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Exodontia & Procedure

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  1. 1. Seminar PresentationPresented BySAHAL ABU
  2. 2.  Since the earliest period of history ,the extraction oftooth has been considered a very formidableprocedure by the layman. Many patients suffer from extractionfobia and areoften difficult to care for despite modern methods ofanesthesia. Many dentists still believe that speed is esential whenextracting teeth.INTRODUCTION
  3. 3.  The painless removal of the whole tooth,orroot,with minimal trauma to the investingtissues,so that the wound heals uneventtully &no post operative problem is created{ GEOFFRAY L HOWE}
  4. 4.  The first dentist was an Egyptian-HIS RE(3100BC) The history of dental extraction forceps is veryold and goes back to time of Aristotle(384 BC)where Aristotle described the mechanics of oralsurgery forceps.
  5. 5.  Intra-alveolar method- Also known as ‘forcepsextraction’ and consists of removing teeth withthe use of forceps/elevators.The blades of theseinstruments are forced down the peridontalmembrane between the tooth root and bonysocket. Trans-alveolar extraction-This method involvesthe disection of the tooth or root from its bonyattachments.This separation is achieved byremoval of some of the bone investing the rootswhich are then extracted by the use of forceps orelevators
  6. 6.  Severe Caries Pulpal Necrosis Peridontally week teeth Teeth in the line of radiation therapy Teeth in line of jaw fracture Fractured teeth Pathology associated with tooth Orthodontic treatmennt Maloposed teeth Retained decidous teeth Extraction due to prosthetic reason Impacted teeth
  7. 7.  Absolute Contraindication-Uncontrolled DiabetesLeukemiaRenal FailureLiver CirosisCardiac Failure
  8. 8.  Relative Cotnrdiaincations-DiabetesHypertensionBleeding DiasthesisPregnancyCardiac DiseaseImmunocompramised PatientPatient with liver dysfunction
  9. 9.  Local Contraindication-Accute infectionSevere CellulitisAccute pericronitisHemangioma
  10. 10.  Intra Oral Examination- It is the quickexamination of oral cavity- 1st soft tissue &than hard tissue. Assessment of tooth to be extracted-It isdone for long evidence
  11. 11.  Peri apical radiograph providethe most accurate and detailedinformation concerning thetooth,its roots and sorroundingtiisue. Panoramic radiograph are usedfrequently but their greatestusefullness is for impactedteeth. The relationship of teeth to beextracted to adjacent eruptedand unerupted teeth should benoticed When performing extractions ofmaxillary molars,its rootsrelation with the floor of themaxillary sinus should be noted.
  12. 12.  A peri apical radiograph taken before theremoval of mandibular premolar teethshould include mental foramen. The surgeon must know the curvature ofroot and degree of root divergence toplan an extraction. Surgeon should look for caries extensionto the root. Teeth with non vital pulp may have cysts& granulation tissue peri apicallyand theseshould be removed at the time ofextraction Bone that is more radiolucent is likely tobe less denser,which makes extractioneasier.
  13. 13.  Surgeons must preventaccidental injury ortransmission of infection totheir patients or tothemselves. To prevent thistransmission, surgicalgloves, surgical mask, andeyewear with side shields arereqiured.required.
  14. 14.  For patient:1. A sterile disposable toweldrape should be put acrossthe patients chest .2. Proper oral hygiene is veryimportant before extraction
  15. 15. For the extraction ofmandibular teeth, the patientshould be positioned in a moreupright position the occlusalplane is parallel to the floor.The chair should be 16cmbelow the level of operatorselbow.For a maxillary extraction thechair should be tipped backwardand maxillary occlusal plane is at60 degrees to the floor. Theheight of the dental chair shouldbe 8cm below the shoulder levelof the operator.
  16. 16.  For all maxillary teeth,anteriormandibular teeth & teeth of the 3rdquadrant the dentist is to the front andright (and to the left, for left-handeddentists) of the patient. For the teeth of the IVth quadrant thedentist is positioned behind and to theright (or to the left, for left-handeddentists) of the patient.) of the patient
  17. 17.  Good illumination ofthe operator field is anabsolute essential forsuccessful extractionof teeth.
  18. 18. For simple closedextraction-1. Equipment for localanesthesia.2. Elevators-forreflection of softtissue and luxation.3. Forceps for removalof teeth.4. Guaze,saline&suction.
  19. 19.  Lever principle- Elevatorsare primarly used aslevers.Thus elevators includes aeffort arm which is thehandle,fulcrum which isthe crest of the alveolarbone & resistance armwhich exerts thepressure on the toothwhich is the resitancehere.Maximum mechanicaladvantage is gained bykeeping the effortarmlonger than theresistance arm.
  20. 20. Wheel and Axle Principle Resembles the wheel of avehicle attached to a axlearound which the wheelmoves. Cryers & Cross bar elevatorsworks on these principle. The handle serves as thewheel and blade engages thetooth. When the handle is rotatedthe force created on theblade of the elevator ismultiplied creating a greatermechanical advantage toelevate tooth out of itssocket.
  21. 21.  Goals of forceps use:1. Expansion of bonysocket by the use ofwedgeshaped beaksof forceps2. Removal of teethfrom the socket.
  22. 22.  Major motions applied by Forcpes on teeth:• Apical Force:This is the first force generated andcauses expansion of bony socket.• Buccal Force:This helps to expand the buccalcortical plate of the tooth socket.• Lingual Force: Causes expansion of the lingualplate.• Rotational Force: Teeth with single conical rootsare extracted by these force causes internalexpansion of socket and helps in movement ofteeth.• Tractional Force:Forces finally applied to removethe tooth completely out of the socket.
  23. 23.  Expansion Of Bony Socket:Bone is relatively elastic so itis possible to expand thebony socket and remove theteeth. This is done by holding thetooth in the apical end andmoved with the help forcepscausing the expanison of thebony socket.
  24. 24. Wedge Principle This is done by wedgingthe elevator or beaks ofthe forceps between thetooth& socket inpeidontal ligamentspace.This displaces thetooth occlusally and theinstrument can further bepushed into the socket todisplace the tooth furthertill it can be removedcompletely.
  25. 25.  3 fundamental requirments-1. Adequate access and visualisation of fieldof surgery.2. An unimpended pathway for removal oftooth.3. Use of controlled force to luxate andremove the teeth.
  26. 26. 1. Positioning of the patient.2. Administration of local aneasthesia.3. Loosening and luxation of soft tissueattachment from the tooth.4. Adaptations of forceps to the teeth.5. Luxation of the teeth by forceps.6. Removal of teeth.
  27. 27.  Loosening of soft tissue attachement aroundthe tooth:• It is done using the no:9 peioteal elevator.Theinstrument has sharp pointed end and boaderrounded end.The ponted end is used to beginperiosteal reflection and reflect dental papillae.• The pointed end is used in a prying motion toelevate dental papillae between the teeth orattached gingiva around the tooth.
  28. 28.  Usually done with straight elevator or no:9 moltelevator. The straight elevator is inserted perpendicular to theinter dental space after reflection of inter dentalpapillae. The elevator is then turned in such a way that theinferior position of blade rests on alveolar bone andthe superior portion of the blade is turned toward thetooth to be extracted. Strong,slow,steady,foeceful turning of the handlemoves the tooth in a posterior direction,whichresultsin some expansion of alveolar bone andtearing of peridontal ligament.
  29. 29.  Beaks of forceps areadapted anatomically to thetooth apical to the cervicalline that is to the rootsurface so that the beaksgrasps the root underneaththe loosened soft tissue. Lingual beak is usuallyseated first. Beaks must be held parallelto the long axis. The beaks acts as wedgesto dilate the crestal bone onthe buccal and lingualaspects.
  30. 30.  The major portion of theforce is directed towards thethinnest and thereforeweakest bone.Thus in maxillaand all but the molar teeth inthe mandible,the majormovment is labial andbuccal.The surgeon usesslow steady force to displacethe tooth bucally. The tooth is then movedagain towards the oppositedirection with slow deliberatestrong pressure.Buccal andlingual pressure continue toexpand the alveolar socket.
  31. 31.  Once the alveolar bonehas expandedsufficiently and thetooth has been luxateda slight tractional forceusually directed bucallycan be used.
  32. 32.  Maxillary Incisor Teeth:• Extracted with no:150 forceps.• Left hand grasp on alveolar process.• Forceps seated as far as apicaly possible.• Luxation begins with labial force.• Slight lingual force is used.• Left index finger reflects the soft tissue &thumb rests on alveolar process.
  33. 33.  Maxillary Canine• Longests tooth in the mouth.• Bone over labial part is quite thin.• Universal no:150 forceps is used.• Initial movement is buccaly.• Small amount of lingual force is applied.
  34. 34.  Maxillary 1st Premolar:• Common root fracture occurs with this case.• No:150 forceps are used.• Should be luxated as much as possible withstraight elevator.• Has 2 thin roots.• Firm apical pressure is applied to lower centre ofrotation as far as possible and to expand crestalbone.• Buccal pressure is applied initially to expandbuccocortical plate.Apices of the roots arepushed lingually and are therefore subjected tofracture• Tooth is delivered in buccolingual direction withcombination of buccal and tractional forces
  35. 35.  Maxillary Molars:• It has 3 large and relatively strong roots.• Paired forceps no.53R and 53L are used.• Luxation begins with a strong buccal force.• Lingual pressure are used moderately.• Teeth is delivered in buccolingual direction. Maxillary Second Molar:Anatomy of the teeth is similiar to maxillary1st molar & extraction procedure is similiar
  36. 36.  Maxillary 3rd molar:Has conical roots and is usually extractedwith no:210 s forceps which is universalforceps used for both right and left molars.
  37. 37.  Mandibular Incisors and Canine:• Both the teeth are similiar in shape with incisor beingshorter and slightly thinner and canine root beinglonger.• Alveolar bone is quite thin in labial and lingual side.• Lower universal no:151 forceps are used.• Moderate labial force followed by lingual force is usedto expand the bone.• Tooth is delivered in labial incisal direction.
  38. 38.  Mandibular Premolars:• They are easiest teeth to remove.• The overlying bone is thin on the buccalaspect and somewhat heavier on lingual side.• Lower universal no 151 forceps is used.• Buccal force followed by slight lingualpressure is used for luxation.
  39. 39.  Mandibular Molars:• No 17 forceps is used.• If tooth roots are closely bi furcated no:23 or cowhorn forceps can be used.• No 17 forceps is seated as far apically aspossible.Luxation of molar begin with a strongbuccal movement.Strong lingual pressure is usedto continue luxation.• Teeth is delivered in buccolingual direction. Mandibular 3rd Molar:• Fixed conical roots.• Bi furcation is not likely the no.222 forceps ashort beaked,right angeled forceps is used.• The 3rd molar is deliverd in linguo occlusaldirection.
  40. 40.  Intraoperative[Immediate]• Failure to move the tooth• Fracture of tooth, alveolus ,mandible &maxillary tuberosity• Mucosal laceration & puncture wounds ongums lips tongue & floor of the mouth.• Luxation of adjacent tooth• Displacement of root into the facial space• Nerve injury• Hemorrhage-Primary
  41. 41.  Delayed Hemorrhage- Reactionary , Secondary Pain Dry socket [alveolar osteitis] Post operative swelling due to• Oedema• Haemotoma formation• Infection Trismus Infection
  42. 42.  Late:• Chronic osteomylitis• Osteoradionecrosis• Nerve damage• Chronic pain Systemic Complications• Syncope• Hyperglycemia• Hyperventilation• Fits• Myocardial infarction• Addisonian Crisis• Respiratory obstruction
  43. 43.  Irrigate the site with saline. Remove the tissue tags and granulation tissuefrom the soft tissue of the site. Compress the alveolar bone with finger pressure. Suture if necessary at the papillae bordering theextraction site and across the middle of the site. Stop the bleeding by placing a guaze packcovering the socket and the instruct the patientto apply gentle and continous presuure by bittingon the guaze for at least 30 minutes.
  44. 44.  Bite firmly the guaze pack over the surgicalarea for at least 30 mints. Dont spit or suck as it will promote bleeding. If bleeding continues in home,advice thepatient to place a guaze pad or cold wetteabag over the area and bite firmly for 30mins. Avoid rubbing the areas with tongue. Do not smoke for 24 hrs as it may inteferewith healing Do not rinse or brush the tooth for 12 hrs.
  45. 45.  After extraction have liquid or soft diet highin protein. Drink a large amount of water and fruitjuices. Avoid hot food for the first 24hrs aftersurgery Anti inflammatory analgesics should bepreffered. Warm saline rinses and gentle brushingshould be advised from the next day.