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Exodontia
- 2. Contents Introduction Definition Indications Contraindications Factors Elevators Forceps Transalveolar extractions Complications of exodontia
- 3. Introduction Since the earliest period of history ,the extraction of tooth has been considered a very formidable procedure by the layman Many patients suffer from “extractionfobia” and are often difficult to care for despite modern methods of anesthesia Many dentists still believe that speed is essential when extracting teeth
- 4. Definition The painless removal of the whole tooth, or root, with minimal trauma to the investing tissues, so that the wound heals uneventfully and no post-operative prosthetic problem is created Geoffrey L Howe
- 5. Principles of Exodontia Expansion of bony socket Use of lever and fulcrum Insertion of wedge
- 6. Indications Caries in 48.8% cases (Allen 1994), abscess Periodontal diseases, in 40.7% cases, to prevent alveolar ridge resorption Tooth with necrosed pulp and periapical lesion, not responding to endodontic treatment Over retained deciduous tooth Orthodontic purpose Prosthetic purpose
- 7. Indications (contd.) Unrestorable tooth Impacted tooth Supernumerary tooth Grossly decayed 1st/2nd molar, make space for 3rd molar Tooth in fracture line Teeth directly involved by cyst and tumor Teeth in the area of therapeutic irradiation Teeth acting as foci of infection
- 8. Contraindications Absolute Central haemangioma Arteriovenous malformation Relative Acute Cellulitis Long term steroid therapy Liver disorders
- 9. Preoperative analysis of patient General disease Nervousness Previous difficulty with extraction Oral hygiene status of the patient Oral prophylaxis Antiseptic mouth rinse Clinical examination of the tooth Clinical examination of the oral cavity- any prosthesis
- 10. Factors complicating extractions Restriction by the lips and cheeks Movement of the tongue 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 mouth, tongue, hard and soft palate may be damaged
- 11. Factors of tooth Abnormal number of roots Abnormal shape of roots Unfavourable root pattern Caries extending into root Ankylosis Resorption of root
- 13. Dental Elevators Elevators are single bladed instruments designed to loosen or remove roots, root fragments, or teeth , which they do by moving them out of the sockets along a path determined by natural curvature of the roots. Rules of using an elevator Never use adjacent tooth as fulcrum Never use lingual plate as fulcrum Never use buccal plate as fulcrum except where odontectomy has been performed Always use finger guards to protect the patient
- 14. Principle of Elevators : Lever Principle Wedge Principle Wheel and Axle
- 15. Lever Principle
- 16. Mechanical Advantage R * ¼ = E * ¾ R = 3E MA=R/E =3 Fulcrum is located in between the input effort and the output load Resistance * Short Arm = Effort * Long Arm Long Arm = ¾ of total arm Short Arm = 1/4 of total arm Example - Straight elevator (coupland elevator)
- 18. Mechanical Advantage Effort * length = resistance* height E*L = R*h where L= 10 mm ; H = 4 mm R/E = 10/4 = 2.5 Wedge is a simple machine & consists of two movable inclined planes which meet & form a sharp angle R – Resistance E – Effort L – Length H - Height R E.g. : Apexo Elevator , Warwick James l E
- 19. Wheel and Axle
- 20. Mechanical Advantage Effort * radius of wheel = resistance * radius of axle E* Rw = R * ra where Rw = 42 ; ra = 9 MA = Rw/ra = 42/9 = 4.6 A machine made up of two circular objects of different size Effort applied to the wheel turns the axle or effort applied to the axle turns the wheel Example : Cross bar elevator , Cryer elevator
- 21. Parts of Elevators :
- 22. The three basic types of Elevator : Straight type Triangle or Pennant-shaped type Pick type
- 25. Pick type : This type of elevator is used to remove roots. This instruments is used as a lever to elevate a broken root from the tooth socket.
- 26. Apexo elevators : No.302 and 303 apexo elevators are used Chompret elevators • a straight, and b curved
- 27. Warwick James
- 28. Sharp-tipped angled elevators suitable for removal of root tips
- 29. Forceps Forceps are the main instruments used in the extraction of teeth. Forceps help in dilation of the alveolar socket, luxation of tooth and its removal.
- 30. The correct way to hold maxillary extraction forceps
- 31. The correct way to hold mandibular extraction forceps
- 32. Extraction movement Primary movement: Along longitudinal axis of root Secondary movement: Main extracting movement Rotatory Buccolingual or labiolingual Mesiodistal Lifting the tooth 32
- 33. Upper central and lateral incisor Rotation only Upper canine Rotation initially, some labio- lingual movement may be needed Upper premolar and molar Bucco-palatal movement 33
- 34. Lower central and lateral incisor Rotatory movement Lower canine Rotatory and labio-lingual Lower premolar Rotatory Lower molar Bucco-lingual movement 34
- 37. Transalveolar extractions Involves the removal of a full thickness mucoperiosteal flap Bone obstructing the removal of tooth is cut Sectioning of the roots is done Entire tooth removed in successive sections
- 38. Incision • Tissue should be handled gently • Sharp dissection should be used • Careful hemostasis should be attained • Tension should be avoided
- 39. # 11 Scalpel # 15C Scalpel
- 40. # 12 Scalpel
- 41. Most endodontic surgery problems can be avoided by using the following incision rules Firm continuous incision An incision should not cross an underlying bony defect The vertical incision should be in the concavities between bone eminences The vertical incision should not extend into the muccobuccal fold The termination of the vertical incision at the gingival crest must be at the mesial or distal line angle of the tooth The base of the flap must be at least equal to the width of its free end
- 42. An incision should not cross an underlying bony defect
- 43. An incision should not cross an underlying bony defect
- 44. An incision should not cross an underlying bony defect
- 45. An incision should not cross an underlying bony defect
- 46. The vertical incision should be in the concavities between bone eminences
- 47. The vertical incision should not extend into the muccobuccal fold
- 48. The termination of the vertical incision at the gingival crest must be at the mesial or distal line angle of the tooth
- 49. The base of the flap must be at least equal to the width of its free end
- 50. Goals of flap design To allow for complete access and visualization of the surgical field To allow for bone removal and tooth sectioning To prevent unnecessary trauma to soft tissue and bony structures
- 51. Principles of flap design The flap should offer adequate access and have an adequate blood supply The flap must be of adequate size and fully reflected The edges must lie on the sound bone Can be maintained with sutures and is expected to heal
- 52. Mucoperiosteal Flap • Mucosa • Connective tissue • Periosteum
- 53. Techniques • Gingival flap • Intrasulcular flap (marginal) – Triangular – Rectangular • Semilunar flap • Submarginal flap – Ochsentein-Luebke flap
- 54. Gingival Flap • Indications – Cervical resorptive defects – Cervical area perforations – Periodontal procedures
- 55. Intrasulcular Flap (Triangular) Indications Periapical Sugery Postrerior areas
- 56. Intrasulcular Flap (Rectangular) Indications Multiple teeth Large lesions Long roots
- 57. Semilunar Flap • Indications – Esthetic crowns
- 58. Submarginal Flap Ochsenbein-Luebke Flap • Indications – Prosthetic crowns
- 59. Ward’s Incision
- 60. Extraction burs
- 61. Moore and Gillbe’s Collar technique
- 65. Immediate Extraction or luxation of surrounding teeth Fracture of maxillary tuberosity Gingival laceration Fracture of mandible Oroantral communication
- 66. Delayed Haemorrhage Localised osteitis Trismus Acute osteomyelitis Nerve damage
- 67. References The extraction of teeth – Geoffrey L. Howe Oral and Maxillofacial surgery – Daniel M. Laskin Online sources
Editor's Notes
- Indications for the use of Elevators To reflect mucoperiosteum Elevators can be used to luxate the tooth before applying the forceps for extraction To luxate and remove the tooth from its socket which might fracture when engaged with forceps. To remove a fracture or carious tooth which might fracture when engaged with beaks. To remove inter-radicular bone. To remove a fracture root when the fracture line is below the cervical line.
- Lever Principle: The lever principle has three basic components : Fulcrum, effort, and load. In a Lever of first order, the position of fulcrum is between the effort and the load. In this principle, to gain a mechanical advantages the effort arm on one side of the fulcrum should be longer than the effort arm on other side of fulcrum. The force is transmitted at the long effort arm and mechanical advantage is gained at the short load arm. Applied to Elevators : this principle is used in elevators wherein the handle of the elevator represents the effort, and the working end engages the tooth represents load.
- Wedge Principle : the wedge consists of two movable inclined planes with a base on one end and a blade on other end which overcome a large resistance at right angle to the applied force. The effort is applied to base of the plane and the resistance has its effect on slant side. Applied to elevators : elevators can also be used on this principle, for example, when the luxating a tooth from its socket, a straight elevator is applied between the tooth and the bone to separate the attachment of periodontal ligament from the bone.
- Wheel and Axle : wheel and axle is a simple machine being a modified form of lever. The effort is applied to circumference of wheel which turns the axle so as to raise weight. Greater diameter of the wheel, more is mechanical advantages. Applied to elevators : crossbar elevators are used for removing the mandibular roots based on this principle. The working point of this elevators is engaged deep into the space between the tooth root and the bone, and the handle is rotated. The root is removed from its socket by moving about a circumference of the circle which the roots would have made if they continued on around.
- it is most commonly used elevators to luxate the tooth. The blade of straight elevators has concave surface on one side that is placed towards the tooth to be elevated. Various sizes of elevators is available in market. Small straight elevator , No. 301 used frequently for beginning the luxatation of tooth, large elevators (No.34S , No.46, 77R) are used to displace roots from their sockets and to luxate the tooth.
- This elevator are provide in pairs : left and right. The triangle elevator is most useful when a broken root remains in the tooth socket and adjacent socket is empty. The tip elevators is placed into socket, with shank of elevator resting on buccal plate of bone. The elevator is turned in wheel and axle rotation, and root is delivered. crossbar elevators are used particularly for removal of mandibular molar roots and impacted mandibular third molars. It is also known as Winter’s crossbar elevator. It is available in various numbers like 11L and 11R, 14L and 14R, and 1L and 1R. The shank is at right angle to handle. the working tip is at angle to shank. it is a straight elevator with a triangular blade. The working tip is angulated, with one convex and another flat surface. The flat surface is the working side. It based on lever and wedge principle.
- when the mandibular root has fractured below the gingival line. In these elevators, the blade is at 90 degree angle to handle. They are used in a similar manner as that straight apexo elevators. Straight Chompret Elevator. The narrow blade of this instrument means that this type of elevator may also be used as a straight elevator (Fig. 4.52 a). The straight Chompret elevator may only be used this way when the width of the straight elevator blade prevents its correct placement for the luxation of the tooth or root. Curved Chompret Elevator (Fig. 4.52 b) and Doubleangled Elevators with Narrow Blades and Sharp- Tipped Ends (Fig. 4.53). These instruments are used by the dentist as the need dictates.
- Warwick James : Root Elevators is a screw type instrument to elevate the roots of the teeth. This elevator are used for the removal of fractured roots(at the gingival line) of maxillary central and lateral incisors, biscuspids and cuspids. These elevators are applied on the mesial and distal sides of root and using wedge principle, a depth of 5 mm is gained and the socket is expanded.
- The beaks of tooth extracting forceps are designed to grasp the tooth with maximum contact on the facial-lingual surface of the root(s) just below the cervix. The inner surface of each of the two beaks is concave and the outer surface is convex The neck is shaped so that the beak can be placed on the tooth and still be parallel with the long axis of the tooth.. The beaks are also shaped so that a force on the handles tends to force the tooth out of its socket. The handles are shaped so that a maximum amount of force can be applied to the beaks, while the handles are still in a comfortable position for the oral surgeon