Exodontia /certified fixed orthodontic courses by Indian dental academy

EXODONTIA
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

EXTRACTION:
Is defined as 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 post-operative prosthetic problem is
created.


OBJECTIVES:
•Severe the periodontal attachments carefully
•Lever the tooth out of the alveolar socket without damaging
adjoining structures and anatomical areas.


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A good radiograph
Adequate anesthesia
Instruments
Adequate illumination
Efficient assistance
Suction apparatus


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To gain adequate access and to obtain secured grip on the
tooth
To apply controlled force in a predetermined direction
To severe the dentoalveolar bondage with minimum trauma
To safely deliver the tooth in-toto out of the socket through an
uninterrupted path of removal with minimum pain and
discomfort to the patient.


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Severe caries or pulpal necrosis
Severe periodontal disease
Therapeutic extraction in orthodontic Rx
Impacted,malposed or supernumerary teeth
Teeth prior to irradiation
Retained decidious teeth
Preprosthetic extractions
Teeth in line of fractures
Infected teeth or teeth associated with pathologic lesions
# tooth/root,teeth which are foci of sepsis


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ABSOLUTE
RELATIVE
SYSTEMIC
LOCAL


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Uncontrolled metabolic diseases like diabetes mellitus,end
stage renal disease
Bleeding disorders like hemophilia,platelet
disorders,uncontrolled leukemias,lymphomas
Severe MI,unstable angina pectoris,uncontrolled hypertension
Acute adrenaline crisis,long term steroid therapy
First and third trimester of pregnancy
Toxic goitre,liver disorders


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Tooth in irradiated area
Tooth in area of malignant tumour
Third molars with severe pericoronitis
Pathology like AV malformation of bone,central hemangioma
Acute abscess


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CLOSED METHOD/FORCEPS EXTRACTION/INTRAALVEOLAR EXTRACTION-consists of removing the tooth
or root by use of forceps or elevators or both

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OPEN METHOD/SURGICAL/TRANS-ALVEOLAR
EXTRACTION-consists of dissecting the tooth or root from
bony attachments by removal of some bone investing the
tooth/roots,which are then delivered by use of elevators and/or
forceps


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Access to the tooth
Mobility of the tooth
Condition of the crown of the tooth
Condition of the adjacent tooth


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IOPA with accurate and detailed information concerning the
tooth,its roots,and surrounding tissues is preffered.
Relationship of associated vital structures
Configuration of roots
Condition of the surrounding bone


EXTRACTION OF MAXILLARY TEETH


EXTRACTION OF MANDIBULAR TEETH

THIRD QUADRANT

FOURTH QUADRANT


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In maxilla ,index finger and thumb of left hand is used to support
the maxilla and rest 3 fingers to stabilize patient’s head
In mandible,index and middle finger is used to retract and support
intraorally ,while thumb supports the mandible.If dentist is standing
behind the patient then thumb and index finger is used intraorally
and rest 3 fingers support mandible.
Retraction of lips,cheek and tongue
Guiding beaks of forceps onto tooth
Couteracting the pressure applied
Prevention and protection against slipping of forceps
Prevent broken fillings or tooth fragments before it reaches
oropharynx
Compressing buccal and lingual cortical plates
Examination of surgical field for bony edges,undercuts

1. LEVER PRINCIPLE OF FIRST ORDER:
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3 basic components-fulcrum,effort,load
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Fulcrum is b/n effort and load
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Maximum advantage is when effort arm
is longer than load arm
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Used in forceps along with wheel and
axle and in elevators


2. WEDGE PRINCIPLE:
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Here 2 movable inclined planes with a base on one end and
blade on other end
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Effort is applied to the base of the plane and resistance has
its effect on slant side
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Used to split,expand or displace the portion that receives it
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Elevators to luxate tooth when applied b/n bone and tooth
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Forceps when inserted b/n mucoperiosteum and surface of
tooth


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WHEEL AND AXLE PRINCIPLE:
Effort is applied to circumference of
wheel which turns the axle so as to
raise the weight
Greater the diameter of wheel more is
the mechanical advantage
Used in crossbar elevators for removal
of mandibular roots
Forceps –applied in the form of arc


Forceps can be applied in five major motions.
1.Apical pressure
2.Buccal pressure
3.Lingual pressure
4.Rotational pressure
5.Tractional pressure


1.Adequate anesthesia
2.Loosening of soft tissue attachment
from the tooth
-using woodson elevator or sharp end of
no.9 periosteal elevator
3.Luxation of tooth with a dental elevator
4.Adaptation of forceps to the tooth
5.Luxation of tooth with forceps
6.Removal of tooth from the socket


First is the apical force.
• Central incisors-labial pressure,lingual,then labial with mesial
rotation
• Lateral incisors-labial with mesial rotation
• Cuspids-labial,lingual,labial with mesial rotation
• 1st PM-Buccal,lingual,removal in buccal direction
• 2nd PM-Buccal,lingual,removal in lingual or buccal direction
• 1st &2nd molar-buccal,lingual & removal in buccal direction
• 3rd molar-buccal & distal rotation


First is the apical force.
• Central & lateral incisors-labial,lingual,slight mesio-distal &
removal in labial direction
• Cuspids-labial pressure with mesial rotation
• 1st & 2nd PM-Buccal pressure with slight mesio-distal rotation
• 1st,2nd & 3rd molar-buccal,lingual & removal in buccal
direction


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Saline or betadine irrigation
Thorough curettage in case of periapical lesion
Compress bucco-lingual plates with finger pressure
In case of severe periodontitis excessive granulation tissue
must be removed
Sharp bony projections if any must be smoothened with bone
file
Gauze pressure pack for control of bleeding


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Explain the patient effects of LA
Hold the gauze in mouth for atleat half an hour
Avoid spitting and gargling for the day
Warm saline rinses after 24hrs
Not to disturb the area with finger or tongue
Avoid hot,spicy and hard food
Analgesics ,antiinflammatory for 3 days
Antibiotics if patient is immunocompromised
Avoid brushing in the area for 24hrs


1.Operator’s fault-application of incorrect instrument and force
-improper technique of application
-improper motions
2.Structural abnormality of tooth-excessively curved roots
-RC treated nonvital tooth
-teeth with gross filling
-extensively carious teeth
-ankylosis or hypercementosis
3.Surrounding bone-sclerosis or condensing osteitis
4.Unco-operative patient


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Retained roots might prove as a source
of infection,chronic irritation giving rise
to neuralgic pain or might interfere
with proper functioning of denture
Excellent light and suction
Closed technique when tooth is well
luxated and mobile before fracture
Root tip pick,small elevator,forceps
with slender beaks,reamers
If not then open method should be
attempted


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First is usually maxillary teeth as they get anesthetized earlier
and prevents fall of enamel or amalgam/debris into mandibular
socket
Most posterior teeth is extracted first
The order is 3rd molar,2nd molar,2nd premolar,1st molar,1st
premolar,lateral incisor,canine,central incisor.


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Indications-gross caries involving pulp
-retained primary teeth interfering with normal
eruption of permanent successor
-periapical pathology/root fracture
Technique -smaller forceps
-for U/L anteriors labial pressure with mesial
rotation and removed to labial side
-for U/L molars buccal pressure ,lingual pressure
and removed to lingual side
-force applied is less and forcep need not be
inserted too deep along the root
-care should be taken not to damage permanent
successor

INDICATIONS:
• Any tooth which resists attempt at closed extraction
• Heavy/dense bone,short clinical crown due to attrition
• Hypercementosis,ankylosis,geminated & dilacerated roots
• Impacted tooth
• Retained fractured tooth/roots which cannot be grasped with
forceps or elevators
• Roots in close proximity with vital structures like nerve or
sinus
• Grossly destructed,heavily restored,RCTreated
• Prosthetic considerations


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Anesthesia-LA,plan for incision
Elevation of mucoperiosteal flap
Removal of bone-chisel mallet or bur
Division of tooth if required
Removal of tooth and roots
Control of bleeding
Alveoloplasty if required
Toileting of the alveolar socket
Suturing of flap


The term local flap indicates a section of soft tissue that
• Is outlined by a surgical incision
• Carries its own blood supply
• Allows surgical access to underlying tissues
• Can be replaced in the original position
• Can be maintained with sutures and is expected to heal


1. ENVELOPE FLAP:most common flap
-2 teeth anterior and one teeth posterior to
area of surgery
-releasing incision 1 tooth ant and 1 tooth post
-3 cornered or 4 cornered
2. SEMILUNAR :to approach root apex
-avoids trauma to papilla & gingival margin
-limited access,used in periapical surgery
-should not cross canine eminence
3. Y INCISION:palatal tori,preserves greater
palatine artery


-no.15 blade is used on a no.3 scalpel handle
and held in a pen grasp
-blade is held at an angle & incision is made
posteriorly to anterior in gingival sulcus
-smooth,continuous stroke with blade in
contact with bone
-if vertical incision is to be placed ,tissue is
apically reflected,with opp hand tensing the
alveolar mucosa


-start reflecting from papilla using woodson
elevator or sharp end of no.9 periosteal
elevator
-carried out in pushing stroke,posteriorly
and apically
-once reflected flap is held with seldin or
minnesota or austin retractor retsing firmly on
sound bone.


Bone removal must be limited carried out with dental burs or
chisel with hand or mallet pressure
CHISEL & MALLET:
• Quicker and cleaner
• Maxillary buccal and lingual plates can be removed
• Limiting cuts are placed vertically and then joined by
horizontal cut
• If force is not controlled it might lead to fracture of basal bone
or adjacent teeth
DENTAL BURS:
• Used for dense mandibular bone
• Round bur no.8 or rose head burs are used,cut efficiently,do
not clog,easier to control.
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flap must be held away from the site with a retractor
Bur must not be allowed to overheat during bone
removal,frequent irrigations with sterile normal saline should
be used to prevent this and also removes debris and prevent
bur from clogging
Bone might be removed by either simply cutting it away or by
bone guttering.
A row of small holes is made with small bur along buccal
crest and joined with fissure bur or chisel cuts.A gutter is
formed.This is called postage stamp method.
In case of lower PM,bone removal should be maximal medial
to 1st PM and distal to 2nd PM to minimize damage to nerve &
vessels traversing mental foramen


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Accomplished with a straight hand piece with a straight bur
such as no.8 round bur or fissure bur no.557 or no.703
Sectioning is done from below upwards so that operator
knows when the roots are completely divided


Root fragment must be small,not more than 3-4mm
• It must be deeply embedded in bone,to prevent subsequent
bone resorption from exposing tooth root & interfering with
prosthesis.
• Must not be infected & no radiolucency around root apex than
The risk of surgery must be greater than benefit such as:
• Removal causes excessive destruction of surroundin
tissue,bone or gingiva
• Endangers vital structures like inf alveolar nerve
• There are chances of displacing root into tissue spaces or into
maxillary sinus
Patient must be informed about the judgement and consent must
be obtained.
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Check for sharp bony edges and filng has to be done.
Currettage if there is periapical lesion
Thorough irrigation with normal saline/betadine.
Most inferior portion of flap is common place for debris to
settle especially in mandibular extractions which causes
delayed healing or even small subperiosteal abscess in 3-4
days
Flap is then set in original position & sutured in place with 3-0
black silk sutures
Pressure pack is placed


Similar to that for closed method
• Inform the patient about swelling
• Antibiotics & analgesics
• Cold pack application may be advised
Recall the patient after 5 days for suture removal and access the
healing.
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Presurgical assessment of the patient includes evaluation of
level of anxiety,determination of health status and necessary
modifications of routine procedures,evaluation of clinical
presentation of tooth to be removed,and radiographic
evaluation of tooth root and bone.
All four factors must be weighed when estimating difficulty of
extraction and least traumatic and efficient tooth removal
should be performed.


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CONTEMPORARY ORAL AND MAXILLOFACIAL
SURGERY-4th ed;LARRY.J.PETERSON
THE EXTRACTION OF TEETH-GEOFFREY.L.HOWE
ORAL AND MAXILLOFACIAL SURGERY-5th ed;W.HARRY
ARCHER
TEXTBOOK OF ORAL AND MAXILLOFACIAL
SURGERY-BALAJI


Leader in continuing dental education


Exodontia /certified fixed orthodontic courses by Indian dental academy

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