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Look Before You Leap: Lessons from the Field Jay B. Reznick, DMD, MD, Diplomate, American Board of Oral and Maxillofacial Surgery continued on

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The aphorism “no good deed goes unpunished” certainly applies to the clinical practice of dentistry. How often are we persuaded to do a “favor” for a patient when we know it is against our better judgment, only to have a less than ideal result ensue?

Case Presentation

A healthy, 32-year-old man presented to my office on emergency referral from his general dentist. He was at his dentist’s office for his regularly scheduled six-month recall with the dental hygienist. He mentioned to her that he had been having occasional intermittent pain in the left third molar region over the last few months. She examined this area and noticed swelling and redness of the operculum over the distal half of tooth number 17. A periodontal probe confirmed a 6mm pocket on the distal aspect of the tooth. At the end of her treatment, the hygienist called over the dentist, who is a smart, skilled, high-quality practitioner, and a friend of mine. He diagnosed pericoronitis and recommended to the patient the he be placed on antibiotics and referred to my office for removal of the problematic tooth, as well as evaluation of the other third molars.

The patient was amenable to this, but the hygienist had a “better” idea. She suggested to the dentist that he remove the tooth while the patient was in the office, since it “looks easy” and he had the time to do it. He was convinced, and proceeded to give local anesthesia and remove the tooth. About an hour later, the crown was off, but the roots would not budge. A call was made to my office and the patient was sent right over. A cone beam CT scan was obtained in the GP office, and this was sent to me with the patient via a CD.

On examination, the extraction site looked to have a small incision, with some minor soft-tissue trauma and inflammation (Fig. 1). On the cone beam CT scan, you could see the two roots of tooth #17, with a large radiolucent area distal to where the crown was located. It was fairly round and located distal to where the crown of tooth #17 had been. This scan shows the remaining roots quite well, as well as the approximate location of the mandibular nerve. An incidental finding here is an elongated, calcified stylohyoid ligament. When this presents with symptoms of unilateral sore throat, difficulty swallowing, unilateral neck or facial pain, tinnitus or ear pain, it is referred to as “Eagle Syndrome (Fig. 2). I called the dentist and asked if he had noticed an area of radiolucency behind tooth #17, as I would like to know whether this was due to pathology versus surgical trauma. He said he was unaware of a lesion and would send over the pre-operative radiographs.



The patient was sent home with a prescription for cephalexin 750mg BID (#12) and chlorhexidine oral rinse BID (16oz), and returned the next morning for removal of tooth #17 under general anesthesia. The procedure was uneventful. The root was removed without complication and the patient was sent home with instructions to continue the chlorhexidine and cephalexin, maintain a soft diet, apply ice packs intermittently for the first day and to return in one week. He reported some pain for a day, but otherwise had an easy recovery. Our postoperative radiograph showed complete removal of the roots (Fig. 3).

Discussion

I mentioned that the patient’s dentist was sending over the pre-op images of tooth #17 so that we could evaluate whether there had been any pathology distal to the area. Two radiographic images were e-mailed over. The first (Fig. 4) was a bitewing that was probably taken some time before, as it showed Class II carious lesions, which were now restored. Less than half of the crown of tooth #17 was visible, and even less of the roots. The other radiograph was more current, as teeth #18 and #19 were restored (Fig. 5). Only a very small portion of the mesial root of tooth #17 was visualized, and there was a distinct shadow of what may be the mandibular nerve overlapping the root tips. So, the question of pathology associated with tooth #17 remains unanswered.

While these radiographs may be acceptable for diagnosis of dental disease, they are unfortunately not acceptable as pre-operative radiographs for the removal of teeth, especially third molars. The standard of care for preoperative imaging prior to removal of teeth is meant to facilitate surgery, protect our patients and keep us out of trouble (Fig. 6). It has been developed over many years of practice and many times in the courtroom.

The first requirement is that it shows the current clinical condition of the tooth to be removed. This helps to justify the procedure, should an issue develop, and it also demonstrates any anatomical variations that may be present, which could modify the surgical technique used. It also needs to show the entire root and periapical region, as well as the relationship to the mandibular nerve and/or maxillary sinus, for upper and lower teeth, respectively. It may be difficult to capture these areas with periapical radiographs, and if they are not clearly visualized, then a panoramic radiograph is indicated. If there is intimate proximity to the mandibular nerve or sinus and the exact relationship cannot be determined from existing images, then a cone beam CT scan may be required to satisfy this need.

I mentioned that the patient was sent home on antibiotics and analgesic and returned for surgery. There are a number of patient management issues here. The first is that the patient has had a long morning and is traumatized from spending an hour in the dental chair getting part of a tooth out. The prospect of another procedure is stressful for most patients, and so being able to offer to complete the procedure under general anesthesia is usually a great relief and patients will rarely refuse.

Another reason has to do with risk management for the subsequently treating specialist. Just imagine that the remainder of the tooth was removed right away, and postoperatively the patient complains of a numb lip or tongue. If the patient had still been numb from the first local anesthetic, it would not be possible to tell if the injury occurred at the general dental office or in the specialist’s office. For that reason, it is recommended by most liability carriers, that the local anesthetic be allowed to wear off completely, and the nerve status assessed, before a further attempt to remove the tooth is made.

Another issue to discuss is one of informed consent. Surgical removal of an impacted tooth requires a discussion with the patient of the nature of the procedure, and the most common potential risks and complications, as well as the alternatives to surgery and the risks of not having surgery. The option of being seen by a specialist should also be discussed. If the general practitioner will be performing the procedure, then the full requirement of informed consent falls on his/her shoulders. If the patient will be going to the specialist, then the bulk of the discussion will be in the specialty office. In addition to having inadequate pre-operative radiographs of the teeth themselves, we are still unsure whether there was any pre-existing pathology distal to tooth #17. We will be able to address that in surgery.

So, now the surgery itself. Why did the dentist, who has successfully taken out hundreds of teeth, fail at completing removal of what looked like should be a straightforward extraction? Looking back at figure 1 might give the first clue. It appears there was minimal flap development, so that access and visualization of the surgical field was inadequate for the procedure. One of the first things I teach in my lectures is the importance of adequate exposure and access to the surgical field. In this case, I started with a sulcular incision and distal release so that the tooth and surrounding anatomy could be clearly seen (Fig. 7). Irrigation and curettage is necessary to get a clear view of the area. I also recommend using a headlight and loupes, so you can really see the surgical field and what you are doing.

In order to remove the roots, which were completely below the bone level, I make a trough with a surgical bur in a surgical handpiece along the buccal of the root. This gives you a purchase point for elevation of the root, as well as reducing the interference to removal. The elevator is placed between the root and the dense buccal bone (Fig. 8). As you may be able to appreciate in the clinical image, there was a large bony defect, as seen in one of the radiographs. This area was explored at surgery and no cystic or solid tissue was present. So, we can assume that this was due to surgical bone removal.

Another potential downfall for the dentist in this case is not having the right instruments. Just as there are instruments that facilitate restorative procedures, there are instruments beyond the basic straight elevator and universal forceps that become familiar in residency to oral surgeons. Before beginning potential surgical extractions, I would recommend becoming familiar with a few of these intruments. It makes surgery much easier and less stressful.

And lastly, if you are doing surgery, invest in a rear-venting or electric surgical handpiece. It will be much more proficient at cutting bone and sectioning teeth and does not carry the risk of causing a subcutaneous air emphysema.

As you have seen here, surgery is much more than just “taking out a tooth.” It requires evaluation and planning to do it well. It involves understanding the anatomy and having clear radiographic and clinical visualization of the surgical field. Even when things don’t work out as planned, we can still learn a lot from a critical evaluation of why it happened and how the situation was remedied. As the cliché goes, that is why we call it “practice.” The other message to take home is next time your hygienist convinces you that a procedure looks easy… let her do it!

The video version of this case presentation can be found at OnlineOralSurgery.com.


Dr. Reznick is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his Dental degree from Tufts University, and his MD degree from the University of Southern California, and trained in Oral and Maxillofacial Surgery at L.A. County- USC Medical Center. His special clinical interests are in the areas of facial trauma, jaw and oral pathology, dental implantology, sleep disorders medicine, laser surgery and jaw deformities. He also has expertise in the integration of digital photography and 3-D imaging in clinical practice. Dr. Reznick is one of the founders of the website OnlineOralSurgery.com, which educates practicing dentists in basic and advanced oral surgery techniques. He is the Director of the Southern California Center for Oral and Facial Surgery in Tarzana, California. He can be reached at jreznick@sccofs.com.
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