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Anaesthesia & Exodontia
Third Year


  1. 1. Extraction of Teeth ((Exodontia
  2. 2. Definition Main Topics :General considerations • Factors complicating dental extraction. • Indications. • Contraindications. • Preoperative assessment before extraction. :Methods and Techniques of dental extraction • Intra-alveolar (forceps extraction(. • Trans-alveolar (Surgical extraction(. Anatomical considerations .Extraction of deciduous teeth .Post-extraction procedures .Complications of dental extraction
  3. 3. Definition .–Tooth extraction The ideal tooth extraction is the painless removal of the whole tooth, or tooth-root, with minimal trauma to the investing tissues, so that the wound heals uneventfully and no postoperative .prosthetic problem is created
  4. 4. General considerations :Factors complicating dental extraction 1. 2. 3. 4. 5. 6. Restriction by the lips and cheeks. Movement of the tongue and macroglossi. Movement of the mandible. Communication of the mouth with the pharynx and larynx. Flooding of the oral cavity with micro-organisms. The related structures such as floor of the mouth, tongue, hard and soft palate, and even the tonsils may be damaged.
  5. 5. :Indications of teeth extraction 1. Unrestorative teeth because of anatomical or economical factors, which may be affected by: • • • • • • Deep caries. Severe abrasion. Acute or chronic pulpitis due to trauma or infection. Apical pathological conditions. Teeth interfering with the stability and fitness of dental restorations. Teeth causing chronic trauma or irritation to the soft tissues.
  6. 6. :Indications of teeth extraction 2. Severe periodontal disease. 3. Before radiation therapy in cancer patients. 4. Malposed, supernumerary, and crowded teeth. 5. Impacted teeth. 6. Traumatic avulsion or intrusion due to fracture of the alveolar bone. 7. Teeth involved in the fracture lines of the jaws.
  7. 7. Contraindications to the extraction of teeth Systemic contraindications before consultation with the patient’s :physician 1. Cardiac pt: Rheumatic heart disease. Coronary heart disease. 2. Blood dyscrasias: .Anemia. Leukemia 3. Diabetes. 4. Nephritis. 5. Toxic goiter. 6. Jaundice. 7. During pregnancy. :Local contraindications 1. Acute gingival or pericoronal infection. 2. Extraction of maxillary molars and premolars during acute maxillary sinusitis. 3. Teeth related to malignant tumors.
  8. 8. Preoperative assessment :Clinical examination 1. 2. 3. 4. Medical and dental history. Examination of the side of complaint. Examine the tooth condition. Examine the relation of the tooth to related important structures 5. Examine the condition of the oral hygiene.
  9. 9. Requirements of Pre-extraction Radiograph A-It should show the whole root structure B-It should show the bone investing C It should show the relation to any important anatomical structure Types of Radiograph : A-Intra-oral radiograph B-Extra-oral radiograph
  10. 10. Dental radiographs Requirements and Indications of dental radiographs: They are mainly indicated in the .following conditions 1.History of difficult extraction.
  11. 11. 2. Tooth abnormally resistant to forceps extraction.
  12. 12. . Teeth related to the maxillary antrum or inferior dental n
  13. 13. 4. Third molar teeth. 5. Heavily restored and pulpless teeth.
  14. 14. 6. Isolated upper molar for a long time.
  15. 15. 7. Any tooth has been subjected to trauma.
  16. 16. 8. Partially-erupted and un-erupted tooth. 9. Any tooth decided to be removed surgically.
  17. 17. 10. Any condition which predisposes to dental or alveolar abnormality.
  18. 18. .Values of dental radiographs :Types which commonly used .Intra-oral. 1
  19. 19. .Extra-oral. 2 Panoramic film
  20. 20. Postero-anterior (PA( view
  21. 21. Lateral view
  22. 22. Oblique lateral view Anterior Posterior
  23. 23. Occipto-mental view
  24. 24. . Choice of anesthesia . Sterilization : Methods of extraction • Intra-alveolar. • Trans-alveolar. : General arrangements • Position of the patient. • Position of the dentist. • Preoperative preparation of the mouth. : Mechanical principles of extraction • Expansion of the walls of the bony socket. • The use of a lever and fulcrum. • The insertion of wedge or wedges between the tooth-root and the bony socket wall.
  25. 25. Techniques of Extraction 1- INTRA-ALVEOLAR EXTRACTION FORCEPS or CONVENTIONAL This is by using dental forceps and elevators. 2- TRANS-ALVEOLAR EXTRACTION This is by using Surgical technique
  26. 26. Intra-alveolar extraction Forceps Elevator • Parts of the dental forceps: A, Blades. B, Joints. C, Handles. • Requirements of the dental forceps
  27. 27. Forceps Style American
  28. 28. English
  29. 29. Forceps design Upper forceps
  30. 30. Lower Forceps
  31. 31. Upper forceps Anterior Premolar R. Molar Premolar Anterior Bayonet Lower forceps Molar L. Molar
  32. 32. Requirement of the Dental Forceps INTRA-ALVEOLAR EXTRACTION    All forceps has blades and handles united by a hinge joint. 1-The handles must possess a suitable size to rest comfortably in the operator’ s hand and should long enough to afford use of strong and steady extraction movements. Also it must be suitable in shape and design to suit the area of the tooth.
  33. 33.  Upper Forceps  Upper Anterior Upper Premolar Upper Left Molar Upper Right Molar Bayonet Lower Forceps Lower Anterior Lower premolar Lower molar        
  34. 34. INTRA-ALVEOLAR EXTRACTION  2- The blades must be sharp to be introduce under the free gum margin. In multirooted teeth the blades should be designed to grip the different root patterns  The angulation design of the blades in relation to the joint and handles should be made to facilitate gripping of the tooth at CEJ
  35. 35.  3-The joint of the dental forceps must have free movement for easy manipulation but must be free from rolling movement Parts of dental forceps A-Blades B-Joint C-Handles
  36. 36. Tooth Extraction Forceps  Instruments are varied based on  Crown shape  Root shape  Tooth size  Location in the mouth  Distinguished by  Angle of and notches on the beak  Instrument contour  Number
  37. 37. Proper selection of the suitable forceps Maxillary teeth  Mandibular teeth  Single rooted teeth  Double rooted teeth  Triple rooted teeth 
  38. 38. Types of Dental :Forceps .Straight e.g. 1 Upper anterior .Curved e.g. 2 All lowers and upper posteriors
  39. 39. Periosteal Elevators  Used to separate and retract soft tissue from teeth and bone. Molt 9 Woodson 1 Freer elevator
  40. 40. Rules of using dental forceps  1-The patient is seated comfortably in the chair after adjusting the chair to the appropriate height , the apron fitted around the patient and aseptic technique should be followed , inspecting the tooth to be extracted and the instruments required for operation are selected
  41. 41. Rules of using dental forceps  2-The forceps are then picked up in the operator’ s right hand with the thumb finger supporting it at its joint and the forceps handles in the palm of the hand this position gives the operator firm grip and fine control over the instrument
  42. 42. Rules of using dental forceps  In the upper molar and premolar forceps the curved side of the handles should rest in the palm of the hand  3-In extraction of maxillary teeth , retract the lip and cheek and support the alveolar process using the thumb and index finger of the left hand  4-In extraction of the left mandibular teeth , the middle and the index fingers of the left hand grips and supports the alveolar process around the tooth being extracted, while the thumb is used to support the mandible
  43. 43. Rules of using dental forceps  In extraction of the right mandibular teeth the operator should stand at the right side and behind the chair and the left hand comes from the other side to support the alveolus with the thumb and index fingers while the other fingers support the mandible
  44. 44. Rules of using dental forceps  The displacement of the tooth from its socket : When the blades have been forced along the root with firm grip and the tooth movement buccal outward and lingual inward with pressure that should be firm smooth and controlled  Accordingly the outward movement is initiated in the extraction of all the maxillary and mandibular teeth with exception of mandibular third and relatively mandibular second molars .  Inward movement is initiated in the extraction of lower 2 nd and 3rd molars due to the fact that the lingual alveolar bone plate is thinner than in the buccal plate .As a general rule the movement is initiated towards the least resistance site.
  45. 45. Rules of using dental forceps  However there might be some deviation from the general rule , when the tooth is involved in very deep decay or abnormal configuration of root .  In deeply decayed teeth it is advisable to initiate the extraction movement towards the decayed side of the tooth and keeping the force of movement more stressed towards decayed side
  46. 46. Rules of using dental forceps  In extraction of teeth with conical roots which usually the upper central incisors and the lower second premolars and mesiodens, these teeth could be detached from their sockets by primary rotatory movement. If such a tooth felt to resist rotation it should be moved buccolingually.  Also rotatory secondary movement could be used after the tooth has been completely loosened.
  47. 47. Rules of using dental forceps  The final movement of the tooth: normally after few buccolingual movements, the tooth is felt to have been loosened and rising out of its socket , when this occurs the final movement should always be directed outward in order to avoid traumatizing the teeth of opposing jaw.  If gum is found to be attached to the tooth this adhesion should be carefully dissected and avoid pulling of the tooth by dental forceps to avoid soft tissue laceration and exposure of the alveolar bone
  48. 48.  Extraction of maxillary incisors  A-Apical grip  B-Labial movement  C-Palatal movement  D,E-Dilation of the socket and final delivery
  49. 49.  Extraction of maxillary  premolars:     A-Apical grip B-Labial movement C-Palatal movement D,E-Dilation of the socket and final delivery
  50. 50.  Extraction of maxillary molars:  A-Apical grip  B-Labial movement  C-Palatal movement  D,E-Dilation of the socket and final delivery
  51. 51.  Extraction of mandibular Incisors :  A-Apical grip  B-Labial movement  C- Lingual movement  D,E-Dilation of the socket and final delivery
  52. 52.  Extraction of mandibular  premolar :  A-Apical grip  B-Labial movement  C-Lingual movement  D-Primary rotatory movement in 2nd premolar only  E,F-Dilation of the socket and final delivery
  53. 53.      Extraction of mandibular molar : A-Apical grip B-Buccal movement C- Lingual movement D,E-Dilation of the socket and final delivery
  54. 54. Rules of using dental forceps • Catch the root not the crown • Parallel to the long axis of the tooth • Initial movement • Deep grip • Firm grip • Principal movement • Final movement
  55. 55. Mechanical principles involved in tooth extractions Applying displacing force to a tooth: Direct application of a forceps Indirect via a fulcrum (elevators) Expansion of the socket
  56. 56. Technique of Forceps Extraction 1- Position of the Operator
  57. 57. Grip of the- 2 extraction forceps Wright Wrong Wright Wrong Wrong
  58. 58. Application of the Forceps - 3 ( (Grip of the tooth
  59. 59. Proper function and Position of Left Hand- 4
  60. 60. Mechanical principles of forceps extraction Wedging Expansion of socket walls
  61. 61. Extraction movements
  62. 62. Anatomical Considerations The Upper Anteriors Central incisor Lateral incisor Canine
  63. 63. The Upper Posteriors First Premolar First Molar Second Premolar Second Molar Third Molar
  64. 64. The Lower Teeth Incisors Canine Premolars
  65. 65. First Molar Second Molar Third Molar
  66. 66. Extraction of maxillary molars
  67. 67. Extraction of mandibular 1st & 2nd molars
  68. 68. • Post-extraction Procedures (Recommendations( • Order of Extraction • Extraction of deciduous teeth:
  69. 69. … Take time to laugh It is the music of the !heart
  70. 70. Removal of Fractured Root  Fractured root should be removed at the time of extraction because it may cause the following complication:  1-Large roots in the alveolus will be localized source of inflammation  2-It may cause residual infection  3-RR may act as a mechanical irritant and set up an inflammatory reaction which may give rise to neuralgic pain of obscure origin
  71. 71. Reason of Root Breakage 1-Faulty application of instruments or extraction movements, wrong pattern forceps on a particular tooth may cause its breakage. Improper grip , inadequate extraction movements. Sudden or jerky extraction movement, gripping of the crown too superficially and not at CEJ
  72. 72. Reason of Root Breakage 2-Pulpless teeth, badly decayed, teeth with abnormal root pattern or Hypercementosis 3-Excessive density of the surrounding bone due condensing osteitis , or isolated tooth and in old age patient 4-Lake of perfect control of instrument or interference from the patient
  73. 73. Removal of broken single rooted teeth • This includes the maxillary incisors and canines and mandibular incisors, canines and premolars: • Removal of Roots Broken at the Gingival Margin: • A-These root may be extracted with forceps , with careful adaptation of the beaks under the gingival margin • B-Straight Apexo elevator or Coupland .The angulated Apexo elevator used to remove mandibular single rooted teeth apply moderate force distal as will as mesial of the root till complete delivery of the RR
  74. 74. Removal of the root broken halfway of the apex • Generally, these are the cases which require the reflection of mucoperiosteal flap and removal of buccal and lingual alveolar bone what we call it TRANS-ALVEOLAR SURGICAL EXTRACTION
  75. 75. Take the time to … !hear It is the power of Intelligence
  76. 76. Removal of Roots of Upper and Lower Molars • 1-Removal of Broken Root of Mandibular Molars : 1-When both roots are fractured at the gingival line , the root trunk is still present a lower premolar forceps can be used, its beaks should be inserted as far under the gingival margin
  77. 77. Removal of Roots of Upper and Lower Molars • 2-The other technique for removal of such roots is a drill used to separate the roots after this Apexo elevator may be used to loosen the mesial root by inserting it into a space between the lamia dura and the surface of the root from the mesial and distal surfaces until loosening of the root occur . The other root could extracted by using Winter or Cryer elevators
  78. 78. Removal of Broken Roots of Maxillary Molars • Maxillary molars roots may be removed by grasping the palatal and the distobuccal roots with the upper roots forceps or with Bayonet Forceps . • This procedure will either remove all three roots or cause breaking of mesiobuccal root which then can be removed by upper root forceps or with Warwick James curved elevator inserted into empty disto-buccal socket
  79. 79. Removal of Broken Roots of Maxillary Molars • Another technique is first to separate the fused roots with drill in the form of “ Y “ shape and then remove them individually by mean of forceps or by Warwick James curved elevator between the separated roots.
  80. 80. … Take time to Love It is the secret of !eternal youth
  81. 81. Post-extraction care and instructions
  82. 82. Post-extraction care • Inspection of the socket • Removal of debris and any tooth fragments • Squeezing the socket • Insuring haemostasis (Gauze pack) • Remove any septic granulation tissue or granuloma from the socket • Trim and smooth any sharp edges from the alveolar plate of bone • Clean the patient lips and face.
  83. 83. Post-extraction Instructions 1-Keep biting on gauze, sponges for about one hour after extraction, by the time if bleeding is controlled, discontinue pressure pack 2-No mouth wash for at least 24 hours after extraction 3-Avoid any hot food or drink for the rest of the day to prevent bleeding 4-The diet must be cold fluids or soft food to avoid irritation of the wound 5-Avoid any hard labour and have an adequate rest
  84. 84. Dental Elevators
  85. 85. Use of Elevators in Extraction of Teeth .Parts of Elevator :Work Principles • Levering. • Wedging. • Wheel and Axle principle.
  86. 86. Wheel & Axle Wedging
  87. 87. Rules • Palm grip • Don’t use the neighbouring tooth as a fulcrum • Don’t use the buccal or lingual plate of bone as a fulcrum • Use the left hand for reflection, guard and support • Take care of the surrounding vital structures • Follow respectfully, root curvature
  88. 88. Principles of Use of Elevator • Wedge principle: straight elevator • Lever principle: Copland elevator • Axel and Wheel principle: Cryer’s elevator
  89. 89. Principles of Use of Elevator Wedge Principle Some elevators are designed primarily to be used as a wedge e.g. Apexo,and coupland. This elevators are forced between the root of the tooth and the investing bony tissue parallel to the long axis of the tooth
  90. 90. Principles of Use of Elevator Lever Principle: On applying this principle the elevator is a lever of the first class the position of the fulcrum is between the effort and resistance in order to obtain a mechanical advantage in a lever of the first class the effort arm on one side of the fulcrum, must be longer than the resistance arm
  91. 91. Principles of Use of Elevator Wheel and Axle Principle The wheel and axle is a simple machine the effort is applied to the circumference of a wheel which turn the axle so as to raise a weight. It could be used as a sole work principle in removing the teeth, it is also used in conjunction with a wedge or lever principles
  92. 92. :Classification •According to Form. •According to Use. Different Forms of Elevators
  93. 93. Handling and Application of the Elevator
  94. 94. Dental Elevators • Parts of Elevators: 1-Handle 2-Shank 3-Blade
  95. 95. Dental Elevators Classification • I-According to use: 1-Elevators designed to remove the entire tooth, straight elevators, hospital pattern and winter elevator 2-Elevators designed to remove roots broken off at the gingival line e.g. Apexo elevator , Coupland and lido lavien elevators 3-Elevators designed to remove roots broken off half way to the apex e.g. curved elevator hospital pattern, winter elevator and Apexo elevator
  96. 96. Dental Elevators Classification • II-According to Form: 1-Straight all types 2-Curved right and left 3-angulated right and left 4-Cross bar “ handle at right angle to the shank”
  97. 97. Types of Dental :Elevators .Straight e.g. 1 Copland's .Curved e.g. 2 Cryer’s
  98. 98. Root Elevators • Used to loosen and frequently remove teeth and roots. – a small straight elevator – a large straight elevator –
  99. 99. Dental Elevator ”Cross bar “winter Curved apexo
  100. 100. Choice of elevators • • • • Remaining tooth structure Space available Availability and position of solid fulcrum Direction of the required movement
  101. 101. Characteristics • Has no joints • Needs a fulcrum to work • Has to be wedged between bone and tooth • Exerts less directional force on the tooth • Different sizes and shapes
  102. 102. Indications of use  Breaking down the periodontal attachment  Luxation or removal of full tooth  Luxation and removal of remaining roots  Bone removal  Mucoperiosteal elevation
  103. 103. Danger in the Use of Elevators      1-Loosening or extracting the adjacent teeth 2-Fracture the alveolar process or fracturing the mandible 3-Penetrating the maxillary antrum or forcing the root into the antrum 4-Forcing a root a root of a mandibular molar through lingual plate of the mandible 5-Damage of soft tissues by slipping of the tip of the elevator
  104. 104. Point to remember in extraction of teeth  Never refer to the extraction of tooth as a “simple extraction”. You may find yourself in the embarrassing position of trying to explain to the patient why this simple extraction taking so much time and effort  Anticipate breakage by knowing all reason why root and crown break. Forewarn the patient of the possibility of breakage or fracture
  105. 105. .Rules in the use of Elevators .Dangers in the use of Elevators
  106. 106. Removal of Fractured Roots .Reasons for Removal .Reasons of Root Breakage .Techniques of Root Removal