Principles of Dentoalveolar Extractions

Foreword ix

About the Companion Website xi

1 Principles of Surgery 1

1.1 Wound Healing 2

1.1.1 Haemostasis 2

1.1.2 Inflammatory Phase 4

1.1.3 Proliferative Phase 4

1.1.4 Remodelling and Resolution 4

1.2 Patient Assessment 4

1.3 Radiographic Assessment 5

1.4 Informed Consent 7

1.5 Anaesthesia 7

1.6 Preparation of Equipment 9

1.7 The Surgeon’s Preoperative Checklist 10

1.8 Operative Note 12

2 Local Anaesthesia 15

2.1 Principles of Anaesthesia 16

2.2 Mechanism of Action 16

2.3 Common Local Anaesthetic Preparations 18

2.4 Side Effects and Toxicity 19

2.4.1 Local Risks 19

2.4.2 Systemic Risks 19

2.5 Basic Oral Anaesthesia Techniques 19

2.5.1 Buccal Infiltration Anaesthetic 20

2.5.2 Mandibular Teeth 21

2.5.2.1 Conventional ‘Open-Mouth’ Technique 22

2.5.2.2 Akinosi ‘Closed-Mouth’ Technique 23

2.5.2.3 Gow–Gates Technique 23

2.5.2.4 Mandibular Long Buccal Block 24

2.5.2.5 Mental Nerve Block 25

2.5.3 Maxillary Teeth 26

2.5.3.1 Greater Palatine Block 27

2.5.3.2 Palatal Infiltration 28

2.5.3.3 Nasopalatine Nerve Block 29

2.5.3.4 Posterior Superior Alveolar Nerve Block 29

2.6 Adjunct Methods of Local Anaesthesia 30

2.6.1 Intraligamentary Injection 30

2.6.2 Intrapulpal Injection 31

2.7 Troubleshooting 32

3 Basic Surgical Instruments 35

3.1 Retractors 35

3.2 Elevators, Luxators, and Periotomes 37

3.3 Dental Extraction Forceps 40

3.4 Ancillary Soft Tissue Instruments 44

3.5 Suturing Instruments 47

3.6 Surgical Suction 49

3.7 Surgical Handpiece and Bur 50

3.8 Surgical Irrigation Systems 51

3.9 Mouth Props 53

4 Simple Extraction Techniques 55

4.1 Maxillary Incisors 55

4.2 Maxillary Canines 57

4.3 Maxillary Premolars 58

4.4 Maxillary First and Second Molars 59

4.5 Mandibular Incisors 61

4.6 Mandibular Canines and Premolars 62

4.7 Mandibular Molars 64

5 Surgical Extraction Techniques 67

5.1 General Principles of Surgical Extraction 68

5.2 Practical Aspects of Surgical Extraction 69

5.3 Common Soft Tissue Flaps for Dental Extraction 70

5.4 Bone Removal 73

5.5 Tooth Sectioning 74

5.6 Cleanup and Closure 75

6 Intraoperative Complications 79

6.1 Lip Burns and Lacerations 79

6.2 Damage to Adjacent Teeth or Restorations 80

6.3 Mandible Fracture 81

6.4 Tooth Aspiration or Ingestion 81

6.5 Instrument Fracture 82

6.6 Intraoperative Bleeding 82

6.7 Oroantral Communication 83

6.8 Dentoalveolar Fracture 84

7 Third Molar Surgery 87

7.1 Treatment Planning of Impacted Third Molars 87

7.2 Difficulty Assessment and Preoperative Workup 89

7.3 Radiographic Assessment of Inferior Alveolar Nerve Risk 91

7.4 Surgical Approach to Third Molars 91

7.4.1 Maxillary Third Molars 91

7.4.1.1 Erupted 91

7.4.1.2 Unerupted/Partially Erupted 92

7.4.2 Mandibular Third Molars 93

7.4.2.1 Mesioangular 93

7.4.2.2 Distoangular/Vertical 93

7.4.2.3 Horizontal 95

7.4.2.4 Full Bony Impaction (Early Root Development) 99

7.4.2.5 Buccolingual/Other Impactions 99

8 Management of the Medically Compromised Patient 101

8.1 Ischaemic Cardiovascular Disease 102

8.2 Patients with a History of Infective Endocarditis 102

8.3 Hypertension 103

8.4 Medication-Related Osteonecrosis of the Jaws 103

8.5 Diabetes Mellitus 107

8.6 Increased Bleeding Risk 108

8.6.1 Bleeding Diatheses 108

8.6.2 Medications 109

8.6.2.1 Management of Antiplatelet Agents Prior to Dentoalveolar Surgery 110

8.6.2.2 Management of Patients Taking Warfarin Prior to Dentoalveolar Surgery 110

8.6.2.3 Management of Patients Taking Direct Anticoagulant Agents Prior to Dentoalveolar Surgery 110

8.7 Adrenal Suppression 110

8.8 The Irradiated Patient 112

8.8.1 Management of the Patient with a History of Head and Neck Radiotherapy 113

8.9 Hepatic or Renal Impairment 113

8.10 Pregnancy and Lactation 114

9 Postoperative Care and Late Complications 115

9.1 Immediate Postoperative Period 115

9.2 Postoperative Instructions 116

9.3 Postoperative Medications 116

9.4 24-Hour On-Call Service and Tertiary Hospital Referral 117

9.5 Management of Late Complications 117

9.5.1 Alveolar Osteitis 117

9.5.2 Acute Facial Abscess 118

9.5.3 Postoperative Haemorrhage 119

9.5.4 Temporomandibular Joint Disorder 119

9.5.5 Epulis Granulomatosa 120

9.5.6 Nerve Injury 121

Appendix A Special Cases: Common Indications for Surgical Extraction 123

Appendix B Extraction of Deciduous Teeth 127

Bibliography 133

Index 135