Maxillary first and second molars Surgically Removed

Surgical Removal of Maxillary first and second molars
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Dr. Parmanand Dhanrajani (dan.dhanrajani@gmail.com) – Oral surgeon, Bds, mds, msc, msc, fracds, fdsrcs, ffdrcsi, Hcf dental centre, Sydney, Australia

Dental News March 2020 Issue

Abstract 

This paper presents technical notes on removal of maxillary upper first and second molars. Maxillary first and second molars are difficult and challenging to remove in best experienced hands. The technique described is easy to learn and implement. 

It preserves bone and imply minimal trauma as well as avoids complication such as perforation of maxillary sinus floor. 

Keywords: Exodontia, Maxillary molar, Surgical Removal

Introduction

The extraction of maxillary first and second molars is often difficult and challenging especially if they are heavily restored. Teeth with large restorations and/or which are root canal treated are prone to fracture during a forceps removal and a planned surgical technique must be used to start with. These extractions are further complicated by the close proximity of these teeth to the maxillary antrum. Surgical technique requires good planning, meticulous tissue handling and proper use of instruments, especially luxators, so that mishaps such as fracture roots or displacing roots into the sinus are avoided. In the era of implant replacement of the tooth it becomes imperative to maintain as much bone as possible and preserve soft tissue around the extraction site for future replacement 1.

This paper describes a systematic approach for removal of maxillary first and second molars which avoids the most common complications such as fractured root tips, sinus perforations and displacing roots into the sinus while simultaneously maintaining bone and soft tissue2.

Technical Notes for removal of maxillary first and second molars

2.1. Pre-operative assessment of the patient’s medical and social history, ensuring that there are no contraindications for surgical procedures. Informed consent is mandatory before the start of the procedure. This must include the warning that prophylactic closure of maxillary sinus may be required.

2.2. Proper clinical and radiographic examination is essential. During examination assess the status of the tooth in regard to decay, restorations and the amount of tooth loss at the gingival and alveolar margins. Assess the soft tissue available if a buccal advancement flap is required. 

2.3. The orthopantomograph (OPG), periapical X-ray and Cone beam CT, if available, should be examined in detail to confirm clinical findings such as the state of tooth crown remaining, shape and length of roots, and if root canal treated or not (Fig 1). Assessment of the proximity of the roots to the maxillary antrum floor and adjacent teeth, and the presence of any pathology such as cyst or granuloma is required.

Orthopantomograph showing heavily filled left maxillary second molar
Figure 1: Orthopantomograph showing heavily filled left maxillary second molar.

2.4. Local anaesthetic should be administered to the buccal and palatal aspect of the tooth; infiltration does work satisfactorily.

2.5. Buccal flap: A buccal full thickness mucoperiosteal flap is designed, usually 3 sided with vertical incisions mesial and distal to the tooth located away from the interdental papillae and a horizontal incision consisting of the gingival margins; alternatively a two-sided flap may be used making one vertical incision mesial to the tooth being removed (Fig 2). Good exposure of buccal aspect of the tooth and the bone is imperative.

Surgical Removal Maxillary first second molars
Figure 2: Photograph showing buccal flap with sectioning of crown and roots in the form of T at CEJ.

2.6. Removal of buccal bone using a Tungsten Carbide round bur (Dentsply HP Rd 8) until the cemento-enamel junction (CEJ) is visible. Start by sectioning the mesiodistal roots buccally at the CEJ so that the palatal root remains intact. This is performed by using a Tungsten Carbide fissure bur (Dentsply Taper 702). Mesial and distal roots are also separated by removing interradicular bone at trifurcation as a figure of T. Luxator number 3 (Hu-Friedy) can be used gently with finger movement to separate the mesial and distal roots from the remaining portion of the crown (Fig 3).

displacing roots into the sinus
Figure 3: Photograph after removal of mesiobuccal and distobuccal roots.

2.7. Gentle luxation separates the mesiobuccal and distobuccal root which then can be elevated leaving the palatal root and the portion of crown intact.

2.8. Full crown or upper premolar forceps can then be used to loosen the remaining palatal root with rotational movement. 

2.9. The socket is examined to see if there is any perforation of maxillary sinus floor before closure (Fig 4).

perforation of maxillary sinus floor
Figure 4: Photograph showing roots and crown.

2.10. Toileting of wound is completed, and closure is carried out with either 3/0 catgut or vicryl sutures (Ethicon, Somerville, New Jersey, USA) (Fig 5).

Surgical Removal Maxillary first second molars
Figure 5: Photograph post inspection and toileting of the socket.

2.11.  Appropriate post-operative analgesics, antibiotics and mouth wash should be prescribed. The patient may be provided with post-operative instructions, monojet syringe for home care and follow-up.

2.12. If required or indicated a post-surgical OPG or Periapical x-ray can be done to confirm complete removal (Fig 6).

Surgical Removal Maxillary first second molars
Figure 6: Orthopantomograph showing post extraction of tooth.

Discussion

Maxillary first and second molars are difficult and challenging to remove. Morphology of tooth, divergent roots, thin buccal plate and approximation of sinus floor makes surgical removal challenging. The technique described here is easy to learn and implement. 

It preserves bone and minimizes trauma as well as avoiding complications such as perforation of maxillary sinus floor. Handling of luxators is most important to avoid undue forces during the separation of roots and/or disjunction from the crown. 

This avoids displacing the roots into the maxillary sinus. It is important to check the socket for oro-antral communication before closure. It is advisable to take a post-surgical radiograph if in doubt for any missing root before discharging the patient. Most important not to use air rotor to section the tooth , this may lead to surgical emphysema.

Advantages of this technique are:

1. Easy to learn and implement

2. Patient’s comfort

3. Does not require special instruments

4. Preserves alveolar bone for a future replacement procedure

5. Chances of breaking roots are minimized

6. Less chances of a communication into the maxillary sinus or displacing roots into the sinus cavity.

Conclusion

Good pre-operative assessment clinically as well as radiographically is of prime importance before attempting removal of upper molar teeth. The success of the procedure depends on efficient planning, meticulous tissue handling and post-op care.

References 

1. Fatfat K, Mundra V. Extraction of a maxillary molar tooth -simplified (A case report). IOSR-JDMS 2017; 16:8: III, 61-65.

2. Bhargava V, Renton T. Routine Exodontia: Preventing failed extractions. Dent Update 2019; 46:866-879.


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