The assessment of the patient has already been described in Chapter 2. A thorough medical history prior to any surgical procedure is obviously essential. This will identify patients who may require special preparation prior to even the simplest dental extraction. Such patients may include those taking anticoagulant medication or those that have undergone irradiation, among many others (Chapter 3). The information obtained will also determine whether surgery should be undertaken by the general dentist or specialist and also the choice of setting. The home circumstances and availability of an escort may also be important if considering conscious sedation or general anaesthesia.

The history also includes questions about previous dental and surgical experience and assessment of patient anxiety (Chapter 4). The sex, general build of the patient or other factors may give an indication as to the expected ease or difficulty of the extraction. For example, an extraction is likely to be more difficult in heavily built men, elderly patients may have more brittle teeth and Afro-Caribbeans more dense alveolar bone, while child patients may have reduced access and less cooperation.

The intraoral examination should include a note of the access to and position of the tooth. The crown of a heavily restored tooth is more likely to fracture during extraction, while endodontically treated teeth may be more brittle.

Radiological examination

Preoperative radiographs need not be taken prior to all extractions, but there are situations when radiographic assessment is essential to demonstrate root morphology, anatomical relationships or associated pathology (Box 6.1). Mandibular and maxillary third molar teeth are known to show a wide variability in root morphology, and so pre-extraction radiographs should always be taken. It is also essential to know the relationship of the inferior alveolar canal in the case of the lower third molar. Cone beam computed tomography (CBCT) is indicated when an intimate relationship of the third molar and the inferior alveolar nerve canal is observed on plain film. In general, where any difficulty is anticipated, it would be wise to take a radiograph before rather than during the extraction, so that the procedure may be planned appropriately. Where a radiograph is judged to be necessary, a periapical view should be the first choice, although other films may be substituted or used in addition when indicated (e.g. panoramic or lateral oblique for lower third molar).

Box 6.1 Checklist of situations where a pre-extraction radiograph is reasonable

• Third molars.

• Isolated (lone-standing) upper molars.

• Previous history of difficult extractions.

• Heavily restored (e.g. crowned, root-filled) teeth.

The greater palatine artery and nerve lie in the palate (see Fig. 6.6 on p. 128) and can be safely retracted within an envelope flap to provide adequate access. The nasopalatine nerve and vessels emerge onto the palate via the incisive fossa in the midline just behind the maxillary central incisor teeth. The neurovascular bundle may have to be cut with a scalpel blade to allow a palatal flap to be raised and it is preferable to do this rather than to tear the bundle. Bleeding can be readily controlled with pressure for a short time and loss of sensation to the anterior palate is usually not of concern to the patient although it should be mentioned in advance of the procedure.

The three most commonly used mucoperiosteal flaps used in oral surgery are the envelope (one-sided), two-sided and three-sided flaps. The envelope flap can be used for removal of superficial retained roots that require little or no bone removal as the access is limited. It can also be used palatally when the access provided is good. The incision in an edentulous patient is made along the crest of the ridge but care must be taken when the mandible is atrophic to avoid the mental nerve which is at risk because of its relative superficial position.

The two-sided flap is used when greater access is required. A relieving incision is usually made from the anterior aspect of the flap to maximise vision. A three-sided flap has anterior and posterior relieving incisions to provide the greatest mobility of the flap and access (see Fig. 5.9 on p. 96).

Postoperative care

Control of postoperative pain is important (Chapter 4). Some clinicians prescribe antibiotics if bone removal is necessary. There is some research evidence to support the use of corticosteroids to reduce postoperative oedema and trismus.

Patients should be given a written set of postoperative instructions (Fig. 6.2) and these should be also given verbally before the patient leaves.

Fig. 6.2 A typical instruction leaflet given to patients after an extraction.

Complications of dental extractions

Postoperative pain

Discomfort after the surgical trauma of dental extractions is to be expected and may be alleviated with an analgesic such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Chapter 4).

Severe pain after a dental extraction is unusual and may indicate that another complication has occurred.

Postoperative swelling

Mild inflammatory swelling may follow dental extractions but is unusual unless the procedure was difficult and significant surgical trauma occurred.

More significant swelling usually indicates postoperative infection or presence of a haematoma. Management of infection may require systemic antibiotics or drainage. A large haematoma may need to be drained. Less likely is surgical emphysema.

Trismus

Trismus or limited mouth opening after a dental extraction is unusual and is likely to be infective in origin.

Fracture of teeth

Teeth may fracture during forceps extraction for a variety of reasons and this is not an unusual event.

The crown may fracture because of the presence of a large restoration, but this may not prevent the extraction from continuing as the forceps are applied to the root. However, if the fracture occurs subgingivally, then a transalveolar approach will be necessary to visualise the root.

If a small (3-mm) root apex is retained after extraction, this may be left in situ, providing it is not associated with apical infection. The patient must be informed of the decision to leave the apex to avoid the morbidity associated with its surgical retrieval and the decision recorded. Antibiotics should be prescribed.

Excessive bleeding

It may be difficult to gauge the seriousness of the blood loss from the patient’s history, because they are usually anxious. However, it is important to establish whether or not the patient is shocked by measuring the blood pressure and heart rate. This can be done while the patient bites firmly on a gauze swab to encourage haemostasis. Typically, if the systolic pressure is below 100 mmHg and the heart rate in excess of 100/minute, then the patient is shocked and there is an urgent need to replace lost volume. This may be done by infusion of a plasma expander such as Gelofusine or Haemaccel or a crystalloid such as sodium chloride via a large peripheral vein. For this purpose, the patient should be transferred immediately to hospital. More commonly, the patient is not shocked and can be managed in the primary care setting.

The next step in management is to investigate the cause of the haemorrhage by taking a history and carrying out an examination.

previous postextraction or surgical haemorrhage

medications

liver disease

family history of disorders of haemostasis.

Examination: Determine the source of the haemorrhage by sitting the patient upright (unless feeling faint) and using suction and a good light. This is commonly from capillaries of the bony socket or the gingival margin of the socket, or more unusually from a large blood vessel or soft tissue tear.

Achieve haemostasis: If the history has suggested a general cause, then local methods will not adequately result in haemostasis and the patient should be transferred to hospital where specialist haematological management is available. Otherwise the following techniques are used:

• Socket capillaries: pack the socket with an absorbable haemostat such as Surgicel oxidised cellulose.

• Gingival capillaries: suture the socket with a material that will permit adequate tension, such as Vicryl (or Surgicryl, or Polysorb), an absorbable braided synthetic material.

• Large blood vessel: ligate vessel, usually by passing a suture about the vessel and soft tissues.

Dry socket (alveolar osteitis)

In some cases, a blood clot may inadequately form or be broken down. Predisposing factors of osteitis include smoking, surgical trauma, the vasoconstrictor added to a local anaesthetic solution, oral contraceptives and a history of radiotherapy. The exposed bone is extremely painful and sensitive to touch. Dry socket is managed by:

• reassuring the patient that the correct tooth has been extracted

• irrigation of socket with warm saline or chlorhexidine mouthrinse to remove any debris

• dressing the socket to protect it from painful stimuli using resorbable Alvogyl paste, an iodoform dressing, or bismuth, iodoform and paraffin paste (BIPP) or lidocaine (lignocaine) gel on ribbon gauze, although this needs to be removed and replaced over 2 or 3 weeks.

Postoperative infection

In some cases, sockets may become truly infected, with pus, local swelling and perhaps lymphadenopathy. This is usually localised to the socket and can be managed in the same way as a dry socket, although antibiotics may be necessary in some instances. A radiograph should be taken to exclude the presence of a retained root or sequestered bone (Fig. 6.3). Positive evidence of such material in the socket indicates a need for curettage of the socket.

Fig. 6.3 Intraoral film of a patient with persistent postextraction infection.
The bone of the crest of the socket is detached, acting as a sequestrum.

Osteomyelitis

Osteomyelitis (Chapter 5) is rare but may be identified by radiological evidence of loss of the socket lamina dura and a rarefying osteitis in the surrounding bone, often with scattered radio-opacities representing sequestra (see Figs 5.20 and 5.21 on p. 105 and 106).