Lecture 5: Management of Impacted Teeth, Surgical Complications, & Informed Consent

impacted

Describes a tooth that does not erupt into the dental arch within the expected time.

alveolar bone too short

Most common cause for impacted teeth.

1. 3rd molars

2. Max canine (should erupt 11-12 yrs)

3. Man premolars (should erupt 10-13 yrs)

The teeth that are most commonly impacted

periodontal disease

Erupted teeth adjacent to impacted teeth are vulnerable to this condition.

caries

If an impacted tooth creates an uncleansable area on the adjacent tooth, _________ is likely.

pericoronitis

Infection/inflammation of soft tissue around the crown of a partially impacted tooth.

Caused by bacteria, occlusal trauma, and food entrapment.

Tx: irrigation & currettage (mild); severe cases show frank purulence & may require extraction & antibiotics.

bacterial infection, occlusal trauma (from opposing 3rd molar) food entrapment

3 causes of pericoronitis.

Prevent by extracting the partially impacted tooth to avoid inflammation.

frank purulence

Symptom that indicates moderate-to-severe pericoronitis.

Likely need to extract tooth & antibiotics may be required.

operculectomy

Removal of soft tissue over the crown of an impacted tooth. Does NOT prevent pericoronitis because the soft tissue can simply re-grow over the tooth.

root resorption (impacted tooth grows into the roots of the adjacent tooth)

This condition is caused by an impacted tooth; may cause the adjacent tooth to require RCT or extraction.

alveolar process resorption, tooth exposure, & infection

Consequences of leaving an impacted tooth under a dental prosthesis. Soft tissue is compressed.

compound odontoma

Odontogenic tumor that looks like miniature teeth

complex odontoma

Odontogenic tumor that is disorganized - does not look like a little tooth

False (leaving in a man 3rd molar weakens the bone at the angle of the jaw - tooth must be removed if it is in the line of fracture)

T/F: Extracting mandibular 3rd molars makes the mandible more vulnerable to fracture

1. Prevent Periodontal disease

2. Prevent caries

3. Prevent pericoronitis

4. Prevent root resorption

5. Under prosthesis

6. Fracture

7. Ortho

7 indications for removing impacted teeth.

under 12, over 50

Ages that are contraindications for removing asymptomatic, non-pathologic impacted teeth.

Also avoid extraction on pt with compromised medical status or if it will be likely to damage adjacent structures.

16-18 yrs (roots 1/3 formed, bone density lower, cerebral cortex isn't fully formed haha)

What is the ideal age to remove impacted 3rd molars?

pano

best radiograph to see impacted teeth.

mesio-angular

The most common class of impacted teeth (53% frequency). The easiest to extract. Long axis of impacted 3rd molar is tilted mesially relative to the long axis of the 2nd molar.

vertical impaction

The 2nd easiest class of impacted teeth to remove (also the 2nd most frequent at 38%). Long axes of impacted tooth are parallel.

disto angular

The 2nd rarest class of impacted teeth (6%) & the hardest to extract. Long axis of impacted tooth is tilted distally relative to long axis of adjacent tooth.

The path of draw goes into the ramus, and the roots are in close contact.

horizontal impaction

The rarest (3%) class of impacted teeth & the 2nd hardest to extract. The long axes of the impacted & adjacent teeth are roughly perpendicular.

class I

Pell & Gregory classification for impacted tooth whose entire crown is anterior to the anterior border of the ramus.

class II

Pell & Gregory classification for impacted tooth whose crown is partially anterior to the anterior border of the ramus.

class III

Pell & Gregory classification for impacted tooth whose crown is posterior to anterior border of the ramus.

class A

Pell & Gregory classification for impacted tooth whose occlusal table is at the level of the 2nd molar's occlusal table.

Relatively easy to extract.

class B

Pell & Gregory classification for impacted tooth whose occlusal table is between the occlusal table & cervical margin of the 2nd molar.

class C

Pell & Gregory classification for 3rd molar whose occlusal table is below the cervical margin of the 2nd molar.

Difficult to extract.

partially developed, fused, straight (easier than fully developed, separate, and curved)

The types of roots that are the easiest to extract.

No roots may be difficult since the crown might spin around in bone.

big (longer PDL fibers means less tight attachment to bone?)

Size of follicular sac that makes for the easiest extraction.

35 yrs

Beginning around this age, the alveolar bone becomes more dense & less pliable, making extraction more difficult.

inferior alveolar nerve (lip, chin, gingiva, teeth paresthesia), lingual nerve (tongue paresthesia - has the worst prognosis of recovering)

2 vital structures to watch out for when removing impacted teeth - damage can cause paresthesia, anesthesia, and unhappy pts.

partial bone impaction

Class of impacted tooth where the height of the tooth's contour is below the level of the adjacent alveolar bone.

complete bone impaction

Class of impacted tooth where the entire tooth is encased in bone.

Often the most difficult to remove.

diverge laterally (going too far towards the tongue risks damaging the lingual nerve)

Correct orientation of the posterior incision when making a flap to extract an impacted mandibular 3rd molar.

3-corner flap (envelope flap may tear when retracting if the tooth is too deep)

Use this type of flap if the tooth being extracted is deeply impacted.

Increased visibility & access apically.

buccodistal bone to cervical line

Location & amount of bone that needs to be removed when extracting a vertically impacted tooth.

Exposes buccal groove of bone in which a straight elevator can be placed to luxate the tooth coronally.

distal half (then remove mesial half with elevator)

Section, then remove this part of a mesioangular 3rd molar when extracting.

2/3 to 3/4 of the buccodistal bone

How much bone to remove for horizontally impacted mandibular 3rd molar.

crown (remove the roots by elevating at the furca)

Section off this portion of a horizontally impacted mandibular 3rd molar when extracting.

Alternatively, may be helpful to make a T cut (horizontal & vertical) with a fissure bur thru the crown (root(s) may be extracted along with a portion of the crown)

furca

When removing the roots of a horizontally impacted tooth following crown removal, this anatomical location is a good spot to gain a purchase point when removing the roots with an elevator.

section off crown, remove roots via furca (may need to section divergent roots)

Technique for removing distoangular mandibular 3rd molars.

Potts elevator

This elevator may be helpful for removing impacted maxillary 3rd molars.

mandibular 3rd molars

Removal of these impacted teeth carries the highest risk for bacterial infection.

Consider prescribing some antibiotics.

1. Health hx

2. Radiographs (includes the whole root & beyond)

3. Plan

4. Pre/post-op instructions

5. Surgical principles (i.e. do a good job)

5 rules for preventing surgical complications

1. Visualization & access (lighting, suction, tissue reflection)

2. Finesse

3. Asepsis

4. Atraumatic

5. Debridement

6. Hemostasis

The 6 basic surgical principles.

tear mucosal flap (don't retract too hard; extend flap or use a vertical releasing incision if necessary)

Most common soft tissue injury seen during surgery.

reposition, suture

What to do if a mucosal flap gets torn.

avulsive injury

Loss of tissue during surgery.

Can be caused by placing forceps beaks on soft tissue instead of just on the tooth. Or from using a screwdriver for DIY dentistry.

shank of bur (use a bur guard)

Instrument that has a risk for causing abrasions & burns.

Tx: Topical antibiotics (until eschar forms - layer of dead tissue), suture, should heal in 5-10 days.

use finger rest, avoid lateral pushing

how to avoid puncturing soft tissue when using a straight elevator.

puncture wound

Type of injury that should NOT be sutured. Allow it to drain (prevents infection) and heal by secondary intention.

air emphysema

Air gets trapped in tissue. Less likely with electric handpieces (vs pneumatic)

maxillary buccal cortical plate (canines, 1st molars), max sinus floor, max tuberosity, man incisor labial bone

likely locations for alveolar bone fracture.

Bone fragment needs to be removed if it has been separated from periosteum (if in doubt, remove the bone).

forceps excessive force

most common cause for injuring osseous structures.

Avoid by sectioning tooth, doing open extraction, and using pre-op radiographs.

pneumatization

condition in which there is an expansion of the sinus towards an extraction site

visualization, (gentle) probing, nose-blow test

How to dx an oro-antral communication.

Complications include maxillary sinusitis (infection) and oro-antral fistula.

sinusitis

Complication that can result from an oro-antral communication. Causes inflammation/infection of the maxillary sinus.

oro-antral fistula

Chronic connection between the oral cavity & maxillary sinus via an extraction site.

Likelihood of developing depends on size of communication (less than 3mm should heal on its own), history of infection, and management of exposure.

<3mm

For this size of an oro-antral communication, don't do additional surgery since the hole should fill on its own.

Follow sinus precautions: Avoid blowing nose, sneezing, sucking on straws, and no wind instruments (keeps constant low sinus pressure)

3-6mm

For this size of an oro-antral communication, promote blood clotting by using gel foam, collagen plug, or sutures.

Follow sinus precautions (no blowing, sneezing, straws) and prescribe antibiotics & decongestants (oxymetazoline, pseudoephedrine).

oxymetazoline (Afrin)

Nasal decongestant spray to use in the case of a moderate (3-6mm) oro-antral communication.

pseudoephedrine (Actifed)

Oral decongestant to use in the case of a moderate (3-6mm) oro-antral communication.

>6mm

Size of oro-antral communication that likely requires additional surgery to heal (not likely to heal naturally). Use flap procedure, sinus precautions (no blowing, sneezing, straws, ect.), medications (antibiotics & decongestants).

6-8 week recall to make sure the oro-antral communication closes up.

excessive force with elevator

Most likely cause for a fractured mandible.

Tx: Refer to oral surg for reduction & stabilization.

fractured restoration

Most common injury to adjacent teeth when extracting a tooth.

avulsed

When extracting a tooth, the adjacent tooth may be ______________ (lifted out of the socket).

"not good"

Extracting the wrong tooth is _________________.

put it back

what to do if wrong tooth is extracted

root fracture

The most common complication from extracting a tooth.

maxillary molars (into maxillary sinus)

What roots are the most likely to be displaced when extracting?

Avoid excess apical pressure.

apical pressure

Too much of this force can displace a root into the maxillary sinus, inferior alveolar canal, submandibular/sublingual space, infratemporal fossa, or between buccal plate & periosteum.

take a radiograph

The 1st thing to do when trying to decide whether to leave a displaced root in place.

less than 3mm

If a displaced root is smaller than this, and there's no history of sinus/dental infection, can consider leaving it in place.

Tell pt and record in note.

Caldwell-Luc procedure

Procedure for removing a root tip (or entire tooth) from the maxillary sinus. A flap is made, cortical bone removed, the sinus membrane (Schneiderian membrane) is penetrated to expose the antrum, and the object is suctioned out.

pharyngeal drape

Use this to prevent swallowing or aspiration of an extracted tooth.

1. Platelet aggregation inhibitors (Aspirin, Clopidogrel aka Plavix)

2. Anti-coagulants (Warfarin, IIa & Xa inhibitors)

3. Antibiotics (esp. cephalosporins --> vit K deficiency)

4. Alcohol

5. Anti-cancer drugs

5 drug groups that can promote bleeding.

gel foam

Hemostatic agent. Absorbable gelatin sponge that promotes platelet aggregation.

surgicel

Hemostatic agent made of oxidized cellulose (promotes platelet aggregation)

topical thrombin

Hemostatic agent that converts fibrinogen to fibrin.

Can coat gel foam with this.

Avitene

Hemostatic agent made of microfibrillar collagen that promotes platelet aggregation.

Bone wax

Hemostatic agent that works by plugging the opening in bone & tamponading bleeding.

tranexamic acid

Substance that helps stop bleeding by working as an antifibrinolytic agent - blocs plasminogen binding sites.

Not a hemostatic agent - does NOT promote clotting - stops clot breakdown.

collagen plug

Hemostatic agent that accelerates the aggregation of platelets.

No

Does ecchymosis (bleeding into subcutaneous soft tissue) increase risk of infection?

liver clot

Clot that is brown & oozes. Need to remove, add hemostatic agent, and suture.

wound dehiscence

separation of the layers of a surgical wound. Can be caused by an unsupported soft tissue flap or suturing under tension.

localized alveolar osteitis (dry socket)

Dull, throbbing pain that develops 3-4 days post-op & can radiate to ear or other teeth. Stinky.

Cause: Bone is exposed in the tooth socket (most commonly in man 3rd molars).

Tx: Irrigate with saline, place medicated dressing

man 3rd molar

Most common site for localized alveolar osteitis (dry socket)

eugenol (carried by Balsam of Peru)

Common ingredient in the medicated dressing used for dry socket.

Remove within several days if non-resorbable.

malpractice

Negligent actions of professionals while performing professional duty

negligence

Failure of professionals to have or to exercise the degree of skill normally possessed and demonstrated by members of their profession practicing under similar circumstances.

oral discussion, written consent, documentation (in chart)

3 phases of informed consent.

Should include info about problem, proposed tx, common side effects, possible complications & risks, anesthesia, and alternatives.

Should be in pt's language if he or she can't speak/read english.

Must be signed by legal guardian if pt is a minor.