INJURIES TO ADJACENT TEETH
When the dentist extracts a tooth, the tocus ot attention is on that particular tooth and the application of forces to luxate and deliver it. When the surgeon’s total attention is thus focused, likelihood of injury to the adjacent teeth increases. The surgeon should mentally step back from time to time to survey the entire surgical field to prevent injury to adjacent teeth.
The most common injury to adjacent teeth is the inadvertent fracture of either a restoration or a severely carious tooth while the surgeon’ is attempting to luxate the tooth to be removed with an elevator (Fig. 11-5). If a large restoration exists, the surgeon should warn the patient preoperatively about the possibility of fracturing it during the extraction. Prevention of such a fracture is primarily achieved by avoiding application of instrumentation and force on the restoration (Box 11-3). This means that the straight elevator should be used with great caution or not
used at all to luxate the tooth before. extraction. If a
Prevention of Injury to Adjacent Teeth
1. Recognize potential to fracture large restoration.
2. Warn patient preoperatively.
3. Employ judicious use’ of elevators.
4. Ask assistant to warn surgeon of pressure on adjacent teeth. .
restoration is dislodged or ,fractured, the surgeon should make sure’ that the ‘displaced restoration is removed from, the mouth and does not fall into the empty tooth socket. Once the surgical procedure has been completed, ‘the injured tooth should be treated by placement of a temporary restoranon. The patient should be informed that , the fracture has occurred and that a replacement restoration must be placed (see Chapter 12). . • Teeth in the opposite arch may also be injured as a ‘result of uncontrolled tractional forces. This usually occurs when buccolingual forces inadequately mobilize a tooth and excessive tractional forces are used. The tooth suddenly releases from the socket, and the forceps strikes
against the teeth of the opposite arch and chips or fractures a cusp. This is ‘more likely to occur with extraction of lower teeth, because these teeth may require more vertical tractional forces for their delivery, especially when using the no. 23 (cowhorn) forceps. Prevention of this type of injury can be accomplished by several methods. First and primary, the, surgeon should avoid the use of excessive tractional forces. The tooth should be, adequately luxated with apical, buccolingual, and rotational forces to minimize the need for tractional forces. Even when this is done, however, occasionally a tooth releases unexpectedly. The surgeon or assistant should
protect the teeth of t he opposite arch by simply holding a finger or suction tip against them to absorb the blow should the forceps be released in that direction. If such an injury occurs, the tooth should be smoothed or restored as necessary to keep the patient comfortable until a permanent
restoration can be constructed.
extracted is’ crowded and has overlapping adjacent teeth, such as is commonly seen in the mandibular incisor region, intn, narrow forceps such as the no, 2H6 forceps, may be useful for the extraction (Fig. 11-6). Forceps with broader beaks .should be avoided, because it will cause injury and luxation of the adjacent teeth. If an adjacent tooth is luxated or partially avulsed, the treatment goal is to reposition the tooth “into its appropriate
position and stabilize it so that adequate healing occurs. This usually requires that the tooth simply be repositioned in the tooth socket and left alone. The occlusion should be checked to ensure that the tooth has not been displaced into a hypererupted and traumatic occlusion. Occasionally, the luxated tooth is very mobile. If this is the case, the tooth should be stabilized with the least possible rigid fixation to maintain the tooth in its position. A simple silk suture that crosses the occlusal table and is sutured to the adjacent gingiva is usually sufficient. Rigid fixation with circumdental wires and, arch bars results in increased chances for external toot resorption and ankylosis of the teeth: therefore it , should usually be avoided (see Chapter 23):
Extraction of Wrong Teeth
A complication that every dentist believes can never happen-but happens surprisingly often-is extraction of the wrong tooth. This should never occur if appropriate attention is given to the planning and execution of the
surgical procedure.This problem may be the result of inadequate attention
to the preoperative assessment. If the tooth to be extracted is grossly carious, it is less likely that the wrong tooth will be removed. The wrong tooth is most commonly extracted when the dentist is asked to remove
teeth for orthodontic purposes, especially from patients , who are in mixed dentition stages and whose orthodon-
Prevention of Extraction of Wrong Teeth
1. Focus attention on procedure.
2. Enlist patient and assistant to ensure correct tooth is being removed.
3. Check, then recheck, to confirm correct tooth.
tists have asked for unusual extractions. Careful preoperative planning and clinical assessment of which’ tooth is to be removed before the forceps is applied is the main method of preventing this complication (Box 11-4). If the wrong tooth is extracted and the dentist realizes this error immediately, the tooth should be replaced , immediately into the tooth socket. If the extraction is for orthodontic purposes, .the dentist should contact the
orthodontist immediately and discuss whether or not the tooth that was removed can substitute for the. tooth that should have been removed, If the orthodontist believes the original tooth must be removed, the correct extraction should be deferred for 4 or 5 weeks, until the fate of the
replanted tooth can be assessed. If the wrongfully extracted tooth has regained its attachment to the alveolar process, then’ the originally planned extraction can proceed. The surgeon should not extract the contralateral
tooth until a definite alternative treatment plan is made. If the surgeon does not recognize that the wrong tooth was extracted until the patient returns for a postoperative visit, little can be done to correct the problem. Replantation -of the extracted tooth after it has dried cannot-be
.successfully accomplished. When the wrong tooth is extracted, it is important to inform the patient, the patient’s parents (if the patient is
a minor), and any other dentist involved with the patient’s care, such as the orthodontist. In some situations the orthodontist may’ be able to adjust the treatment plan so that extraction of the wrong toothnecessitates
only a minor adjustment.