Surgical teeth extraction: techniques

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A dentist has to perform a surgical teeth extraction when the pathological state of the tooth, its coronary and / or root morphology requires a specific surgical procedure.

Indications

Root morphology

Large, slender roots cause difficulties Subject to excess retention or fracture during mobilization, teeth sometimes require the practice of a surgical teeth extraction before being completely removed.

Curved roots, undercuts, convergence or divergence when it comes to multi-rooted teeth, contribute to the complexity of the act.

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Tooth condition

Internal or external resorption, deep caries, dental trauma, teeth with coronal reconstitution.

All these situations make the teeth fragile, fracturing easily during normal operating maneuvers.

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The dentist is frequently confronted with the persistence of the root part in a deep alveolar situation offering little grip on the forceps.

Periodontal difficulties

Ankylosis of the root. This makes it difficult, if not impossible, for the practitioner to cleave the root element without resorting to bone relief.

Contraindications of surgical teeth extraction

Local contraindications

-Poor oral hygiene

-Inflammation of the mucous membrane

-Suppurative collection

-Trismus

General contraindications

-Unbalanced diabetes

-Patient on bisphosphonates

-Irradiated patient

-Herpes labialis

Fractured apex

Asymptomatic fractured apex with vital pulp tissue; extraction is not indicated in this case. Especially if there is a risk of repression of the apex into the maxillary sinus or when the apex is close to the mandibular canal or the mental foramen.

Surgical teeth extraction techniques

Root separation

It is performed by a coronal and interradicular section of multi-rooted teeth, using a bur mounted on a rotating instrument holder.

Aim: to remove the obstacle constituted by the divergence or root convergence which mechanically opposes the “exit” of the tooth from the socket.

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Alveolectomy

Definition

A surgical technique that allows to partially or totally expose the root(s) of the tooth to be extracted. Generally, it consists of an osteotomy of the alveolar external table, whether or not the proximal septa are involved.

Technique

Incision:

Using a scalpel with a 15 blade, an intrascular incision is made, with or without a discharge line.

Under no circumstances should the discharge line be done in the middle of the tooth to be avulsed but at a distance from it. Therefore, the incision extends approximately one tooth from the surgical site.

Surgical detachment:

The detachment of the flap starts from the mesial discharge line (if practiced) and progresses along the length of the dental collars, gradually mooving towards the end of the vestibule.

Alveolectomy:

After the detachment of the flap using a retractor, the operator makes a groove in the vestibular alveolar bone using the rotary instrument of his choice with the appropriate bur; the dental rampart serving as a guide. The osteotomy performed is in fact an enlargement of the periodontal space, facilitating access to the root part. The height of the buccal bone is lowered until sufficient clearance is obtained to allow avulsion of the tooth root.

Avulsion, alveolar revision, site closure:

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Usually, the avulsion is achieved through the use of an instrument with a fine working part: Chompret’s sickle syndesmotome or Bernard’s syndesmotome, fine elevators, root forceps.

The alveolus should be revised. The flap should be repositioned and sutured in separate, simple and loosely stitched.

Postoperative complications

These can involve the tooth, bone, soft tissue and instrumentation. The more difficult a tooth extraction is, the more likely it is to cause postoperative complications

Instrument fracture during a surgical teeth extraction

The fracture of a bur is not uncommon, especially if the supporting rotary instrument is a turbine. The blockage of the active part of the cutter can be the cause of its separation from the mandrel by clean breakage. Fractured material should be clinically and radiologically investigated and removed as it can lead to infections.

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Adjacent teeth complications

During mobilization maneuvers:

– Risk of coronary fractures of neighboring teeth (decayed or with significant coronary reconstitution),

-Accidental dislocation of the bordering teeth (postoperative apical periodontitis pain)

-Loosening of an adjacent prosthetic crown or bridge.

Soft tissues

-soft tissue contusions may occur.

– Prolonged use of the handpiece generates overheating of the mechanical part which can be the cause of burns.

– Slipping of the scalpel blade in neighboring soft tissues or during an unexpected movement of the patient.

-Lip cut when moving the blade (or bur) to the operative site according to the mouth opening.

-Sutures that have come loose → resumption of sutures

-Uncureted granulation tissue, bone sequestration or a root fragment persisting in the alveolus → X-ray + curettage and local hemostasis.

Bone tissue

Maxillary sinus floor lesion

It is important to diagnose it and make sure that no foreign body of dental or instrumental origin has been pushed into the air cavity.

A simple breath test is enough to show the presence of buccosinus communication. Checking the integrity of the root elements makes it possible to suspect or not the possibility of the projection of an apex in the maxillary sinus.

Mandibular canal lesion during a surgical teeth extraction

Relatively rare. When it does occur, it is usually accompanied by a sheet hemorrhage that is easily controllable by simple compression, possibly supplemented with hemostatic materials. The projection of an apex within the canal is even more rarely described.

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