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Quality Resource Guide -

Minimally Traumatic Surgical Extractions in General Practice 2nd Edition

www.metdental.com

An elevator (such as a #301) is placed horizontally

between two teeth to luxate the

tooth needing

removal, yet the fulcrum for the elevator is the

interseptal bone, not the adjacent tooth. To fulcrum

against the tooth not being extracted can cause

injury to the tooth and periodontium leading to

unnecessary luxation of that tooth, pain, tooth

fracture, and breakage/dislodgement of a prosthetic

crown on the adjacent tooth.

When an elevator is

correctly used, rotation of the instrument can be

clockwise or counter-clockwise - each of these

two directions providing a different force vector for

luxation.

Erupted teeth in an adult have a PDL width in the

range of 1-3 tenths of a millimeter.

Older patients

may have an atrophied PDL, or it may be non-

existent with the tooth attached directly to bone

(ankylosis). Ankylosis usually requires that roots

needing removal be drilled out peripherally with a

periotome bur or piezo bone cutting device or by

attrition with a round bur.

Handpiece Selection

hoosing the right handpiece is important when

preparing for surgical extractions. Options for

handpieces include either a straight handpiece

(air turbine or electric) or a “surgical” highspeed

handpiece. Both types of handpieces (Figure

1) are designed so they do not blow air into the

surgical field. When air is forced into soft tissue

during surgery, it creates the possibility of air

emphysema into fascial spaces. This complication

is not limited to oral surgery procedures as the

dental literature also includes many case reports

occurring during restorative procedures or by the

patient blowing air– usually when the soft tissue

attachment around a tooth is violated.

7-10

Air emphysema is manifest by sudden

subcutaneous swelling of soft tissue in the vicinity

of the drilling. It can affect tissue overlying the

mandible or maxilla - and/or extending more

deeply into the infraorbital area, the neck,

and even to the mediastinum. Oral organisms

accompanying the air can potentially cause life-

threatening infections. Should emphysema occur,

a consultation with a specialist is recommended.

Treatment, depending on severity, generally

consists of a clinical evaluation, cone-beam

CT imaging, and appropriate follow-up care

including antibiotic therapy, an anti-inflammatory

medication, and possibly hospitalization.

All drilling of teeth and bone with a handpiece

should be accompanied by irrigation to prevent

overheating and flush away debris. As mentioned

above, the irrigation medium should not be

mixed with air (air-water spray). Sterile saline is

recommended and non-disinfected water coming

through biofilm-laden dental unit tubing is not.

Water is typically delivered through the handpiece

when using a highspeed drill. With a straight

handpiece, irrigation can be delivered separately

by way of a bulb syringe, 12 cc Monoject syringe,

20-30 cc syringe with an irrigation needle, or

from a IV bag with water pumped through tubing

attached to the handpiece.

Complications leading to an untoward experience

during tooth extraction should be infrequent.

If “exceptions” happen routinely, there is the

probability that the dentist is operating outside his/

her range of ability, and thus, outside the standard

of care. One good subjective criterion to use as a

guide during patient case selection is the dentists’

“comfort zone”. If the dentist does not feel right

about starting a case, it should be referred. On

the other hand, clinicians should keep learning

and broadening their expertise throughout their

professional career so that over time, their comfort

level expands.

Care Near Vital Structures and

Inaccessible Areas

Good visibility and careful technique are especially

necessary when a surgical procedure takes place

in close proximity

to vital structures, such as

the mandibular canal (inferior alveolar

nerve),

mental

foramen, lingual nerve, floor of the

mouth

(including the lingual artery), infratemporal space,

the maxillary sinus, facial artery/anterior facial

vein, and the greater palatine artery. Whenever

a surgery procedure approximates these areas

or structures, significant care must be exercised.

If one tries to curette out an abscess apical to

a lower premolar, the mental nerve could be

injured. Excessively long buccal releasing incisions

between the mandibular first and second molars

could approximate the region of the facial artery

and/or anterior facial vein. Manipulation of palatal

tissue lingual to the maxillary second molar could

endanger the greater palatine artery. Inadvertently

letting a straight elevator slip into the floor of the

mouth could puncture the lingual artery.

Bleeding Problems

Bleeding is expected with oral surgery, but

occasionally it can become serious and even life-

threatening. As mentioned previously, the clinician

should avoid actions that could compromise the

lingual artery or facial artery/anterior facial vein.

Incisions near the greater palatine arteries can

lead to difficult-to-control spurting of blood from

the palate. Drilling bone will sometimes expose

a nutrient canals (small blood vessels in bone),

also causing spurting. In the latter case, bleeding

can usually be managed by burnishing adjacent

bone into the bleeding orifice or by pressing a

small amount of bone wax or bone graft into that

spot.

If there is profuse bleeding from a socket,

the clinician can use non-absorbable Iodoform

cotton gauze as a temporary tamponade (leaving it

in place for several days before removing it) along

with the normal 2 X 2 gauze over the socket with

biting pressure. If a dentist does extractions he/she

should use one or more hemostatic local measure,

such as Gelfoam™ hemostatic gauze, Colla-Plug™,

additional sutures, silver nitrate sticks, etc.

Figure 1

Examples of surgical high-speed handpiece (left)

and surgical electric straight handpiece (right).

Both

are engaging a 702 surgical bur, and

both types of

handpieces are acceptable for exodontia.