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What are the general principles to consider when performing surgical extractions?

Preoperative Assessment

Prior to extraction, dentists must review the patient’s medical and social history and take stock of any medications he/she may be taking. The preoperative evaluation will include both a clinical as well as radiographic examination to assess any challenges that may be encountered during the procedure.

Clinical Examination

The clinical examination should include an evaluation of how accessible the tooth is in the dental arch. Assess whether the patient has a restricted opening, the tooth’s positioning in the arch, as well as crowding which may interfere with access and extraction of the tooth.

Large carious lesions or large restorations will also impact the removal of the tooth as they often result in crown fractures during the procedure. Placement of the forceps may be difficult in these situations so surgical exposure may be required to assist in seating the forceps apically on uncompromised tooth structure.

If the buccal bone is dense, it will prove difficult to expand during the extraction and may cause the tooth to fracture.  Denser bone is typically found in older patients, as well as patients who grind. Exostoses may also create challenges for expansion of buccal bone.

Radiographic Examination

The radiographic examination is as important as the clinical examination. Information gleaned from the radiograph is different from the clinical exam. Periapical and/or panoramic films are often used to assess the tooth and its surrounding structures; however, more detailed information is provided by a periapical x-ray of good quality. At times, an occlusal radiograph may be indicated to visualize the buccolingual or buccopalatal position of an impacted tooth. Good radiographs will also allow the clinician to evaluate the density of the bone.

The number, shape, length and size of the roots must be evaluated to help predict any problems that may arise during the procedure. Dilacerations as well as divergent roots should be noted as sectioning may be indicated to facilitate easier removal.

Additionally, proximity to other anatomical structures such as the maxillary sinus or inferior alveolar nerve must be examined. Extraction of maxillary posterior teeth may result in sinus involvement, ranging from displacement of root tips in the sinus to the development of an oroantral fistula. Extractions involving mandibular third molars can often lead to injuries of the inferior alveolar nerve bundle.  As such, the relationship of the nerve to the tooth and its roots must be assessed carefully.

X-rays can also help determine the presence or degree of internal or external resorption of the tooth. Teeth with resorption are best removed via surgical extraction. Ankylosis, hypercementosis and endodontically-treated tooth can all be problematic for removal and are best gauged through radiographic analysis.

Source: Manual of Minor Oral Surgery for the General Dentist, Wiley, 2006

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