When teeth are hopelessly compromised from a restorative or periodontal standpoint, extraction may be required. In some cases, teeth may be salvageable, but the patient does not possess the time, financial resources, or motivation to undergo the necessary procedures required to save them. Sometimes the recommendation to extract is made because, if retained, the teeth would not serve as satisfactory abutments for prostheses, or might jeopardize the prognosis for the surrounding teeth.
Other surgical procedures may be necessary or benefi- cial before fabrication of any prosthetic appliances. Such procedures include removing exophytic lesions, reducing bulbous maxillary tuberosities, and removing tori or other exostoses. In some situations, preprosthetic surgery is mandatory to achieve a successful prosthetic outcome. In others, the surgery is optional. When faced with the cost, time, and inconvenience of undergoing preprosthetic surgery, some patients may decline, but all patients who could potentially benefit from the surgery should be given the option.
Extraction
Simple dental extraction typically involves the removal of a tooth or root fragments with elevation and forceps delivery. A surgical extraction for severely broken down or impacted teeth entails elevating a gingival flap for access. Extraction is indicated to remove hopeless teeth and to provide space for orthodontic treatment or succedaneous tooth eruption and, in some instances, third molars (see the In Clinical Practice box). The most common complications associated with extrac- tion include bleeding, postoperative pain, dry socket, and infection.
In Clinical Practice
Should Asymptomatic Third Molars Be elimination of pericoronitis. Patients may request their removal to preclude crowding of the anterior teeth, a projected outcome that has now been discredited. Research has cast doubt on the value and the necessity of routinely removing asymptomatic and clinically sound, but impacted, thrid molars.1Public health studies assessing the cost/benefit ratio
of third molar removal typically weigh in favor of no treat- ment.2But there is also an increasing body of knowledge that
links the presence of periodontal pathogens and periodontal pocketing around third molars with preterm birth and
Removed?
The Issues
Third molars, also known as wisdom teeth, are sometimes viewed as unnecessary and potentially problematic and are often seen as candidates for extraction. Some practitioners have recommended their universal removal as a means of prevent- ing infection, cysts, tumors, caries, periodontal disease, or destruction to adjacent teeth. Extraction of third molars has been the definitive treatment of choice for the prevention or
Preprosthodontic Surgery
Patients scheduled to receive fixed or removable partial or complete dentures may have abnormalities of the bone or soft tissue that will underlie the prosthesis. Four clin- ical conditions that often require surgical attention are discussed in this section and summarized in Table 8-5.
Exophytic Soft Tissue Lesions Many different forms of pathologic conditions can be included under this heading. Some of the more notable are hypertrophic or
hyperplastic (flabby) ridges, epuli, and denture (palatal) papillomatosis. If minor, these lesions may be somewhat innocuous, but in an advanced state they may make suc- cessful denture wearing impossible.
Bulbous Tuberosities Enlarged tuberosities may be of soft tissue or bony origin or both. Overextended, “drooping” tuberosities can alter the occlusal plane; limit the space for teeth or denture base material; interfere with retention; and in extreme cases, render the denture unusable.
In Clinical Practice
Should Asymptomatic Third Molars Be Removed?—cont’d
• If there is a reasonable probability that the wisdom tooth may be needed in the future as an abutment for a pros- thesis, as an anchor for orthodontic treatment, or to main- tain the occlusal plane, more weight should be given to retention of the tooth or teeth.
• If loss of the third molars will compromise the patient’s occlusion, function, or mastication, more weight should be given to retention.
In addition to these issues, the patient will want to weigh the impact of other personal considerations, such as the finan- cial cost, potential loss of time at work, pain and anxiety control, and the timing of the procedure with other life events. Two often unspoken but relevant considerations are the patient’s prior experience with elective surgical procedures and personal philosophy in dealing with risk or uncertainty. Some patients have had unfortunate past experiences with surgical procedures and as a result are extremely apprehensive of such procedures. These patients are more likely to have complica- tions or postoperative problems and, in addition, are more likely to decline extraction unless it becomes imperative. Other patients may have a more proactive orientation, seeking an avoidance of uncertainties. Such patients are more comfortable choosing the extractions to prevent potential future problems. In contrast, the risk takers prefer to wait and take their chances. If problems do develop, they will deal with them then. The wise practitioner is attentive to these varying perspectives and helps the patient factor them into the decision making.
1. Tulloch JF, Antczak-Bouckoms AA: Decision analysis in the evaluation of clinical strategies for the
managment of mandibular third molars, J Dent Educ 51(11):652-660, 1987.
2. Tulloch JF, Antczak-Bouckoms AA, Ung N: Evaluation of the costs and relative effectiveness of alternative strategies for the removal of mandibular third molars, Int Technol Assess Health Care 6(4):505-515, 1990. 3. White RP: Third molar oral inflammation and
systemic inflammation, J Oral Maxillofac Surg 63(8); Supplement 1:5-6, 2005.
4. Ruvo AT, Moss KL, Mauriello SM et al: The systemic impact of third molar periodontal pathology, J Oral Maxillofac Surg 63(8); Supplement 1:69, 2005. markers for systemic inflammation.3,4Although this evidence
is not compelling enough to suggest the necessity of remov- ing all periodontally involved third molars, it does suggest the need to carefully assess the periodontal health of third molars especially for women of childbearing age and individuals with immunocompromising conditions, including the inflamma- tory arthropathies. In light of sometimes conflicting evidence, the dentist must consider carefully whether or not to recom- mend the extraction of the third molars. Furthermore, the requirements of informed consent make it necessary that the patient be an active partner in the decision-making process. Reaching a Decision
A healthy patient in the age range of 19 to 25 years whose impacted third molars have caused repeated episodes of pain from pericoronitis is a good candidate for extraction. When there is no reasonable prospect for the wisdom teeth to become properly aligned and fully functional, and the patient has a strong desire to stave off future potential problems, con- sideration should certainly be given to removal. Regardless of the patient’s age, third molars that have a poor periodon- tal or restorative prognosis and that the patient is not highly motivated to retain are usually best removed. Aside from these fairly clear-cut situations, the decision as to whether or not to extract becomes the purview of the patient after the dentist has presented in detail the arguments for and against extraction. Although there are no absolutes, the following general guidelines are helpful and can form the basis of the consent conversation with the patient.
• Younger and healthier patients (ASA I or II) generally have an easier time with the surgery, heal faster with fewer com- plications, and have more normal architecture in the eden- tulous ridge after healing.
• When the risk of future complications or problems in the presence of the third molars is high (caries, periodontal disease, pericoronitis), more weight should be given to extraction.
• When the possibility of surgical complications (paresthe- sia, fracture, dry socket, or infection) is high, more weight should be given to not extracting.
Exostoses and Tori Like enlarged tuberosities, large exostoses may impair the retention, fit, strength, and function of a denture. They are also notorious for causing denture sores because the overlying soft tissue tends to be thin, friable, and, because of its location, easily abraded or traumatized.
Ridge Augmentation Procedures Some patients have extensive bone loss and ridge resorption in the eden- tulous areas. The severity and pattern of bone loss vary by individual and site, but these sites are typically unsat- isfactory as denture-bearing areas and do not provide a long-term stable base for a conventional removable partial or complete denture. If a conventional denture is the chosen course of treatment, then modifying the alve-
olar ridge to improve the ridge shape and increase the size of the denture-bearing area may be the only recourse. Vestibuloplasty or repositioning of the vestibular fold more apically—often with concurrent placement of grafts from skin or oral mucosa—can effectively increase the usable ridge height and area. Some cases may require osseous surgical procedures, such as a total or segmental bone graft, a palatal osteotomy, or a maxillary sinus floor graft. A relatively new technique called
distraction osteogenesis has been developed as an
alternative to conventional augmentation procedures. Here the edentulous ridge is enhanced by incrementally separating the buccal and lingual plates and encouraging new bone deposition to develop between the bony segments.
Table 8-5 Conditions That May Warrant Preprosthetic Surgery
Condition Treatment Options Keys to Decision Making
Exophytic lesions: flabby, edentulous No treatment Patient declines surgical correction; no-treatment option does ridges, epulis fissuratum, and not preclude successful denture fabrication and use; medical denture (palatal) papillomatosis contraindication to surgery
Surgical excision Patient wishes surgical correction; no-treatment option precludes successful denture fabrication and use; currently the most frequently used and predictable mode of treatment Electrosurgery Alternative to conventional surgical technique when
practitioner has the armamentaria and training Laser surgery Alternative to conventional surgical technique when
practitioner has the armamentaria, training, and expertise, and laser surgery is an appropriate alternative
Bulbous tuberosity No treatment Patient declines surgery and no-treatment option does not preclude successful denture fabrication and use; medical contraindication to surgery
Soft tissue and/or bone reduction Present condition precludes successful fabrication, retention, or use of prosthesis; patient seeks improved outcome afforded by tuberosity reduction; sufficient interarch clearance can be obtained by soft tissue and/or bone reduction (i.e., surgery will not encroach on sinus floor)
Segmental osteotomy Tuberosity reduction required, soft tissue reduction will not provide adequate space, and a pneumatized sinus precludes sufficient bone removal to accomplish desired objective; teeth in the quadrant need to be intruded, in which case, teeth and tuberosity can be moved superiorly at the same time
Torus or other exostosis No treatment Bony bulge and undercut are of insufficient magnitude to impair denture construction, retention, or function; denture can be fabricated without removal of bone; outcome is uncertain and patient accepts responsibility if result is unfavorable; medical contraindication to surgery
Removal Patient requests improved outcome afforded by the surgery, osteotomy is necessary for successful full or partial denture construction
Ridge deficiency No treatment Inadequate ridge form does not preclude attempt at denture construction; patient declines surgery and accepts that retention will be compromised; medical contraindication to surgery
Augmentation Patient values the benefit that improved ridge form and increased denture stability and retention will provide