GBR approaches have been studied to be effective: ePTFE membranes, bioresorbable membranes, freeze-dried bone allograft, bone autograft, bone xenograft, alloplastic materials, and others (McAllister and Haghighat 2007; Camargo et al. 2004; Block 2006; Moy 2004). When selecting the augmentation material, consider biocompatibility, bioresorbability, functional and structural stability, and ease of use (Moy 2004; McAllister and Haghighat 2007; Block 2006). Studies have shown freeze-dried bone allograft to lack adequate bioresorbability as compared to bioglass material and bovine bone materials (Moy 2004) (Figs. 15.2 and 15.3).

          Fig. 15.2

          This photo illustrates an extraction surgical site, utilizing bone preservation techniques. This patient had severe horizontal and vertical bone loss prior to extraction, and thus the case warranted a particulate bone graft to reconstruct the alveolar ridge
          Fig. 15.3

          This photo illustrates the mineralized particulate bone graft in place immediately after extraction of the tooth of the same patient as in Fig. 15.2, with healthy bleeding tissue at the site. The site will then be closed primarily to prevent complications such as dehiscence, infection, and failure of the graft
        • Immediate implant placement, often with bone augmentation, has shown comparable success to the traditional delayed implant placement, but this will not be further discussed in this chapter (McAllister and Haghighat 2007).
        • When augmenting and grafting early in the practitioner’s experience, it is important to release the soft tissue adequately to allow for primary soft tissue closure and to completely cover the graft site. Management of graft sites where secondary healing is necessary requires a higher level of experience and soft tissue management skills. Membrane exposure is associated with higher bone resorption and other complications. Maintenance of primary wound closure is critical to prevent dehiscence with membrane exposure and infection (McAllister and Haghighat 2007; Camargo et al. 2004; Block 2006; Misch 2008).
        • Alveolar ridge resorption after bone augmentation should be considered, especially if implant placement is the treatment goal; resorption usually occurs in the first 6–8 months but varies according to the GBR technique used (Moy 2004; Bartee and Lignelli 2008; Block 2006).

      15.1.5 Complex Exodontia

      • Simple flap design

        • Envelope flap: Incise the gingival sulcus at the cervical margin of the teeth, through the periosteum, two to three teeth anterior and one to two teeth posterior to the tooth in question. Apically reflect the full-thickness mucoperiosteal flap. If a vertical releasing incision is necessary for visualization, a posterior vertical releasing incision is more aesthetic. Two releasing incisions, an anterior and a posterior, may be necessary in rare cases (Peterson 2002).
        • Mandibular third molars: Incise the gingiva two to three teeth anterior to the extraction site, scalloping around the gingival sulcus. Then, continue the incision to the central groove on the distal of the second molar. Turn the blade and cut 1–1.5 cm distal through soft tissue, and then turn to incise an obtuse angle toward the buccal, about 1 cm, to create a vertical release (the hockey stick incision) (Sakar et al. 2008; Ness and Peterson 2004; Peterson 2002) (Fig. 15.4).

          Fig. 15.4

          The overlay illustrates an example of an impacted mandibular third molar incision utilizing the “hockey stick incision”
        • Maxillary third molars: Cut two to three teeth anterior, scalloping around the gingival sulcus. Distal to the second molar, cut a C-shaped incision, hugging the maxillary tuberosity toward the buccal. Retract the gingiva superiorly enough to be able to fully view the third molar. You may need to use a #9 Periosteal Elevator to flake away maxillary bone anterior to the third molar (Sakar et al. 2008; Ness and Peterson 2004; Peterson 2002) (Fig. 15.5).

          Fig. 15.5

          The overlay illustrates an example of an impacted maxillary third molar incision utilizing the “C-shaped incision”
        • The flap should always be a full-thickness mucoperiosteal flap. Ensure all tissue retractors are only resting on bone, deep to periosteum (Peterson 2002).
        • The base of any flap must be wider than the apex (free margin) to prevent ischemia of the flap (Peterson 2002).
      • Surgical extraction

        • The guiding principle is to create a space in the alveolar bone surrounding the tooth root.
        • Sectioning a tooth to facilitate individual root extraction:

          • Section a molar parallel to the roots at the bifurcations: perpendicular to buccal bone for mandibular molars and in a “Y” formation for maxillary molars. Always use radiographs to understand the root morphology to know the vector in which to section the tooth (Sakar et al. 2008).
          • Section and remove a molar crown to create better access to the roots in order to simplify the sectioning of the roots, as above (Sakar et al. 2008).
        • Be sure to remove adequate bone covering the impacted third molar, and to create a deep buccal trough, with a distal component. However, avoid using the drill to trough the lingual bone of mandibular teeth. Be cognizant of the depth of the surgical cut (Sakar et al. 2008).
        • When using surgical burs, know the exact measurements of the bur being used. Below is an example of the specifications for a #702 crosscut Extra Long/Surgical Bur from Patterson Dental (Patterson Dental surgical burs 2016):

          • Head length: 4.5 mm
          • Head diameter: 1.6 mm
          • Numeric shank length: 25 mm
        • Utilize radiographs to know the distance to the vital structures, such as the inferior alveolar nerve, maxillary sinus, and inferior border of the mandible.
        • Have a thorough understanding of all pertinent anatomy to avoid complications, especially pertaining to the inferior alveolar and lingual nerves.
        • Coronectomies of impacted third molars are a valid treatment option when the risk of nerve damage is highly suspected. Ensure the tooth has not been elevated, and the roots are not mobile (Monaco et al. 2012; Auyong and Le 2011; Miloro and Kolokythas 2011).

      15.1.6 Debridement and Closure

      • Use a bone file or rasp to smooth all surrounding alveolar bone (Sakar et al. 2008).
      • Irrigate all extraction sites and beneath the mucoperiosteal flaps. Curette the follicle unless curetting presents a danger to the inferior alveolar nerve (Sakar et al. 2008).
      • Intraorally, chromic gut suture is commonly used. Vicryl suture often lasts too long and may have to be removed at a subsequent appointment. 3-0 or 4-0 size sutures are commonly used sizes for intraoral suturing. A study by Otten et al. shows resorbable sutures aggregate fewer colonies of bacteria than nonresorbable sutures (Otten et al. 2005).
      • Place one to two interrupted sutures to reapproximate the mandibular flap sites. Watertight closure is not advised (Sakar et al. 2008).
      • Often, maxillary posterior incisions do not need to be sutured unless the tissue does not reapproximate well or if there are buccal gingival tears.

      15.1.7 Medications

      • Common analgesics are listed in Table 15.2 (see also Chap. 22: Prescriptions)

        Table 15.2

        Common analgesics (Sakar et al. 2008; Fletcher and Spera 2002)
        Analgesic, generic name
        Common brand name
        Common dosage
        Common sig
        600–800 mg
        Codeine, acetaminophen
        Tylenol #3
        30 mg codeine/300 mg acetaminophen
        Hydrocodone, acetaminophen
        5 mg hydrocodone/325 mg acetaminophen
        Oxycodone, acetaminophen
        5 mg oxycodone/325 mg acetaminophen
      • Always inform the patient of the dangers of pain medication use:

        • Addiction
        • Tolerance
        • Alcohol use in conjunction with narcotics
        • The possibility of respiratory depression
        • Driving while impaired

      15.1.8 Informed Consent

    • Dec 11, 2016 | Posted by in General Dentistry | Comments Off on Oral and Maxillofacial Surgery
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