Principles of Dentoalveolar Extractions

Principles of Dentoalveolar Extractions

Seth DelpachitraAnton SklavosRicky Kumar

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Library of Congress Cataloging-in-Publication DataNames: Delpachitra, Seth Navinda, 1988– author. | Sklavos, Anton William, 1990- author. | Kumar, Ricky Ritesh, 1976– author. Title: Principles of dentoalveolar extractions / Seth Navinda Delpachitra, Anton William Sklavos, Ricky Ritesh Kumar. Description: Hoboken, NJ : Wiley-Blackwell, 2020. | Includes bibliographical references and index. Identifiers: LCCN 2020025027 (print) | LCCN 2020025028 (ebook) | ISBN 9781119596400 (cloth) | ISBN 9781119596417 (adobe pdf) | ISBN 9781119596448 (epub) Subjects: MESH: Tooth Extraction–methods Classification: LCC RK531 (print) | LCC RK531 (ebook) | NLM WU 605 | DDC 617.6/6–dc23 LC record available at https://lccn.loc.gov/2020025027LC ebook record available at https://lccn.loc.gov/2020025028

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Contents

Foreword ixAbout the Companion Website xi

1 Principlesof Surgery 11.1 WoundHealing 21.1.1 Haemostasis 21.1.2 InflammatoryPhase 41.1.3 ProliferativePhase 41.1.4 Remodellingand Resolution 41.2 PatientAssessment 41.3 RadiographicAssessment 51.4 InformedConsent 71.5 Anaesthesia 71.6 Preparationof Equipment 91.7 TheSurgeon’sPreoperativeChecklist 101.8 OperativeNote 12

2 Local Anaesthesia 152.1 Principlesof Anaesthesia 162.2 Mechanismof Action 162.3 CommonLocalAnaestheticPreparations 182.4 SideEffectsand Toxicity 192.4.1 LocalRisks 192.4.2 SystemicRisks 192.5 BasicOralAnaesthesiaTechniques 192.5.1 BuccalInfiltrationAnaesthetic 202.5.2 MandibularTeeth 212.5.2.1 Conventional‘Open-Mouth’Technique 222.5.2.2 Akinosi‘Closed-Mouth’Technique 232.5.2.3 Gow–GatesTechnique 232.5.2.4 MandibularLongBuccalBlock 242.5.2.5 MentalNerveBlock 252.5.3 MaxillaryTeeth 262.5.3.1 GreaterPalatineBlock 27

Contentsvi

2.5.3.2 PalatalInfiltration 282.5.3.3 NasopalatineNerveBlock 292.5.3.4 PosteriorSuperiorAlveolarNerveBlock 292.6 AdjunctMethodsof LocalAnaesthesia 302.6.1 IntraligamentaryInjection 302.6.2 IntrapulpalInjection 312.7 Troubleshooting 32

3 BasicSurgicalInstruments 353.1 Retractors 353.2 Elevators,Luxators,and Periotomes 373.3 DentalExtractionForceps 403.4 AncillarySoftTissueInstruments 443.5 SuturingInstruments 473.6 SurgicalSuction 493.7 SurgicalHandpieceand Bur 503.8 SurgicalIrrigationSystems 513.9 MouthProps 53

4 SimpleExtractionTechniques 554.1 MaxillaryIncisors 554.2 MaxillaryCanines 574.3 MaxillaryPremolars 584.4 MaxillaryFirstand SecondMolars 594.5 MandibularIncisors 614.6 MandibularCaninesand Premolars 624.7 MandibularMolars 64

5 SurgicalExtractionTechniques 675.1 GeneralPrinciplesof SurgicalExtraction 685.2 PracticalAspectsof SurgicalExtraction 695.3 CommonSoftTissueFlapsfor DentalExtraction 705.4 BoneRemoval 735.5 ToothSectioning 745.6 Cleanupand Closure 75

6 IntraoperativeComplications 796.1 LipBurnsand Lacerations 796.2 Damageto AdjacentTeethorRestorations 806.3 MandibleFracture 816.4 ToothAspirationorIngestion 816.5 InstrumentFracture 826.6 IntraoperativeBleeding 826.7 OroantralCommunication 836.8 DentoalveolarFracture 84

7 ThirdMolarSurgery 877.1 TreatmentPlanningof ImpactedThirdMolars 877.2 DifficultyAssessmentand PreoperativeWorkup 89

Contents vii

7.3 RadiographicAssessmentof InferiorAlveolarNerveRisk 917.4 SurgicalApproachto ThirdMolars 917.4.1 MaxillaryThirdMolars 917.4.1.1 Erupted 917.4.1.2 Unerupted/PartiallyErupted 927.4.2 MandibularThirdMolars 937.4.2.1 Mesioangular 937.4.2.2 Distoangular/Vertical 937.4.2.3 Horizontal 957.4.2.4 FullBonyImpaction(EarlyRootDevelopment) 997.4.2.5 Buccolingual/OtherImpactions 99

8 ManagementoftheMedicallyCompromisedPatient 1018.1 IschaemicCardiovascularDisease 1028.2 Patientswith a Historyof InfectiveEndocarditis 1028.3 Hypertension 1038.4 Medication-RelatedOsteonecrosisof the Jaws 1038.5 DiabetesMellitus 1078.6 IncreasedBleedingRisk 1088.6.1 BleedingDiatheses 1088.6.2 Medications 1098.6.2.1 Managementof AntiplateletAgentsPriorto DentoalveolarSurgery 1108.6.2.2 Managementof PatientsTakingWarfarinPriorto DentoalveolarSurgery 1108.6.2.3 Managementof PatientsTakingDirectAnticoagulantAgentsPriorto 

DentoalveolarSurgery 1108.7 AdrenalSuppression 1108.8 TheIrradiatedPatient 1128.8.1 Managementof the Patientwith a Historyof Headand NeckRadiotherapy 1138.9 HepaticorRenalImpairment 1138.10 Pregnancyand Lactation 114

9 PostoperativeCareand LateComplications 1159.1 ImmediatePostoperativePeriod 1159.2 PostoperativeInstructions 1169.3 PostoperativeMedications 1169.4 24-HourOn-CallServiceand TertiaryHospitalReferral 1179.5 Managementof LateComplications 1179.5.1 AlveolarOsteitis 1179.5.2 AcuteFacialAbscess 1189.5.3 PostoperativeHaemorrhage 1199.5.4 TemporomandibularJointDisorder 1199.5.5 EpulisGranulomatosa 1209.5.6 NerveInjury 121

AppendixA SpecialCases:CommonIndicationsfor SurgicalExtraction 123AppendixB Extractionof DeciduousTeeth 127Bibliography 133Index 135

ix

The attachment of teeth to bone, facilitated by the periodontal ligament, is a unique connective tissue articulation. It enables tooth eruption, appropriate physiological responses to compressive force, and planned orthodontic tooth movement. However, as odontogenic infections may be potentially fatal, specialised skills for efficient tooth extraction have evolved from the days of the ‘barber-surgeons’ of the Middle Ages to contemporary exodontia. Today, every conceivable type of useful instrumentation and imaging is available to the clinician.

Tooth removal in the middle of the last century occupied a large part of the dental practitioner’s work and skill set, but this has markedly reduced due to better dental care and tooth main-tenance. The time devoted to the discipline of exodontia in the dental curriculum has thus diminished proportionally, and many graduates emerge with minimal experience in removing teeth. A fresh, comprehensive guide to the principles of dentoalveolar extractions for all interested practitioners who wish to underpin their clinical experience with clear guidelines is therefore most welcome.

In a logical sequence, the authors have addressed all aspects of managing a patient for simple and surgical extractions. By introducing the ‘principles of surgery’ from the outset, the reader is reminded that tooth removal is within the surgical spectrum and carries the same responsi-bilities in terms of providing careful patient assessment, consent, a controlled clinical environ-ment, and necessary documentation. A detailed knowledge of the associated anatomy and competence in the administration of local anaesthesia are fundamental for successful dentoal-veolar surgery in the outpatient setting and are well covered in this book, as are the available surgical instruments.

A methodical approach in performing simple and surgical extractions, including the manage-ment of intraoperative events and third molar surgery, is also provided, with headings for assess-ment, equipment, and patient position. These chapters are supported by good-quality anatomical diagrams to assist in the understanding of the suggested techniques.

With our ageing population, there are many medications and diseases that must be thoroughly understood by the dental practitioner. A chapter on medical compromise is an important addition to this text as it covers issues such as the newer anticoagulant agents and medications for bone loss that influence healing. The taking of these drugs may significantly modify a treatment plan, and decisions regarding joint management with the patient’s prescribing physician are often indicated. Finally, postoperative care and complications are discussed, as these represent vital knowledge in surgical care.

Many books covering this field have included chapters devoted to exodontia, as part of a broader spectrum of oral and maxillofacial surgery. However, this neat, clear, and inclusive volume fulfills

Foreword

Forewordx

the objective of providing a modern reference text devoted to dentoalveolar surgery alone. It will instruct all those who set out to master the skills of exodontia in their practising lives, from under-graduate students to surgical trainees and newly qualified dental practitioners. I have no doubt that this excellent resource will be consumed and enjoyed by many in the years to come.

Professor Andrew A.C. Heggie, AMOral and Maxillofacial Surgeon

Melbourne, Australia

xi

Don’t forget to visit the companion website for this book:

www.wiley.com/go/delpachitradentoalveolarextractions

There you will find valuable material designed to enhance your learning, including:

● MCQs

Scan this QR code to visit the companion website.

­About­the Companion­Website

1

Principles of Dentoalveolar Extractions, First Edition. Seth Delpachitra, Anton Sklavos and Ricky Kumar. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/delpachitradentoalveolarextractions

surgery n. manual treatment of injuries or disorders of the body, operative therapeutics.surgeon n. a person skilled in surgery.

Exodontia, the removal of teeth, involves the manipulation of hard and soft tissues and the ampu-tation of the dentition or parts thereof in order to treat or prevent disease, or as part of an overall treatment plan. The surgeon who carries out this treatment must possess qualities, skills, and deci-sion-making abilities to the standard of any other trained surgeon who diagnoses and treats disease. It is the responsibility of this surgeon to provide the highest standard of care of which they are capa-ble, and when they cannot provide it to a suitable level, to refer to the appropriate specialist service.

It is somewhat self-evident, though easily forgotten, that the surgeon’s responsibility is not lim-ited to the operation only, but also involves preoperative consultation and postoperative monitor-ing, as well as other aspects of care such as liaising with other practitioners and communicating treatment plans. Surgeons are trained to possess several qualities and characteristics not limited to procedural skills:

● Knowledge. Knowledge can be considered the facts, information, skills, and experience gained through education, training, and professional practice. It is a fundamental and essential aspect of the carrying out of dentoalveolar extractions. It includes technical and medical expertise, which facilitate safe patient management. As scientific knowledge evolves over time, there is a need for ongoing maintenance through continuing professional development and keeping up to date with evidence-based practice.

● Quality and Safety. Quality is the commitment to excellence, providing a service that is guided primarily by the best interests of the patient. This is achieved through recognition of one’s own strengths and limitations, stringent self-audit, and the fortitude to request assistance when needed. Safety is the avoidance of risk or injury to oneself, one’s staff, and one’s patients. Maintenance of a safe workplace is the responsibility of all individuals employed in a health environment, and requires appropriate training and awareness of risk-mitigation strategies such as aseptic and sterilisation techniques. Quality and safety are dynamic components of surgery and necessitate constant refinement and improvement to ensure the wellbeing of patients and a high standard of care.

● Communication and Collaboration. Good communication is essential in the interaction both with patients and with other health professionals. Clear, concise, and relevant document ation of patient management will improve interactions with specialists and foster a culture of collabo-ration and professional development. This is particularly important when patients are

1

Principles of Surgery

1  Principles of Surgery2

undergoing tooth extraction as part of a wider treatment plan where multiple other medical comorbidities require interdisciplinary management. In such situations, good communication minimises delays to receiving time-critical treatment, such as in the case of dental extractions prior to head and neck radiotherapy or bisphosphonate treatment.

● An Individualistic Approach. Patients will have a wide variety of backgrounds, demands, and prior medical knowledge. A tailored and individualised approach is required in order to ensure they understand the proposed procedure, its risks, and its expected outcomes, and are able to compare options in order to make an informed decision.

● Leadership and Management. A surgeon will often find themselves the leader of a multifac-eted treatment team, including nursing staff, dental assistants, anaesthetic staff, and sterilisation technicians. This leadership comes with great responsibility: the expert surgeon must guide oth-ers in the team, provide feedback and education, and thus help maintain a standard of excel-lence. The surgeon must ensure that all staff are orientated towards the goal of achieving the best outcome for the patient. When the highest standard of care is compromised, the responsibil-ity is on the surgeon to make sure the team gets back on track.

● Decision Making. The word ‘decision’ shares a common root with another word often associ-ated with surgery: incision. Both are derivatives from the Latin word caedis, meaning ‘to cut’. Incision means to cut into something, such as the operative site; decision literally means ‘to cut away’. A decision thus precludes other options, and sets one upon a particular course of action. A skilled surgeon will be able to make treatment planning decisions that are in the best interests of their patients.

1.1 Wound Healing

Good outcomes following surgery depend on satisfactory wound healing. This involves a range of inflammatory, biochemical, and physiologic changes at the operative site, which will ultimately lead to resolution, healing, and bone remodelling. Wound healing does not always follow a predict-able course, and therefore an understanding of its key aspects will serve as a foundation for inter-preting clinical signs and determining when it is compromised.

There are four key stages in wound healing (Figure 1.1):

1) Haemostasis.2) Inflammatory phase.3) Proliferative phase.4) Remodelling and resolution.

An interruption at any one of these stages will lead to a protracted recovery period.

1.1.1 Haemostasis

Any tissue trauma will result in bleeding from the local vasculature supplying the tissues. The immediate physiologic reaction is haemostasis, which involves reactive vasospasm, formation of a platelet plug, and activation of the coagulation cascade.

Reactive vasospasm occurs in the seconds to minutes following damage to the blood vessels. This is mediated through neurologic mechanisms, as well as the local release of endothelin. It rapidly reduces blood loss from trauma. In surgery, exogenous vasoactive medications such as adrenaline utilise this response to improve visual access to the surgical field by reducing blood flow.