Most tooth extractions are relatively straightforward, non-surgical procedures. However, they can be complex processes, in some cases requiring high levels of risk management and/or surgical intervention.
Extractions may be required in a number of different circumstances, including dental caries, periodontitis, trauma, periapical disease, impaction or preparation for orthodontic treatment.
The goal is an atraumatic, minimally invasive extraction without complications and is particularly important for patients requiring post-extraction treatment like immediately placed implants. Despite amazing advances in technology and procedures, complications can still arise, so clinicians must prepare careful risk assessments, maximise patient awareness of possible complications, and perform detailed diagnostic tests before proceeding.
Possible complications
Complications vary depending on the nature of the condition affecting patients as well as the location of the problem tooth, but an important consideration is potential damage to the complex network of nerves in the oral and maxillofacial anatomy. Risk assessments must also take into consideration any possible damage to other teeth, as well as impacts on occlusion after extraction. And soft-tissue healing should be optimised to minimise the risk of infection.
Oral and maxillofacial surgeons are presented with impacted lower third molars regularly, many of which require surgical extraction. Post-operative pain, swelling and trismus are common yet usually short-lived side-effects. However, dry socket (alveolar osteitis), prolonged temporomandibular joint symptoms and trigeminal nerve injuries may also occur. Mandibular fracture is rare but also a possible complication after extraction of third molars from the lower jaw. Additionally, the porous, honeycomb-like network of the mandible’s trabecular bone is less vascularised than the maxilla, tending towards more difficult extractions and a slower healing response.
Extractions in the posterior maxilla also risk nerve damage and can lead to oro-antral communication (OAC). A great deal of planning is important to avoid trauma or perforation of the maxillary sinus, for example, when removing teeth with bulbous roots or periapical abnormalities. Failure of external sinus floor elevation and/or augmentation can also lead to the formation of an OAC.
The treatment of OACs varies depending on the size of the opening access. Communications less than two mm in diameter can close spontaneously, and therefore treatment is not necessary. However, if larger than two mm, OACs may require surgical interventions. The surgical closure of OACs within 48 hours is recommended. If left untreated, OACs can act as an avenue for bacteria into the maxillary sinus, causing infections, sinusitis, or delayed healing.
Special considerations
Most extractions in the UK are caused by dental caries. Hospital extractions due to dental caries among children has been at the forefront of the news, as a government report demonstrated a shocking 17 per cent increase in recent years. The decision to remove first permanent molars (FPM), most often affected by caries, is not straightforward, as outlined in the guidance published by the Royal College of Surgeons.
Children with affected FPMs can experience a great deal of sensitivity and pain due to dental caries, and treatment can require complex restorations or extractions. When correctly planned, early extraction of an affected FPM can be followed by successful eruption of the second permanent molar (SPM) to provide a suitable replacement, ideally allowing the third molar eruption (TPM) to complete the molar dentition. FPM treatment planning decisions should ideally be made in partnership with both the general dental practitioner (GDP) or paediatric dentist and a specialist orthodontist.
Atraumatic extraction
Implants are an increasingly popular treatment for edentulous adults. Studies have shown the comparative benefits of immediate placement of implants in fresh sockets. Survival rates compare well with implants placed in fully healed sockets, and fewer interventions promote healing, which is preferable for patients and can be of benefit in the osseointegration process. Atraumatic extraction is hugely advantageous, as it minimises gingival recession and marginal bone loss.
Most minimally invasive methods depend on the exertion of forces on the periodontal ligament of the tooth, which in turn creates hyaluronic acid build-up in the periodontal ligament space, supporting a hydraulic pressure release in the socket. Other techniques involve sectioning the tooth and root while taking care to preserve the alveolar bone and buccal wall.
A bladed periotome has been successfully used to detach gingival fibres, enabling an extraction by forceps with minimal laceration to the soft tissue. Slow-speed handpieces have also been used successfully in atraumatic extraction. Holes are drilled around the tooth, while progressively sliding down root surfaces. This disrupts the periodontal ligament space, reduces hydraulic pressure, and increases hyaluronic acid build-up allowing for an estimated 40 per cent to 50 per cent reduction in extraction trauma.
Excellent tools for atraumatic extraction
Extraction methods will be dependent on the clinician’s risk assessment. W&H offers the most advanced tools to conduct atraumatic extractions according to each patient’s needs. The Piezomed from W&H offers ultrasound technology that is shown to be minimally invasive due to the incredible power of its high-frequency micro-vibrations. This results in an incredibly precise and controlled action. Additionally, the cavitation effect leaves surgical sites almost blood-free for enhanced healing effects.
Atraumatic extractions result in fewer complications and offer more restorative options. Outcomes are optimised by advanced techniques, and the best possible tools.
Reference available on request.