Oral Surgery Lec 1&2 PDF

ORAL SURGERY Lec.1&2 ‫علي قيس‬.‫د‬ DENTAL EXTRACTION (EXODONTIA) Extraction of teeth is the most important part of minor oral surgery and the most common procedures to general dental practitioner (dentist). Definition: Exodontia is...

ORAL SURGERY Lec.1&2 ‫علي قيس‬.‫د‬ DENTAL EXTRACTION (EXODONTIA) Extraction of teeth is the most important part of minor oral surgery and the most common procedures to general dental practitioner (dentist). Definition: Exodontia is a painless removal of teeth from their bony alveolar socket with a relatively minimal amount of trauma to the investing or surrounding tissues, so that the wound heals without postoperative problems. Types of extraction: 1) Simple extraction (intra-alveolar extraction or forceps extraction). 2) Surgical extraction (trans- alveolar extraction). Simple extractions are performed on teeth that are visible in the mouth, usually under local anesthetic, and require only the use of instruments to elevate and/or grasp the visible portion of the tooth. Typically the tooth is lifted using an elevator, and subsequently using dental forceps, rocked back and forth until the periodontal ligament has been sufficiently broken and the supporting alveolar bone has been adequately widened to make the tooth loose enough to remove. While surgical extractions involve the removal of teeth that cannot be easily accessed, either because they have broken under the gum line or because they have not erupted fully. Surgical extractions almost always require an incision. In a surgical extraction the doctor may elevate the soft tissues covering the tooth and bone and may also remove some of the overlying and/or surrounding bone tissue 1 with a drill or osteotome. Frequently, the tooth may be split into multiple pieces to facilitate its removal, and also using elevators and/ or forceps. Surgical Extraction 2 Reasons or indications of extraction: The most common reason for extracting a tooth is tooth damage due to breakage or decay, if conservative treatment has either failed or is not indicated. The reasons for extraction of teeth are based on the presence of local pathology, the feasibility of restorative procedure, function of the dentition as a whole and the patient’s attitude and education. Although the modern dentistry tries and takes all measures to preserve and maintain teeth in the oral cavity but these are a variety of general indications for removing teeth: 1- Severe caries: This is the most common reason to remove a tooth. Badly carious teeth that beyond restoration should be removed. Badly carious teeth result in deterioration of the oral hygiene which can lead to poor oral hygiene and foul smell. In addition to that sharp edges of the carious teeth leads to repeated ulceration to mucosa as well as to pain during eating and drinking. Untreated teeth with caries may end with pulpitis, periapical pathology etc…. 2- Severe periodontal disease: Severe and extensive periodontal disease is a common reason for tooth removal. In chronic periodontitis there is excessive bone loss and mobility in the tooth. As a rough guide loss of about half of the normal alveolar bone or extension of pockets to the bifurcation of the roots of posterior teeth and hypermobility of the teeth means that extraction of the involved tooth is necessary. Patients with advanced periodontitis may complain of mild to severe throbbing pain in case of development of periodontal abscess. 3- Pulp pathology: For example acute pulpitis or chronic pulpitis, non treatable pulpal lesion. If endodontic therapy wasn’t possible or if the tooth isn’t amenable for endodontic treatment, extraction is indicated. 3  4- Apical pathology: Periapical lesions like periapical abscess, periapical granuloma and cyst. If teeth fail to respond to all conservative treatment to resolve apical pathology due to technical reasons or other causes such teeth are indicated for extraction. 5- Orthodontic reasons: During the course of orthodontic treatment, tooth or teeth may be extracted for: A) Therapeutic extraction e.g. extraction of upper 4 tooth for treatment of malposed upper 3 tooth to provide space for teeth alignment. B) Malposed teeth: teeth which erupt out of line of the arch that are difficult to clean and not amenable for orthodontic treatment are indicated for extraction. C) Preventive extraction: means that during mixed dentition (permanent and deciduous teeth) period dental surgeon may extract few deciduous teeth to prevent malocclusion and all these extractions should be done after proper evaluation by specialist expert in orthodontic treatment. 6- Prosthetic considerations: Extractions of teeth are indicated for: A) Providing efficient dental prosthesis. B) To provide better design and success of partial denture, so few teeth may be extracted. C) To enable the patient to have complete denture e.g. full mouth clearance. 7- Impacted teeth: Retention of unerupted teeth beyond the normal time of eruption may sometimes be responsible for: 4  A) Vagal facial pain. B) Periodontal problems of the adjoining teeth. C) T.M.J problems. D) Bony pathology e.g. cyst (dentigerous cyst), tumor, pathologically fracture. E) May predispose to anterior teeth crowding. F) Significant infection (pericoronitis) e.g. partially erupted 3rd molar. 8- Supernumerary teeth: The teeth may be impacted or malposed and such teeth may predispose to malocclusion, periodontal disturbances, facial pain, bony pathology (cyst), esthetic problems and preventing eruption of teeth. 9- Tooth in the line of fracture of the jaws: This tooth may be extracted if: A) It is a source of infection at the site of fracture. B) The tooth itself is fractured. C) Interfere with fracture reduction. D) Interfere with healing of fracture. 10- Teeth in relation to bony pathology: They are indicated for extraction, e.g. if they are involved in: A) Cyst formation. B) Neoplasm (tumor). C) Osteomyelitis (infection of bone). If tooth interfere with complete surgical removal of the lesion, the tooth should be extracted. 11- Root fragments: Retained roots may remain embedded in the bone without problems for a long period, but some times removal of such roots may be 5  necessary, for example, root may be at the submucosal level producing recurrent ulceration under the denture, sometimes may be involved in the initiation of bony pathology like osteomyelitis, cyst lesion or neoplasm. If such fragments are in close relation to the neurovascular bundle (e.g. inferior dental nerve of the mandible), the patient may complain of facial pain or numbness in the area supplied by that nerve. As a general rule, very small fragments may be left alone and that patient should be kept under periodic observation, and all other root fragments are indicated for removal. 12- Teeth prior to irradiation: Irradiation is one of the methods of treating oral carcinomas and teeth which can’t be kept in a sound condition should be removed before irradiation, trauma (extraction) with superadded infection will lead to development of osteoradionecrosis of the jaw bone which is unpleasant complication and difficult to be treated. 13- Focal sepsis: Sometimes teeth or a tooth may appear sound clinically, but on radiographic examination the tooth may appear to be considered as a foci of infection (teeth associated with periapical pathology or periodontal problems), these teeth or tooth should be extracted in certain conditions e.g. heart surgery, heart valve replacement, kidney transplant, eye surgery. 14- Aesthetic: Poor aesthetic, severely stained (tetracycline & fluorosis), attrition or hypoplastic (hypoplasia) of enamel or dentin and teeth can’t be restored may be indicated for extraction. 6 Contraindications of dental extraction: Few conditions are absolute contraindications for extraction of teeth. Teeth have been removed in the presence of all types of complications because of necessity. In these situations much more preparation of the patient is necessary to prevent serious damage or death or to obtain healing of the local wound. For example, the injection of a local anesthetic lets alone the extraction of a tooth can cause instant death in a patient in an addisonian crisis. Surgical intervention of any kind, including exodontia, may activate systemic or local disease. Therefore, a list of relative contraindications is given. In some instances these conditions become absolute contraindications. In general the contra-indications are divided into 2 groups: 1- Local contra-indications. 2- Systemic contra-indications. Local contra-indications: (L.C s) Local contraindications are associated mainly with infection and, to a lesser extent, with malignant disease. There are several L.C s to extractions of indicated teeth: 1) Acute infection with an uncontrolled cellulitis must be controlled so that it does not spread further. The patient may exhibit a toxemia which brings complicating systemic factors into consideration. The tooth that caused the infection is of secondary importance at the moment; however, to better control the infection, the tooth is removed as soon as such removal does not endanger the life of the patient. Before antibiotics became available the tooth was never removed until the infection had become localized, the pus was drained, and the infection had subsided to a chronic state. This sequence of events took much longer than the present method of removing the tooth as soon as an adequate blood level of a specific antibiotic had brought systemic factors under control. 7 2) Acute pericoronitis is managed more conservatively than other local infections because of the mixed bacteriologic flora found in the area. The fact that the third molar area has more direct access to the deep fascial planes of the neck, and the fact that removal of this tooth is a complicated procedure involving ossisection. 3) Acute infectious stomatitis is a labile, debilitating and painful disease which is complicated by intercurrent exodontia. 4) Malignant disease disturbed by the extraction of a tooth embedded in the growth will react with exacerbated growth and non-healing of local wound. 5) Irradiated jaws may develop an acute radio-osteomyelitis after extraction because of a lack of blood supply. This condition is severely painful and may terminate fatally. Systemic contra-indications: Any systemic disease or malfunction can complicate or be complicated by an extraction. Systemic contra-indications preclude extraction because the patient’s systemic health is such that the ability to withstand the surgical work may be compromised. So extraction should be postponded until the severity of the problem has been resolved and may be arranged after consultation with physician to perform extraction safely without complications. Therefore, caution is advised in the following conditions: 1) Uncontrolled diabetes mellitus is characterized by infection of the wound and absence of normal healing as well as end stage renal disease. 2) Cardiac disease, such as coronary artery disease, uncontrolled hypertension, myocardial infarction, unstable angina pectoris, dysrhythmias and cardiac decompensation can complicate exodontia. Management may require the help of a physician. Usually a post-infarction patient is not subjected to oral surgery within 6 months of the infarction. 8 3) Blood dyscrasias include simple as well as more serious anemias, hemorrhagic diseases such as hemophilia, thrombocytopenia and leukemia. Preparation for extraction varies considerably with underlying factors. 4) Debilitating diseases of any kind make patients at poor risks for further traumatic insults (e.g. uncontrolled lymphomas and leukemia) 5) Addison's disease or any steroid deficiency is extremely dangerous. The patient who has been treated for any disease with steroid therapy, even though the disease is conquered and the patient has not taken steroids for a year, may not have sufficient adrenal cortex secretion to withstand the stress of an extraction without taking additional steroids. 6) Fever of unexplained origin is rarely cured and often is worsened by extraction. One possibility is an undiagnosed subacute bacterial endocarditis, a condition that would be complicated considerably by an extraction. 7) Nephritis requiring treatment can create a formidable problem in preparing the patient for exodontia. 8) Patients who take a variety of medications e.g. patient on anticoagulants, patient on steroids and immunosuppressive drugs and cancer and chemotherapy. 9) Pregnancy without complications presents no great problem. Precautions should be taken to guard against low oxygen tension in general anesthesia or in extreme fright. Obstetricians hold varied opinions regarding the timing of extractions, but they usually prefer that necessary extractions can be done in the second trimester. Menstruation is not a contraindication, although elective exodontia is not done during the menstrual period because of less nervous stability and greater tendency toward hemorrhage of all tissues. 10) Senility is a relative contraindication that requires greater care in overcoming a poor physiologic response to surgery and a prolonged negative nitrogen balance. 11) Psychoses, uncontrolled epilepsy and neuroses reflect a nervous instability that complicates exodontia. References: Contemporary Oral and Maxillofacial Surgery (Larry J. Peterson). 9