Principles of Exodontia


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Anaesthesia & Exodontia
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Principles of Exodontia

  1. 1. ‫سبحان ال وبحمده سبحان ال العظيم‬ Principles of Exodontia Lec. # 4 Dr. Adel I Abdelhady )BDS, MSC, (Egypt) PhD (USA , Egypt .Oral and Maxillofacial Surgery Dept .College of Dentistry, KSA 20/01/14
  2. 2. Principles of Exodontia Lec. # 4 20/01/14
  3. 3. 20/01/14
  4. 4. Preparations before exodontia Patient and surgeon preparation regarding proper position of the patient and proper standing of the operator. Chair position for forceps extraction 20/01/14
  5. 5. 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 Flaps technique with bone removal and tooth sectioning 20/01/14
  7. 7. 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. 20/01/14
  8. 8. Intra-alveolar Extraction Requirement of the Dental Forceps 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 20/01/14
  9. 9. 3-The joint of the dental forceps must have free movement for easy manipulation but must be free from rolling movement 20/01/14
  10. 10. Upper Forceps Upper Anterior central; lateral incisors and canine teeth Upper Premolar Upper Left Molar Upper Right Molar Bayonet Forceps for wisdom teeth  Lower Forceps Lower Anterior Lower premolar Lower molar 20/01/14
  11. 11. Preparations before exodontia • Patient and surgeon preparation • Patient and surgeon position for forceps extraction 20/01/14
  12. 12. EXTRACTION of TEETH Forceps These have two blades with sharp edges to cut the periodontal fibers. The blades are wedgeshaped to dilate the socket and are hollowed on their inner surface to fit the roots The blades are hinged which allows them to close and grasp the root the handle act as a lever which gives the operator a mechanical advantage. The farther from the blades the surgeon grasps the handles the less effort he will have to make to apply force to the tooth. 20/01/14
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  14. 14. Extraction of teeth with forceps The extraction of teeth is a surgical operation based primarily on an anatomical appreciation of their attachment in the jaw. First the soft tissues of the gingival attachment and periodontal membrane are cut to separate the tooth from the bone . Next the socket is dilated by moving the root to expand its bony socket .Finally when the tooth is loose it may be drawn out of the alveolus .When completed with forceps extractions are performed in two movement. 20/01/14
  15. 15. Extraction of teeth with forceps First movement This is same in all teeth of both jaws the forceps are applied on the buccal and the palatal or lingual aspects of the tooth, regardless of whether it is normally or abnormally positioned in the arch. In multirooted teeth the blades must be kept on a root , not the bifurcation .The blades are passed carefully under the gingival margin of the tooth and driven up or down in the same plane as the long axis of the tooth to penetrate as far as possible 20/01/14
  16. 16. Role of left hand of operator 20/01/14
  17. 17. Extraction of teeth with forceps Considerable force is used particularly in the upper jaw. In the lower jaw this must be limited to that the operator can counteract by supporting the mandible with his free hand. Whilst driving up the root in this way the blades contact the root surface not gripping it. This movement cuts the gingival attachment and the wedge shaped blades to dilate the socket 20/01/14
  18. 18. Extraction of teeth with forceps Second movement : The 1st movement completed ,the blades of the forceps are closed to grasp the root and the second movement is performed which by moving the tooth roots using them to dilate further the socket , during this action, to prevent the blades slipping off the tooth , a firm vertical pressure up or down the long axis of the root must be maintained. Avoid use of excessive force and every effort is made to develop feeling through the forceps . This enables the surgeon to recognise to excursions in certain direction 20/01/14
  19. 19. The combined use of forceps and elevators The combined use of these instruments will facilitate the extraction the coupland elevator driven vertically up the long axis this will cut the periodontal attachment and dilate the bony socket on both buccal and lingual aspects and indicate if undue resistance is present 20/01/14
  20. 20. The combined use of forceps and elevators The supporting Hand The jaws should be adequately supported by free hand of the operator this particularly important in the lower jaw the other function of supporting hand is retraction of the cheek, tongue and lip .This done by placing the finger and thumb on each side of the gum on the buccal and lingual or palatal aspects of the tooth ,and also the operator is able to feel that the blades of the forceps are under the m.m. and the watching finger can feel any slipping of the forceps or any tendency of the 20/01/14 adjacent tooth to move
  21. 21. Extraction of Deciduous Teeth In general deciduous teeth are much easier to extract than the permanent ones But some factors may complicate their extraction: 1-Small mouth of the children patient 2-Permanent premolars are enclosed within the roots of their predecessors , deciduous molars have no root mass and caries often invades roots making it difficult to grip 20/01/14 them
  22. 22. Extraction of Deciduous Teeth 3-Pediatric forceps should be used 4-Care must be taken not to place the beaks of forceps deep down on the root of D. teeth because great possibility of removing the partially formed permanent teeth. 20/01/14
  23. 23. Hazard of Extraction of Primary teeth When this inadvertently happens, the partially formed tooth should be carefully freed from the primary roots and replaced in the alveolus , the soft tissues are then sutured over the alveolus to hold the bone and the tooth in position 20/01/14
  24. 24. Modifications for extraction of primary teeth • Thin diverged roots • Resorbed roots 20/01/14
  25. 25. Modifications for extraction of primary teeth • Successors • Inferior alveolar nerve • Resilient bone • Restricted access 20/01/14
  26. 26. Dental Elevators 20/01/14
  27. 27. Dental Elevators Parts of Elevators: 1-Blade 2-Shank 3-Handle 20/01/14
  28. 28. 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 20/01/14 and Apexo elevator
  29. 29. 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” 20/01/14
  30. 30. Types of Dental :Elevators .Straight e.g. 1 Copland's .Curved e.g. 2 Cryer’s 20/01/14
  31. 31. Root Elevators Used to loosen and frequently remove teeth and roots. – a small straight elevator 20/01/14 – a large straight elevator
  32. 32. Dental Elevator ”Cross bar “winter Hospital pattern Straight and curved Curved apexo 20/01/14
  33. 33. Choice of elevators Choice of elevators according to: • Remaining tooth structure • Space available • Availability and position of solid fulcrum • Direction of the required movement 20/01/14
  34. 34. 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 20/01/14
  35. 35. Indications of use • Breaking down the periodontal attachment • Luxation or removal of full tooth • Luxation and removal of remaining roots • Bone removal • Mucoperiosteal elevation 20/01/14
  36. 36. Mechanical Principles To obtain maximum mechanical advantage of the elevator the fulcrum should be near the point of resistance and the effort arm should be longer than resistance arm (Principle of class I levers ) 20/01/14
  37. 37. Rules of Use of Elevators • 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 20/01/14
  38. 38. Principles of Use of Elevator • Wedge principle: straight elevator • Lever principle: Copland elevator, straight elev. • Axel and Wheel principle: Cryer’s elevator 20/01/14
  39. 39. 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 20/01/14
  40. 40. 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 20/01/14
  41. 41. 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 20/01/14
  42. 42. 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 20/01/14
  43. 43. Elevation of teeth Wedge elevator between tooth and bone at neck of tooth and rotate handle with slight twisting, quarter-turn movement Observe for tooth movement Do not use excessive force •Crown fracture •Loosen adjacent teeth As tooth loosens, move elevator more into bone towards root end 20/01/14
  44. 44. Elevation of teeth Uses leverage at a mechanical advantage point used to luxate tooth in alveolar socket Movement of tooth expands alveolar bone to allow tooth to be removed Start with smaller elevator and move to larger as tooth luxates 20/01/14
  45. 45. 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 20/01/14
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  47. 47. Mechanical principles involved in tooth extractions • Removal of bone surrounding the root • Sectioning the tooth 20/01/14
  48. 48. … Take time to laugh It is the music of the !heart 20/01/14
  49. 49. 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 20/01/14
  50. 50. 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 20/01/14
  51. 51. 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 20/01/14
  52. 52. 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 20/01/14
  53. 53. 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 TRANSALVEOLAR SURGICAL EXTRACTION 20/01/14
  54. 54. Take the time to … !hear It is the power of Intelligence 20/01/14
  55. 55. 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 20/01/14
  56. 56. 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 20/01/14
  57. 57. 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 20/01/14
  58. 58. 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. 20/01/14
  59. 59. … Take time to cry It is the sign of a large !heart 20/01/14
  60. 60. … Take time to Love It is the secret of !eternal youth 20/01/14
  61. 61. 20/01/14
  62. 62. 20/01/14
  63. 63. Post-extraction care and instructions 20/01/14
  64. 64. 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. 20/01/14
  65. 65. 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 20/01/14
  66. 66. Post-extraction prescription • Pain killer (NSAI) • Mouth wash (warm salty water) • Antibiotics?! 20/01/14
  67. 67. Post-extraction instructions • Instruction leaflet • Food or drinks • Smoking • Rest • Pack • Emergency 20/01/14
  68. 68. Complications of exodontia • During anesthesia • During extraction • After extraction 20/01/14
  69. 69. Complications of exodontia  During extraction: • soft tissue laceration • Broken tooth • Haemorrhage • Oroantral communication • Luxation of the neighbouring tooth • TMJ problem • Fracture jaw • Tooth ingestion or aspiration 20/01/14
  70. 70. Complications of exodontia  Post extraction • Haemorrhage • Infection, dry socket • Pain • Numbness • Referred pain 20/01/14
  71. 71. 20/01/14
  72. 72. Dental Elevators 20/01/14