Category Archives: Principles of Complicated Exodontia

Immediate Treatment

The best treatment of a potential sinus exposure is avoiding the problem through careful observation and treatment planning. Evaluation of high-quality radiographs before surgery begins usually reveals “the presence .or , absence of an excessively pneumatized sinus or widely . divergent or dilacerated roots, which have the potential of having a communication with the sinus or causing fractures in the bony floor of the antrum during removal (see Fig. 1~-7). If this observation is made, surgery may be altered to section the tooth, and remove it one root at a time (see Chapter 8). ‘ When exposure and perforation of the antrum result,the least invasive therapy is indicated initially. If -the opening to the sinus is small and the sinus is disease free, efforts should be made to establish a blood.clot in the extraction ‘site and preserve it in place. Additional soft tissue= elevation is not required. Sutures are placed to reposition the soft tissues, and a gauze pack is,placed over the surgical site for to 2 hours. The patient is instructed to use nasal precautions for 10 to 14 days. These include opening the mouth while sneezing, not sucking on a straw or cigarettes; and avoiding nose blowing and any other situation that may produce pressure changes between the nasal passages and oral cavity. The patient is placed on an antibiotic, usually penicillin; an antihistamine; and a systemic decongestant for 7 to 10 days to” prevent infection, to shrink mucous membranes, and to lessen nasal and sinus secretions. The patient is seen postoperatively at 48- to 72-hour intervals and is instructed to return if an oroantral communication becomes evident by leakage of air into the mouth or fluid into the nose ‘or if symptoms. of maxillary sinusitis appear, The majority of patients treated in this manner heal uneventfully if there was no evidence of preexisting sinus , disease. If larger perforations occur, the patient should be referred to an oral and maxillofacial surgeon for immediate treatment.

 BIBLIOGRAPHY

Berman SA: Basic principles ‘o(d(‘ntoalveola~ surgery. In I.JPeterson, editor: Principles of ural and maxillotacial sursal’, Philadelphia, 1992, JB Lippincott.
Brown RP: Knotting technique and suture materials, Br I Surg 79:399, 1992. Cerny R: Removing broken roots: a simple method, AlISt Dent I 23:351 1978.

Extraction Sequencing

The order in which multiple teeth are extracted deserves some discussion. Maxillary teeth should usually be re

moved first for several reasons. First of all, an infiltration anesthetic has a more rapid onset and also disappears more rapidly. This means that the surgeon can begin the surgical procedure sooner after the injections’ have been given; in addition, surgery should not ‘be delayed because profound anesthesia is lost more quickly in the maxilla. In addition, maxillary teeth-should be removed first, because during the extraction process debris such as portions of amalgams, fractured crowns, and bone chips may fall intothe empty sockets of the lower teeth if the lower surgery is performed first. In addition, maxillary teeth ate removed with a major component of buccal force. Little or no vertical, traction force is used in removal of these teeth, as is commonly -required with mandibular teeth. ‘ Therefore mandibular extractions that follow maxillary extractions are usually easier to perform. A single minor ‘. disadvantage for extracting maxillary teeth first is that if
hemorrhage is not controlled in the maxllla’ before’ mandibular teeth’ are extracted, the hemorrhage mayinterfere with visualization during mandibular surgery. Hemorrhage is usually not a major problem, because
hemostasis should be achieved in one area before the.surgeon turns, his or their attention to another area of surger~ and the surgical assistant should be able to keep the surgical field free from blood with adequate suction. Extraction usually begins with extraction’ of the most posterior teeth first. This allows for the more effective use of dental elevators to luxate and mobilize teeth before the forceps is used to extract the tooth. The two teeth that are the most difficult to remove, the molar- and canine, should be extracted last. Removal of the teeth on either side weakens the bony socket an. the mesial and distal side of these teeth, and their subsequent extraction is – made easier. In summary, if a maxillary and mandibular left quadrant” is to be extracted, the following order is recommended: (1) maxillary posterior teeth, leaving the first’ molar; (2) maxillary anterior teeth, leaving the canine

This patient’s remaining teeth are to be extracted. The broad zone of attached gingiva is demonstrated in adequate vestibular depth. 8, After adequate anesthesia is achieved, soft tissue attachment to teeth is incised with no. 15 blade. Incision is carried around necks of teeth and through interdental papilla. e, Woodson elevator is used to reflect labial soft tissue just to crest of labioalveolar bone. 0, Small straight elevator is used to luxate teeth before forceps is used. Surgeon’s opposite hand is reflecting soft tissue and stabilizing mandible. E, Teeth adjacent to mandibular canine are extracted first, which makes extraction of remalntnq canine tooth easier to accomplish. (3) maxillary molar; (4) maxillary canine; (5) mandibular” posterior teeth, leaving the first molar; (6) mandibular anterior teeth, leaving the canine; (7) mandibular molar; and (8) mandibular canine.

 

Policy for Leaving Root Fragments

When a root tip has fractured, when closed approaches of. .removal have been unsuccessful, and when. the open approach may be excessively traumatic, the surgeon may consider leaving the root in place. As with any surgical approach, the surgeon must balance the benefits of surgery against the risks of surgery. In some situations the risks of removing a small root tip may outweigh the benefits. Three conditions must exist for a tooth root to be left in the alveolar process. First, the root fragment must be small, usually no more than 4 to 5 mm in length. Second, the root must be deeply embedded in bone and riot superficial, to prevent subsequent bone  esorption from  posing the tooth root and interfering with the prosthesis
that will be constructed over the edentulous area. Third,·the tooth involved must not be infected, and there must be no radiolucency around the root apex. This lessens the likelihood that subsequent infections ‘Will
result from .leaving the root in position. If these three   8-49 A, conditions exist, then consideration can be given to leaving the root. For the surgeon to leave a small, deeply embedded, noninfected root tip in place, the risk of surgery must be greater than the benefit. This risk is considered to be greater if one of the following three conditions exists: First, the risk is too great if removal of the root will cause excessive destruction of  surrounding tissue; that is, if excessive amounts of bony tissue must be removed to retrieve the root. For example, reaching a small palatal root tip of a maxillary first molar may require the removal of large amounts of bone.Second, the risk is too great if removal of the root  ndangers vital structures, most commonly the inferioralveolar nerve,  either at the mental foramen area or along the course of the canal. If surgical retrieval of a root may result in a ‘permanent or even a prolonged temporary anesthesia of the !:,fprior alveolar nerve, the surgeon should seriously consider- leaving the root tip in place. finally, the risks outweigh the benefits if attempts at recovering the root tip can displace the root into tissue spaces or into the maxillary sinus. The roots most often displaced into the maxillary sinus are those of the maxillarymolars. If the preoperative radiograph shows that the bone is thin over the roots of the teeth and that the separation between the teeth and maxillary sinus is  mall, the prudent surgeon will choose to leave a small root fragment  ather than risk displacing it into the maxillary sinus. Likewise, roots of the mandibular second and third molars can be displacedinto the submandibular space   uring attempts to remove them. During retrieval of any root tip, apical pressure may displace teeth into tissue spaces or into the sinus. If the surgeon elects to leave a root tip in place, a strictprotocol must be observed. The patient must be informed that, in the surgeon’s judgment, leaving the root in its position  will do less harm than surgery. In addition, radiographicdocumentation of the root tip’s presence and position must be obtained and retained in the patient’s record. The fact that the patient was informed of-the decision to leave the root tip in position must be recorded in the patient’s chart. In addition, the patient must be recalled for everal routine periodic follow-ups over the ensuing year t-o track the fate of this root. The patient should be instructed to contact the surgeon immediately should any problems . develop in the area of the retained root.

Removal of Small Root Fragments and Root Tips

If fracture of the apical one third (3 to 4 111m)of till’ root occurs during a closed extraction, an orderly procedure should be used to remove the root tip from the socket. Initial attempts should be made to extract the root fragment by a closed technique, but the surgeon should

begin a surgical technique if the closed technique is not immediately successful. Whichever technique is chosen, two requirements for extraction are critically important: excellent light and’ excellent suction, preferably with a suction tip of small diameter. Itis impossible to remove a
small root tip fragment unless the surgeon can clearly visualize it. It is also important that an irrigation syringe’ he available to irrigate blood and debris from around the root tip so that it can be clearly seen. ‘I he dosed technique for root tip retrieval is defined as (11/)’ technique that does not require reflection of soft tissue flaps and removal of bone. Closed techniques are most useful when the tooth was well luxated and mobile before the root tip fractured. If sufficient luxation otcurred before thefracture, the root tip often is mobile and can. be removed with the closed technique. However, if the tooth was not well mobilized before the fracture, the closed technique is less likely to be successful. The closed techniq.ue is also less likely to be successful if the clinician finds. a bulbous hypercementosed root with bony interferences that prevent extraction of the root tip fragment- In addition, severe dilaceration of the root end may prevent the use of the closed’ technique.

Once the fracture has occurred, the patient should be repositioned so that adequate visualization (with proper lighting), irrigation, and suction are achieved. The tooth

socket should be irrigated vigorously and suctioned with ,a small suction tip, because the loose tooth fragment occasionally can be irrigated from the socket. Once irrigation and suction are completed, the surgeon should .inspect the tooth socket carefully to assess whether the root has been removed from the sod .c.et. If the irrlgation-suctlon technique is unsuccessful, the next step is to tease the loose’ root apex from the socket with a root tip pick. A root tip PICl\. is a delicate instrument and cannot be used as the Cryer elevator can to remove bone and elevate entire roots. The root tip pick is inserted into the periodontal ligament space, and the, root is teased out of the socket (Fig. 8-47). Neither exces-‘ sive apical or lateral force should be ‘applied to the root tip pick. Excessive apical force could result in displace-” ment of the root tip into other ‘anatomic locations, such as the maxillary sinus. Excessive lateral force could result in the bending or fracture of the end of the root tip pick. The root tip also can be removed with the small straight -elevator used as a shoehorn. This technique is indicated more often for the removal of larger root fragments than for small root tips. The technique is similar to that of the root tip pick, because the small straight elevator is forced into the periodontal ligament space, where it acts like a wedge to deliver the tooth fragment toward the occlusal plane (Fig. 8-48). Strong apical pressure should be avoided because it may force the root into the underlying tissues. This is more likely to occur in the maxillary premolar and molar areas, where tooth roots can be displaced into -the maxillary ‘sinus. When’the straight elevator is used in this fashion, the surgeon’s hand must always be supported on an adjacent tooth or a solid bony prominence. This

support allows the surgeon to deliver carefully controlled force and to decrease the possibility of displacing tooth fragments or the instrument. The surgeon must be able to visualize clearly the top of the fractured root to see the periodontal ligament space. The straight elevator must be inserte 0 this space and not merely pushed down into the socket.

If the closed technique is unsuccessful, the surgeon should switch without delay to the open technique. It is important for the surgeon to recognize that a smooth, efficient, properly performed open retrieval of a root fragment is less traumatic than a prolonged, time-consuming, frustrating attempt at closed retrieval. Two main open techniques are used to remove root tips. The first is simply an extension of the technique described for surgical removal of single-rooted teeth. A soft tissue flap is reflected and retracted with a periosteal elevator. Bone is removed with a chisel or bur to expose the buccal surface of the tooth root. The root is buccallv delive with a small straight elevator. The flap is repositioned and sutured (Fig. 8-49). .

A modification of’the open technique just described can be performed to deliver the root fragment without removal of the entire buccal plate overlying the tooth. This technique is known as the open-window technique. A soft tissue flap is reflected in the usual fashion, and the apex area of the tooth fragment is located. A dental bur is used to remove the bone overlying the apex of the tooth and expose the root fragment. An instrument is then inserted into the window, and the tooth is displaced ~ut
of the socket (Fig. 8-50).

The preferred flap technique is the three-cornered flap because of a need for more extensive exposure of the apical areas. This approach is especially indicated when the buccocrestal bone must he left intact. An important and’ common example is the removal of maxillary premolars for orthodontic purposes, especially in adults.

Technique for Surgical Removal of Multirooted Teeth

If the decision is made to perform an open extraction of a multi rooted tooth, such as a mandibular or maxilIary molar, the same surgical, technique used for the single rooted tooth is generally used. The major difference is that the tooth may be divided with a bur to convert a multi rooted tooth into several single-rooted teeth. If the crown of the tooth remains intact, the crown portion is sectioned in such a way as to facilitate removal of roots. However, if the crown portion of the tooth is missing and only the roots remain, the goal is to separate the roots to make them easier to remove with elevators.

Removal of. the lower first molar with an intact crown is usually done by sectioning, the tooth buccolingually and thereby dividing the tooth into a mesial half (with mesial root and half of the crown) and a distal half. An envelope incision is also made, and a small amount of crestal bone is removed. Once the tooth is sectioned, it is luxated with straight elevators to begin the mobilization process. The sectioned tooth is treated as a lower premolar tooth and is removed with a.lower universal forceps (Fig. 8-41). The flap is re-positioned and sutured.

The surgical technique begins with the reflection of an adequate flap (Fig. 8-42, A and B). The surgeon selects either an envelope or three cornered flap as the requirement for access and personal preference dictate. valuation of the need for sectioning roots and removing bone is made at this, stage, as it was with the single-rooted tooth. Occasionally, forceps, elevators or both are positioned with direct visualization to achieve better mechanical advantage and to remove the tooth without removing the bone.

However, in most situations a small’ amount of crestal bone-should be removed, and the tooth should be divided. Tooth sectioning is usually accomplished with a straight hand piece with a straight bur, such as the no. 8 round bur, or with a fissure bur, such as the no. 557 or no. 703 bur (Fig. 8-42, C).

Once the tooth is sectioned, the small straight elevator is used to luxate and mobilize the sectioned roots (Fig. 8-42, D). The straight elevator may be used to deliver the mobilized sectioned tooth (Fig. 8-42, E). If the crown of the tooth is sectioned, upper or lower universal forceps is used to remove the individual portions of the sectioned tooth (Fig. 8-42, F). If the crown is missing, then straight and triangular elevators are used to elevate the tooth roots from the sockets.

Sometimes, a remaining root may be difficult to remove and additional bone removal (as is described for a single rooted tooth) may be necessary. Occasionally, it is necessary to prepare a purchase point with the bur and to use an elevator, such as the Crane pick to elevate the remaining root.

After the tooth and all the root fragments have been removed, the flap is repositioned and the surgical area palpated for sharp bony edges. If any are present, they are smoothed with a bone file. The wound is thoroughly irrigated and debrided of loose fragments of tooth, bone, calculus, and other debris. The flap is repositioned again and sutured in the usual fashion (Fig. 8-42, G).

An alternative method for removing the lower first molar is to·reflect the soft tissue flap and remove sufficient buccal bone to expose the bifurcation. Then the bur is used to section the mesial root from the tooth and convert the molar into a single-rooted tooth (Fig. 8-43). The crown with the mesial root intact is extracted with no. 17 lower molar forceps. The remaining mesial root is elevated from the socket with a Cryer elevator. The elevatar is inserted into the empty tooth socket and rotated, using the wheeland axle principle. The sharp tip of the elevator engages the cementum of the remaining root, which is elevated occlusally from the socket. If the interradicular bone is heavy, the first rotation or two of the Cryer elevator  removes the bone, which allows the elevator to engage the cementum of the tooth on the second or third rotation.

procedure again begins with the reflection of an envelope flap and removal of a small amount of crestal bone. The bur is used to section the two roots into mesial and distal components (Fig. 8-H, A). The small straight elevator is used to mobilize and luxate the mesial root, which is delivered from its socket by insertion of the Cryer elevator into the slot prepared by the dental bur (Fig. 8-4-1, ll). The Cryer elevator is rotated in the wheel and axle manner, and the mesial root is delivered occlusally from the tooth socket. The opposite member of the paired Cryer instruments is inserted into the empty root socket and rotated through the interridicular bone to engage and deliver the remaining root (Fig, R-4-1, C).

Extraction of maxillary molars with widely divergent buccal and palatal roots that require excessive force to extract can be removed more prudently by dividing the root into several sections. This three-rooted tooth must be divided in a pattern different from that of the two rooted mandibular molar. If the crown of the tooth is intact, the two buccal roots are sectioned from the tooth and the crown is removed along with the palatal root.

The standard envelope flap is reflected, and a small portion of crestal bone is removed to expose the trifurcation area. The bur is used to section off the mesiobuccal and distobuccal roots (Fig. 8-45, A). With gentle but firm bucca-occlusal pressure, the upper molar forceps delivers the crown and palatal root along the long axis of the root (Fig. 8-45, B). No palatal force should be delivered with the forceps to the ‘crown portion, because thi~ results in fracture of the palatal root. The entire delivery force  should be in the buccal direction. A small straight elevator is then used to luxate the buccal roots (Fig. 8-45, C), Which can then be delivered either with a Cryer elevator used in the usual fashion (Fig. 8-45, D) or with a straight elevator. If straight elevators are used, the surgeon should remember that the maxillary sinus might be very close to these roots, so apically directed forces must be kept to a minimum and carefully controlled. The entire force of the straight elevator should be in a mesiodistal direction,and slight pressure should be applied apically.

If the crown of the maxillary molar is missing or fractured,the roots should be divided into two buccal roots and a palatal root. The same general approach as before is used. An envelope flap is reflected and retracted with a periosteal elevator. A moderate amount of buccal bone is removed to expose the tooth for sectioning (Fig. 8-46, rI). The roots are sectioned into the two buccal  roots and a single palatal root. Next the roots are luxated with a straight elevator and delivered with Cryer elevators,according to the preference of the surgeon (Fig. 8-40. H , and C). Occasionally, enough access to the roots exists so that a maxillary root forceps or upper universal forceps can be used to deliver the roots independently (fig-46. lJ). Finally, the palatal root is delivered after the two buccal roots. have been removed. Often much of the interradicular bone is lost by this time; therefore the small
straight elevator can be used efficiently. The elevator is forced down the periodontal ligament space on the palatal aspect with gentle, controlled wiggling motions, which causes displacement of the tooth in the buccoocclusal direction (Fig. H-46, E).

Technique for Open Extraction of Single Rooted Tooth

The technique for open extraction of a single rooted tooth is relatively straightforward but requires attention to detail, because several decisions must be made during . the operation. Single-rooted teeth are those that have resisted attempts at closed extraction or that have fractured at the cervical line and therefore exist only as a root. The technique is essentially the same for both.

The first step is to provide adequate visualization and access by reflecting a sufficiently large mucoperiosteal flap. In most situations an envelope flap that is extended two teeth anterior and one tooth posterior to the tooth to be removed is sufficient. If a releasing incision is necessary,it should be placed at least one tooth anterior to the extraction site (see Fig. 8-2).

Once an adequate flap has been reflected and is held in its proper position by a periosteal elevator, the surgeon must determine the need for bone removal. Several options are available First, the surgeon may attempt to reseat the extraction forceps under direct visualization and therefore achieve a better mechanical advantage and remove the tooth with no bone removal at all (Fig. 8-32).

The second option is to grasp a bit of buccal bone under the buccal beak of the forceps to obtain a better mechanical advantage and grasp of the tooth root. This may allow the surgeon to luxate the tooth sufficiently to remove it without any additional bone removal (Fig.8-33). A small amount of buccal bone is pinched off and  removed with the tooth.

The third option is to use the straight elevator as a shoehorn elevator by forcing it down the periodontal ligament space of the tooth (Fig. 8-3-t). The index finger of the surgeon’s hand must support the force of the elevator so that the total movement is controlled and no slippage of the elevator occurs. A small wiggling motion should be  used to help expand the periodontal ligament space, which allows the small straight elevator to enter the space and act as a wedge to displace the root occlusally.

The fourth and final option is to proceed with bone removal over the area of the tooth. The surgeon who makes the decision to remove some buccal bone from till tooth may use either the bur or the chisel. If the bone is thin, a chisel is convenient. and frequently requires hand pressure only. However, most surgeons currently prefer a bur to remove the bone. The width of buccal bone that is removed is essentially the same width as the tooth in a mesiodistal direction (Fig. 8-35). In a vertical dimension,bone should be removed approximately one-half to two thirds the length of the tooth root (Fig. 8-36). This amount of bone removal sufficiently reduces the amount of force necessary to displace the tooth and makes removal relatively easy. Either a small straight elevator (Fig. 8-37) or a forceps can be used to remove the tooth (Fig. 8-38).

If the tooth is still difficult to extract after removal of bone, a purchase point can be made in the root with the bur at the most apical portion of the area of bone removal (Fig. 8-39). This hole should be about 3 mm in diameter and depth to allow the insertion of an instrument. A heavy elevator, such as a Crane pick can be used to elevate or lever the tooth from its socket (Fig. 8-40, A). The soft tissue is repositioned and sutured (Fig. 8-40, B).

The bone edges should be checked; if sharp, they should be smoothed with a bone file. By replacing the soft tissue flap and gently palpating it with a finger, the clinician can check edge sharpness, Removal of bone with a rongeur is rarely indicated, because it tends to remove too much bone.

Once the tooth is delivered, the entire surgical field should be thoroughly irrigated with copious amounts of saline. Special attention should be directed toward the most inferior portion of the flap (where it joins the bone), because this is a common place for debris to settle, especially in mandibular extractions. If the debris is, not removed carefully by curettage or irrigation, it can cause delayed healing or even a small subperiosteal abscess in the ensuing 3 to 4 weeks, The flap is then set in its original position and sutured into place with 3-0 black silk sutures. If the incision were properly planned and executed, the suture line will be supported on sound, intact bone.

Indications for Surgical Extraction

It is prudent for the surgeon to evaluate carefully each patient and each tooth to be removed for the possibility of an open extraction. Although the vast majority of decisions will be to perform a closed extraction, the surgeon must be aware continually that open extraction may be the less morbid of the two.

As a general guideline surgeons should consider performing an elective surgical extraction when they perceive a possible need for excessive force to extract a tooth.

The term excessive means that the force will probably result in a fracture of bone, a tooth root, or both. In any case the excessive bone loss, the need for additional surgery to retrieve the root, or both can cause undue morbidity. The following are examples of situations in which closed extraction may require excessive force.

The dentist should strongly consider performing an open extraction after initial attempts at forceps extraction have failed. Instead of applying unnecessarily great amounts of force that may not be controlled, the surgeon should simply reflect a soft tissue flap section the tooth remove some bone, and extract the tooth in sections. In these situations the philosophy of divide and conquer results in the most efficient extraction.

If the preoperative assessment reveals that the patient has heavy or especially dense bone, particularly on the buccocortical plate, surgical extraction should be considered. The extraction of most teeth depends on the expansion of the buccocortical plate. If this bone is especially heavy, then adequate expansion is less likely to occur and fracture of the root is more likely. Dense bone in the older patient warrants even more caution.

Whereas young patients have bone that is more elastic and more likely to expand with controlled force, older patients usually have denser, more highly calcified bone that is less likely to provide adequate expansion during luxation of the tooth.

Occasionally, the dentist treats a patient who has very short clinical crowns with evidence of severe attrition. If such attrition is the result of bruxism (a grinding habit),it is likely that the teeth are surrounded by dense, heavy bone with strong periodontal ligament attachment (Fig, 8-26). The surgeon should exercise extreme caution if removal of such teeth is attempted with a closed technique.An open technique usually results in a quicker,easier extraction.

Careful review of the preoperative radiographs may reveal tooth roots that are likely to cause difficulty if the tooth is extracted by the standard forceps technique. One condition commonly seen among older patients is hypercementosis. In this situation, cementum has continued to be deposited on the tooth and has formed a large bulbous root that is difficult to remove through the available tooth socket opening. Great force used to expand the bone may, result in fracture of the root or buccocortical bone and in a more difficult extraction procedure (Fig. 8-27).

Roots that are widely divergent, especially the maxillary first molar roots (Fig. 8-28) or roots that have severe dilaceration or hooks, also are difficult to remove without fracturing one or more of the roots (Fig. 8-29). By reflecting a soft tissue flap and dividing the roots prospectively with a bur a more controlled and’ planned extraction can be performed and will result in less morbidity overall.

If the maxillary sinus has expanded to include the toots of the maxillary molars, extraction may result in removal of a portion of the sinus floor along with the tooth. If the roots are divergent, then such a situation is even more likely to occur (Fig. 8-30).

Teeth that have crowns with extensive caries, especially root caries, or that have large amalgam restorations are candidates for open extraction (Fig. 8-31). Although the root primarily grasps the tooth, a portion of the force is applied to the crown. Such pressures ‘can crush and shatter the crowns of teeth with extensive caries or large restoranons, Open extraction din circumvent the need for extensive force and result in a quicker, easier extraction.Teeth with crowns that have already been lost to caries and that present as retained roots should also be considered for open extraction. If extensive periodontal disease is found around such teeth, it may be possible to deliver them easily with straight elevators or Cryer elevators. However, if the bone is firm around the tooth and ‘no periodontal disease exists, the surgeon should consider an open extraction.

PRINCIPLES AND TECHNIQUES
FOR SURGICAL EXTRACTION

Surgical extraction of an erupted tooth is a technique that should not be reserved for the extreme situation. Aprudently used open Extraction technique may be more conservative and cause less operative morbidity than a closed extraction. Forceps extraction techniques that require great force may result not only in removal of the tooth but also of large amounts of associated bone and occasionally the floor of the maxillary sinus (Fig. 8-25). The bone loss may be less if a soft tissue flap is reflected and a proper amount of bone removed it may also be less if the tooth is sectioned. The morbidity of fragments of bone that are literally torn from the jaw by the conservative closed technique exceeds by far the morbidity of controlled surgical extraction.

Principles of Suturing

Once the surgical procedure is completed and the wound properly irrigated and debrided, the surgeon must return the flap to its original position or, if necessary, arrange it in a new position the flap should be held in place with sutures. Sutures perform multiple functions. The most . obvious and important function that sutures perform is to coapt wound margins that is, to hold the flap in position and approximate the two wound edges. The sharper the incision and the less trauma inflicted on the wound margin, the more probable is healing by primary intention. If the space between the two wound edges is minimal, wound healing will be rapid and complete. If tears or excessive trauma to the wound edges occur, wound healing will be by secondary intention.

Sutures also aid in hemostasis. If the underlying tissue is bleeding, the surface mucosa or skin should not be closed, because the bleeding in the underlying tissues may continue and result in the formation of a hematoma. Surface sutures aid in hemostasis but only as a tamponade in a generally oozing area, such as, a tooth socket. Overlying tissue should never be sutured tightly in an attempt to gain hemostasis in a bleeding tooth socket.

Sutures help hold a soft tissue flap over bone. This is an extremely important function, because bone that is not covered with soft tissue becomes nonvital and requires an excessively long time to heal. When mucoperiosteal flaps are reflected from alveolar bone it is important that the extent of the bone be recovered with the soft tissue flaps. Unless appropriate suture techniques are used, the flap ‘may retract away from the bone, which exposes it and results in delayed healing.

Sutures may aid in maintaining a blood clot in the alveolar socket. A special stitch, such as a figure-eight stitch, can provide a barrier to clot displacement (Fig. 8-15). However, it should be emphasized that suturing across an open wound socket plays a minor role in maintaining the blood clot in the tooth socket.

The armamentarium includes a needle holder, a suture needle, and suture material. The needle holder of choice is 15 cm in length and has a locking handle. It is held with the thumb and ring finger through the rings and with the index finger along the length of the needle holder to provide stability and control (Fig. 8-16).

The suture needle usually used in the mouth is a small three eighths to one-half circle with a reverse cutting edge. The cutting edge helps the needle pass through the relatively tough mucoperiosteal flap. Needle sizes and’ shapes-have been assigned numbers. The most common needle shapes used for oral surgery are the FS-2 and X-I (Fig. 8-17).

Sutures are made of a wide variety of materials and come in several sizes each designed for a particular purpose. The two basic types of suture material are (1) resorbable (i.e. the body is capable of easily breaking the material down) and (2) nonresorbable. In general, resorbable sutures do not require removal, whereas nonresorbable sutures do.

Three types of resorbable sutures are commonly used for oral and maxillofacial surgery (1) gut, (2) polyglycolic acid, and (3) polyglactin. Gut is fabricated from the submucosa of sheep intestines or the serosa of beef intestines. Plain gut is susceptible to rapid digestions by proteolytic enzymes produced by inflammatory cells. Treating the gut suture with basic chromium salts produces chromic catgut, which is more resistant to proteolytic enzymes. Plain gut sutures retain ‘their strength for
approximately 5 days, whereas chromic gut sutures maintain their strength for 7 to 9 days. Polyglycolic acid and polyglactin sutures do not enzymatically break down. Rather they undergo slow hydrolysis, eventually being resorbed by macrophages. Polyglycolic and polyglactin sutures have the advantage of being less stiff than gut sutures and are morelikely to remain tied. However, they may last too long and are more costly than gut sutures.

Resorbable sutures are highly reactive compared with nonresorbable sutures; that is, resorbable sutures evoke an intensive inflammatory reaction that may impede wound healing, occasionally to a clinically significant extent. This is the reason that neither plain nor chromic gut is used for suturing the surface of a skin wound.

The most commonly used nonresorbable sutures in oral and maxillofacial surgery are silk, nylon, polyester, and polypropylene. Nonresorbable sutures are either monofilament or multifilament. The multiflament form increases the strength of the suture, but also increases suture abrasiveness and is more likely to allow.bacteria to “wick” into the wound. Silk and polyester sutures are
available only in multifilament form. Polypropylene is produced only as a monofilament, whereas nylon comes as both a monofilament and a multifilament form.

All nonresorbable sutures have some reactivity. Of the commonly used nonresorbable sutures, silk revokes the most intensive inflammatory reaction and nylon is the least reactive. In situations in which it is important to minimize wound inflammation, such as any facial laceration,nylon is usually the cutaneous suture of choice.

Sutures are available in various sizes that range from the largest diameter, 7, down to the smallest extremely fine suture size, 11-0. The increasing number of O’s correlates with decreasing suture diameter and strength. For example, size 1-0 suture is larger in diameter than size 2-0, size 3-0 is larger than 7-0, etc. Because suture material is foreign to the human body, the smallest diameter of suture sufficient to keeping a wound closed properly should be used. Generally the size of the suture is chosen to correlate with the tensile strength of the tissue being sutured. Most oral and maxillofacial surgeons use 3-0 or 4-0 suture.

The technique used for suturing is deceptively difficult. The use of the needle holder and the technique that is necessary to pass the curved needle through the tissue arc difficult to learn, The following discussion presents the technique used in suturing practice is necessary before suturing can be performed with skill and finesse.

When the envelope flap is repositioned into its correct location, it is held in place with sutures that arc placed through the papillae only. Sutures are not placed across the empty tooth socket, because ‘the edges of the wound would not be supported over sound bone (Fig. 8-18). When reapprox.mating the flap, the suture is passed first through the mobile (usually facial) tissue; the needle is
rcgrasped with the needle holder and passed through the attached tissue of the lingual papilla. If the two margins of the wound are close together, the experienced surgeon may be able to insert the needle through both ,sides of the wound in a single pass. However, it is best to use two passes in most situations (Fig. 8-1″9).

When passing the needle through the tissue, the needle should enter the surface of the mucosa at a right .angle, to make the smallest possible hole in the mucosal flap (Fig. 8-20). If the needle passes through the tissue obliquely, the suture will tear through the surface layers of the flap when the suture knot is tied, which results in greater injury to the soft tissue.

When passing the needle through the flap, the surgeon must ensure that an adequate bite of tissue is taken, to prevent the suture from pulling through the soft tissue flap. Because .the flap that is being sutured is a mucoperiosteal flap and should not be tied tightly, a relatively small amount of tissue is necessary. The minimal amount of tissue between the suture and the edge of the flap should be 3 mm. Once the sutures are passed through both the mobile flap and the immobile lingual tissue, they are tied with an instrument tie (Fig. 8-21).

The surgeon must remember that the purpose of the . stitch is merely to reapproximate the tissue, and therefore the suture should not be tied too tightly. Sutures that are too tight cause ischemia of the flap margin and result in tissue necrosis, with tearing of the suture through the tissue. Thus sutures that are too tightly tied result in wound dehiscence more frequently than sutures that are loosely tied. As a clinical guideline, there should be no blanching or obvious ischemia of the wound edges. If this occurs the suture should be removed and replaced. The knot should be positioned so that it does not fall over the incision line, because this causes additional pressure on the incision. Therefore the knot should be positioned to the side of the incision.

If a three-cornered flap is used, the vertical end of the incision must be closed separately. Two sutures usually are required to close the vertical end properly. Before the sutures are inserted, the Woodson periosteal elevator ‘should be used to elevate slightly the nonflap side of the incision, freeing the margin to facilitate passage of the ‘ needle through the tissue (Fig. 8-22). The first suture is placed across the papilla, where the vertical release incision was made. This is a known, easily identifiable landmark
that is most important when repositioning a three cornered flap. The remainder of the envelope portion of he incision is then closed, after which the vertical component is closed. The slight reflection of the nonflap side of the incision greatly eases the placing of sutures.

The sutures are left in place for approximately 5 to 7 days. After this time they play no useful role and, in fact, probably increase, the contamination of the underlying submucosa When sutures are removed, the surface debris that has collected on them should be cleaned off with a cottontipped applicator stick soaked in peroxide, chlorhexidine, iodophor, or other antiseptic solution. The suture is cut with sharp, pointed suture scissors and removed by pulling it toward the incision line (not away from the suture line).

Sutures may be configured in several different ways.The simple interrupted suture is the one most commonly used in the oral cavity. This suture simply goes through one side of the wound, comes up through the other side of the wound, and is tied in a knot at the top. These sutures can be placed relatively quickly, and the’ tension, on each suture can be adjusted individually. If one suture is lost the remaining sutures stay in position.

A suture technique that is useful for suturing two papillae with a single stitch is the horizontal mattress suture (Fig. 8-23). A slight variation of that suture is the figure eight suture, which holds the two papilla in position and puts a cross over the top of the socket so that may help hold the blood clot in position (see Fig. 8-15).

If the incision is long, continuous sutures can be used efficiently. When using this technique, a knot does not have to be made for each stitch, which makes it quicker to suture a long-span incision. The continuous simple suture, can be either locking or nonlocking (Fig. 8-24). The horizontal mattress suture also ‘can be used in a running fashion. A disadvantage of the continuous suture is that if one suture pulls through, the entire suture line becomes loose.