Principles of Routine Exodontia

Extraction of a tooth combines the principles of surgery and elementary physical mechanics. When these principles are applied correctly, a tooth can usually be removed from the alveolar process, even by someone without great strength and without untoward force or sequelae. This chapter presents the principles of surgery and mechanics related to uncomplicated tooth extraction. In addition, there is a detailed description of techniques for removal of specific teeth with specific instruments. Because the crown is already “removed” from the bone in fully erupted teeth, a dental extraction focuses on root extraction. Following this concept prevents the surgeon from untoward focus on using force on the crowns to remove teeth. Ignoring this concept commonly leads to fracturing the crowns or roots of teeth or fracturing the bone around the roots.

Proper tooth removal does not require a large amount of strength; instead, when done properly, it is accomplished with finesse. Removal of an erupted tooth involves the use of controlled force so that the tooth is not pulled from bone, but instead is gently lifted from its socket. During preextraction planning, the degree of difficulty anticipated for removing a particular tooth is assessed. If that assessment leads the surgeon to believe that the degree of difficulty will be high or if initial attempts at tooth removal confirm this, a deliberate surgical approach—not an application of excessive force—should be taken. Excessive force may injure local soft tissue and damage the surrounding bone and teeth. Such force may fracture the crown, usually making the extraction substantially more difficult than it would have been otherwise. Moreover, excessive force and haste during an extraction heightens intraoperative and postoperative patient discomfort and anxiety.

Presurgical Medical Assessment

When conducting the preoperative patient evaluation, it is critical that the surgeon examine the patient's medical status. Patients can have a variety of health problems that require treatment modification or medical management before the surgery can be safely performed. Special measures may be needed to control bleeding, lessen the chance of infection, or prevent a medical emergency. This information is discussed in detail in Chapter 1 , which includes information regarding the specifics of altering surgical treatment for medical management reasons.

Indications for Removal of Teeth

Teeth are extracted for a variety of reasons. This section discusses a variety of general indications for removing teeth. These indications are only guidelines, not absolute rules.

Caries

Perhaps the most common and widely accepted reason to remove a tooth is that it is so severely carious that it cannot be restored. The extent to which the tooth is carious and is considered nonrestorable is a judgment call to be made between the dentist and the patient. Sometimes the complexity and cost required to salvage a severely carious tooth also makes extraction a reasonable choice. This is particularly true with the availability and success of reliable implant-supported prostheses.

Pulpal Necrosis

A second, closely aligned rationale for removing a tooth is the presence of pulpal necrosis or irreversible pulpitis that is not amenable to endodontics. This may be the result of a patient declining endodontic treatment or when a tooth has a root canal that is tortuous, calcified, and untreatable by standard endodontic techniques. Also included in this category of general indications is the case in which endodontic treatment has been done but has failed to relieve pain or provide drainage, and the patient does not desire retreatment.

Periodontal Disease

A common reason for tooth removal is severe and extensive periodontal disease. If severe adult periodontitis has existed for some time, excessive bone loss and irreversible tooth mobility will be found. In these situations, the hypermobile teeth should be extracted. Also, ongoing periodontal bone loss may jeopardize the chance for straightforward implant placement, making extraction a sensible step even before a tooth becomes moderately or severely mobile.

Orthodontic Reasons

Patients who are about to undergo orthodontic correction of crowded dentition with insufficient arch length frequently require the extraction of teeth to provide space for tooth alignment. The most commonly extracted teeth are the maxillary and mandibular premolars, but a mandibular incisor may occasionally need to be extracted for this same reason. Great care should be taken to double-check that extraction is indeed necessary and that the correct tooth or teeth are removed if someone other than the surgeon doing the extraction has planned the extractions.

Malpositioned Teeth

Teeth that are malposed or malpositioned may be indicated for removal in several situations. If they traumatize soft tissue and cannot be repositioned by orthodontic treatment, they should be extracted. A common example of this is the maxillary third molar, which erupts in severe buccal version and causes ulceration and soft tissue trauma of the cheek. Another example is malpositioned teeth that are hypererupted because of the loss of teeth in the opposing arch. If prosthetic rehabilitation is to be carried out in the opposing arch, the hypererupted tooth may interfere with construction of an adequate prosthesis. In this situation, the malpositioned tooth should be considered for extraction.

Cracked Teeth

An uncommon indication for extraction of teeth is a tooth with a cracked crown or a fractured root. The cracked tooth can be painful and be unmanageable by a more conservative technique. Cracked teeth have often already undergone endodontic therapy at some point in the past, which tends to make the crown and root more brittle and difficult to remove.

Impacted Teeth

Impacted teeth should be considered for removal. If it is clear that a partially impacted tooth is unable to erupt into a functional occlusion because of inadequate space, interference from adjacent teeth, or some other reason, it should be considered for surgical removal. See Chapter 10 for a more thorough discussion of this topic.

Supernumerary Teeth

Supernumerary teeth are usually impacted and should be removed. A supernumerary tooth may interfere with the eruption of succedaneous teeth and has the potential for causing their resorption and displacement.

Teeth Associated With Pathologic Lesions

Teeth involved in pathologic lesions may require removal. This is often seen with odontogenic cysts. In some situations, the tooth or teeth can be retained and endodontic therapy performed. However, if maintaining the tooth compromises the complete surgical removal of the lesion when complete removal is critical, the tooth should be removed.

Radiation Therapy

Patients who are to receive radiation therapy for oral, head, or neck cancer should consider removal of teeth that are in the beam of radiation therapy, particularly if the teeth are compromised in some manner. However, many of these teeth can be retained with proper care. See Chapter 19 for a more thorough discussion of the effects of radiation therapy on teeth and jaws.

Teeth Involved in Jaw Fractures

Patients who sustain fractures of the mandible or the alveolar process sometimes must have teeth removed. In some situations, the tooth involved in the line of fracture can be maintained, but if the tooth is injured, infected, or severely luxated from the surrounding bony tissue or interferes with proper reduction and fixation of the fracture, its removal is usually indicated.

Financial Issues

A final indication for removal of a tooth relates to the financial status of the patient. All of the indications for extraction already mentioned may become stronger if the patient is unwilling or unable to financially support the decision to maintain the tooth. The inability of the patient to pay for the procedure may require that the tooth be removed. Also, implant dentistry is often more cost effective for a patient than maintaining a compromised tooth.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here