4.2 ­axillarry anines 57

4.2Maxillary Canines

1)Difficulty Assessment. Removal of the maxillary canine can often be more difficult than expected for the novice dentoalveolar surgeon due to the deceptive straight, single root (Figure 4.2). First, maxillary canines have a significantly larger periodontal surface area than maxillary incisors due to the longer root structure. Second, the buccal bone overlying the maxillary incisor may be thick and unforgiving – this can be assessed clinically by running one gloved finger over the alveolar bone and mucosa in the area. Third, maxillary canines undergo millions of cycles of repetitive and heavy lateral loading, and this can cause ankylosis or a reduced periodontal ligament space. Difficulty significantly increases when any of these three factors is seen.

2)Obtain Consent. In addition to the general risks of dental extraction, patients should be specifically informed of the risk of buccal alveolar fracture, as this can be common with removal of canines, and can affect future prosthetic rehabilitation.

3)Basic Equipment Required. Short-beaked upper straight forceps, sometimes referred to as ‘stubbie’ forceps, are the gold standard for removing upper canine teeth, as the shorter beak allows for greater grip force to be applied to the canine. Upper straight forceps can be used, but their thinner, longer beaks may not provide sufficient force to the tooth. A straight elevator should be available to expand the periodontal ligament prior to forceps placement.

Frontal view

Stubbie forceps

Figure 4.2 Extraction of a maxillary canine tooth.

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584  Simple Extraction Techniques

4)Final Check. Confirm the tooth number and location with radiograph.

5)Local Anaesthetic. Infiltration of the buccal vestibule will provide sufficient anaesthesia for the maxillary buccal soft tissue and periodontal ligament. Localised palatal infiltration is required to anaesthetise the palatal gingiva.

6)Positioning. Lie the patient flat in the dental chair, with the maxillary canine at the same vertical height as the surgeon’s elbow. Stand on the side of the patient that corresponds with the hand dominance of the surgeon. For example, a right-handed practitioner standing on the right side of the patient increases biomechanical advantage when removing the tooth.

7)Elevation. Apply the straight elevator to the mesial and distal areas of the periodontal ligament. Using a wheel-and-axle motion, gently expand the periodontal ligament until a small amount of mobility is noted in the tooth. Take care to elevate between tooth and bone only, and not against adjacent teeth. The thumb and finger of the nondominant hand should be used to support the alveolus of the tooth being extracted, to guide the application of force to the tooth socket only, and to prevent instrument slippage.

8)Delivery. Apply the beaks of the stubbie forceps on to the cementoenamel junction of the tooth. Initially, use apical pressure to slide the beaks as deep on to the root as possible. Employ a rapid clockwise–counterclockwise rotational movement to continue tearing the periodontal ligament. Finally, rotate the crown 90° to deliver the crown and root.

9)Assessment. Assess the tooth root to ensure it has been removed complete. Flush the socket with saline to remove any surgical debris. Examine the socket for bleeding, alveolar bone fracture, or soft tissue trauma, and manage as appropriate.

4.3Maxillary Premolars

1)Difficulty Assessment. Maxillary first premolars always have two roots: buccal and palatal. Maxillary second premolars may have either two separate roots or two roots fused together (Figure 4.3). Root configuration should be assessed radiographically; this should be correlated clinically, as maxillary premolars are commonly found to be rotated slightly, which can affect the vectors of extraction. As with all multirooted teeth, complex root configurations warrant surgical extraction.

2)Obtain Consent. General risks apply for maxillary premolar teeth.

3)Basic Equipment Required. Upper universal forceps can be used for all maxillary premolars. The curved handle of the instrument allows for ideal placement of the beaks without interfering with the lower arch. A straight elevator should be available to expand the periodontal ligament­ prior to forceps placement.

4)Final Check. Confirm the tooth number and location with radiograph.

5)Local Anaesthetic. Infiltration of the buccal vestibule will provide sufficient anaesthesia for the maxillary buccal soft tissue and periodontal ligament. Localised palatal infiltration is required to anaesthetise the palatal gingiva.

6)Positioning. Lie the patient flat in the dental chair, with the maxillary molars at the same vertical height as the surgeon’s elbow. Stand on the side of the patient that corresponds with the hand dominance of the surgeon. For example, a right-handed practitioner standing on the right side of the patient increases biomechanical advantage when removing the tooth.

7)Elevation. Apply a straight elevator to the mesiobuccal aspect of the periodontal ligament. Using a wheel-and-axle motion, gently push the tooth in a distal direction. Care should be taken to not use excessive force during this movement, as root fractures commonly occur at this stage. Only a

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4.4  ­MaxiiMary xarst Mand Secan ­ciMar 59

Frontal View

Rapid, small buccal-palatal, Ititial movements

apical pressure

Upper universal forceps

Figure 4.3 Extraction of a maxillary premolar tooth.

slight amount of tooth mobilisation is required before progressing to tooth delivery. The thumb and finger of the nondominant hand should be used to support the alveolus of the tooth being extracted, to guide the application of force to the tooth socket only, and to prevent instrument slippage.

8)Delivery. Apply the beaks of the upper universal forceps on to the cementoenamel junction of the tooth. Initially, use apical pressure to slide the beaks as deep on to the roots as possible. Employ rapid, small, buccopalatal movements to expand the socket. Rotation of upper premolars is not recommended as this goes against the strongest axis of the tooth and may cause root fracture. Excessive palatal tilting is also not recommended as this will cause palatal root fracture, necessitating surgical extraction. Complete the extraction with a final buccal movement, to deliver the tooth laterally.

9)Assessment. Assess the tooth root to ensure it has been removed complete. Flush the socket with saline to remove any surgical debris. Examine the socket for bleeding, alveolar bone fracture, or soft tissue trauma, and manage as appropriate.

4.4  Maxillary   First and Second Molars

1)Difficulty Assessment. The multirooted nature of maxillary molars warrants early consideration of a surgical extraction approach over simple extraction (Figure 4.4). In younger individuals (less than 40 years of age), a simple extraction is likely to be successful; in older individuals, where other maxillary teeth in the posterior region have been removed already, attempting a simple extraction can be difficult, and fraught with complications. Radiographically, assessment

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of the root configuration will give the first indication that surgical extraction may be indicated, due to splaying of roots. The surgeon must also assess for pneumatisation of the sinus from extractions of adjacent teeth; this indicates that the bone between the tooth and maxillary sinus is very thin and is likely to fracture during extraction, with subsequent oroantral communication. Worse, displacement of the tooth or roots into the maxillary sinus cavity can occur.

2)Obtain Consent. In addition to the generic extraction risks, patients must be informed of the risk of oroantral communication or displacement of tooth roots into the sinus. Both outcomes may require secondary surgery or referral to a specialist oral and maxillofacial surgeon and can have a significant effect on the prosthetic rehabilitation of the newly edentulous site. If the maxillary second molar is being removed, patients must be warned of the risk of tuberosity fracture.

3)Basic Equipment Required. Upper left or right molar forceps are designed specifically for the typical root configuration of upper molars; that is, the beaks of the forceps are designed to adapt around two buccal roots and one palatal root. A straight elevator should be kept available at all times. Occasionally, other elevators may be required to remove fractured root fragments.

4)Final Check. Confirm the tooth number and location with radiograph.

5)Positioning. Lie the patient flat in the dental chair, with the maxillary premolars at the same vertical height as the surgeon’s elbow. Stand on the side of the patient that corresponds with the hand dominance of the surgeon. For example, a right-handed practitioner standing on the right side of the patient increases biomechanical advantage when removing the tooth.

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