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.