Exodontia /certified fixed orthodontic courses by Indian dental academy

EXODONTIA

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

ORAL AND MAXILLOFACIAL
SURGERY
IS THE SPECIALITY OF DENTISTRY
THAT INCLUDES THE DIAGNOSIS ,
SURGICAL AND ADJUNCTIVE
TREATMENT OF
DISEASES,INJURIES,DEFECTS,
INCLUDING BOTH THE FUNCTIONAL
AND ESTHETIC ASPECTS OF THE
HARD AND SOFT TISSUES OF THE
ORAL AND MAXILLOFACIAL REGION.

EXODONTIA
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 POST OPERATIVE
PROSTHETIC PROBLEM IS CREATED.

BASIC REQUIREMENTS
 A GOOD RADIOGRAPH
 ADEQUATE ANESTHESIA
 PROPER INSTRUMENTS
 ADEQUATE ILLUMINATION
 EFFICIENT ASSISTANCE
 GOOD SUCTION APPARATUS


PREPARATION
PAIN AND ANXIETY:
1.ANESTHESIA
2.SEDATION
PRE SURGICAL MEDICAL ASSESSMENT:
1.SYSTEMIC
2.LOCAL


INDICATIONS









periodontal disturbances
severe caries
pulpal necrosis/pathology
peri apical pathology
orthodontic reasons
-therapeutic
-malposed
-serial extractions
prosthetic extractions
impactions

INDICATIONS
 SUPERNUMERARY TEETH
 TOOTH IN THE LINE OF FRACTURE
 ROOT FRAGMENTS
 PRE RADIATION THERAPY
 ESTHETIC PURPOSE
 ECONOMICS


CONTRA INDICATIONS
1. SYSTEMIC
2. LOCAL

systemic: absolute
un controlled metabolic diseases
-diabetes
-end stage renal disease with severe uremia
un controlled leukemias and lymphomas

infection:non functioning white cells
bleeding:inadequate number of platelets
un controlled cardiac diseases
-angina
-ischemia
-mi
cirrhosis of liver

LOCAL CONTRAINDICATIONS
-HISTORY OF RADIATION
-SITE OF MALIGNANT TUMORHASTENS METASTASIS
-SEVERE PERICORONITIS
-ACUTE DENTO ALVEOLAR ABSCESS


RELATIVE CONTRAINDICATIONS:
PREGNANCY-1ST AND 3RD TRIMESTERSUNSAFE
2ND TRIMESTER-SAFE
DEFER-IF COMPLICATED
PATIENTS ON DRUGS-WITH CAUTION
-CORTICOSTEROIDS
-IMMUNOSUPPRESIVES
-CHEMOTHERAPEUTIC AGENTS


PATIENT AND SURGEON
1.hand gloves
2.mouth mask
3.head cap
4.wash
5.mouth rinses
6.gauze-to prevent aspiration
no finger rings,no watches,no
bracelets….

TYPES OF EXTRACTION
1.CLOSED EXTRACTIONintra alveolar
regular conventional method
2.OPEN METHODtrans alveolar extraction
if the crown fractures,
retained root stumps.

Elevators in oral surgery
 Indications:
 Removal

of teeth: impactions,
malposed teeth, decayed , tilted.

 Removal

of roots : roots fractured at the
gingival line, roots left in the alveolus from
previous extractions

Complications in the use of
elevators
 Damaging or even extracting adjacent

teeth
 Fracturing the maxilla or mandible
 Fracture of alveolar process
 Slipping and plunging the point of the
instrument into the soft tissue, with
possible perforation of great blood vessels
and nerves

 Penetrating into the maxillary antrum


forcing a root or apical third of the root of
the lower third molar into the mandibular
canal or through the lingual plate of the
mandible into the sub maxillary or
pterygomandibular space


Rules when using elevators
 Never use an adjacent tooth as a fulcrum

unless that tooth is to be extracted also.
 Never use the buccal plate at the gingival
line as a fulcrum ,except where
odontectomy is performed or in the third
molar areas.
 Never use the lingual plate at the gingival
margin as fulcrum

 Always

use finger guards to protect the
patient in case the elevator slips.

 Be certain that the forces applied by the

elevator are under control and that the
elevator tip is exerting pressure in the
correct direction.


Parts of elevator
 Handle

: this may be a continuation of the
shank or at right angles to it

 Shank
 Blade

or root

: the part which engages the crown


Classification of elevators






According to the use:
Elevators designed to remove the entire tooth
Elevators designed to remove roots broken at
the gingival margin
Elevators designed to remove roots broken off
half way to the apex
Elevators designed to remove the apical third of
the root


 Elevators designed to reflect the

mucoperiosteum (periosteal elevators)
before forceps or extracting elevators are
used


 According

to the form:
 Straight: wedge type (straight apex)
 Angular: right &left
 Cross bar (handle at right angles to the
shank)


Work principles in use of
elevators
 Lever principle
 Wedge principle
 Wheel &axle principle


PRE EXTRACTION
EVALUATION
1.access to the tooth
2.mobility of the tooth
3.condition of crown
4.radiographic examination
-proximity of associated vital structures
-configuration roots
-condition of surrounding bone

ORDER OF EXTRACTION
FIRST-MAXILLA
NEXT-MANDIBLE
THIRD MOLAR
SECOND MOLAR
SECOND PRE MOLAR
FIRST MOLAR
FIRST PRE MOLAR
LATERAL INCISORS
CANINE


CHAIR POSITIONS
POSITION:
MAXILLA




tipped backward
45 degrees to the floor
should be 3 inches below shoulder level.

operatorright front of the patient


MANDIBLE
 parallel to the floor on opening.

 should be 6 inches below elbow level

operator left quadrant

- right front
 right quadrant - right back


Position of the dentist
1. Posture
2. Relation to the patient
3. Dentist left hand:
A. during forceps application:
1. retraction of lips ,cheeks and
tongue

2.Guiding the beaks of the forceps onto the
tooth to be extracted.
3.Stabilizing the patients head during
operations on the maxillary teeth and
stabilizing the mandible during operations
on the lower teeth.


B. During tooth luxation.
1.Supporting the buccal and lingual cortical
plates.
2.Estimating the amount of pressure
applied and the amount of alveolar bone
dilatation.


3.Counteracting the pressure applied. Unless the
mandible is supported, the forces exerted
through the forceps to the tooth and hence to
the mandible will result in sublaxation of the
temporomandibular joint, tearing of the
intercapsular fibers and in many cases result in
chronic painful dysarthrosis of the
temporomandibular joint.


4. Prevention and protection against slipping
of forceps and elevators.
5. Removal of broken fillings, tooth
fragments or a whole tooth before it
reaches the oropharynx.


C. After tooth extraction.
1.Compressing the buccal and lingual
cortical plates back into position.
2.Examination of the surgical field and
detection of sharp, bony edges, bony
undercuts or loose bone fragments.


FUNDAMENTALS
OF A GOOD EXTRACTION:
1.adequate access and visualization
2.an unimpeded pathway for the
removal
3.the use of controlled force to luxate and
remove.


PRINCIPLES OF FORCEPS
EXTRACTION
1.expansion of bony socket
2.removal of the tooth


5 MAJOR MOTIONS TO LUXATE AND
EXPAND
1. apical pressure
2. buccal pressure
3. lingual pressure
4. rotational pressure
5. tractional forces


GENERAL STEPS OF EXTRACTION


STEP 1:
loosening of soft tissue attachment from the
tooth



STEP 2:
luxation of tooth with a dental elevator



STEP 3:
adaptation the forceps to the tooth

 STEP 4:

luxation of the tooth with forceps
 STEP 5:

removal of the tooth from the socket


REASONS OF ROOT BREAKAGE
 a. improper application of beaks of forceps

1. beaks placed on enamel instead of
on cementum
2.beaks not parallel to long axis of tooth
 b. wrong type of forceps
 c. extensive caries


 d. brittleness due to age or nonvitality of

tooth ,root canal filling indicate the
possibility of root fracture

 e. peculiar root formation

1. curved roots
2.hypercementosis
3.supernumerery roots


 f. excessive density of surrounding bone

due to:
1.condensing osteitis
2.osteopetrosis(marble bone,albersschonberg disease)
3.defensive osteitis
4.isolated tooth, because of extraction
of adjacent teeth some years previously


 5.bridge abutments ,fixed or removable





subjected to great stress
6. a coarse diet stimulating osteoblastic
activity
7. chewing of tobacco
8.low-grade chronic gingivitis, giving rise
to periostitis ,with resultant exostosis of
labial cortical plate


 G. incorrect application of force in

extraction of teeth
 1. wrong direction
 2. jerking a tooth (sudden violent
application of force in one direction)
 4. use of twisting motion when not
indicated
 5. pulling a tooth


ODENTECTOMY & TOOTH DIVISION
Is the surgical removal of a tooth or teeth by
reflection of an adequate mucoperiosteal
flap and the removal of overlying bone
from between the buccal roots of molars
by means of chisels ,burs and or roungers


Indications for odontectomy and tooth
division
 hypercementosis of the roots

 widely divergent roots of mandible

maxillary molars
 Locked roots
 Teeth with apices at right angles to the
long axis of the teeth
 Teeth with post crowns







Extensively decayed teeth ,particularly those
with deep gingival cavities
Teeth with root canal fillings
When a thick ,dense buccal or labial cortical
plate or multinodular exostosis is present
When the maxillary alveolar Tuberosity is hollow
because the antral cavity extends into this area


 Thin mandibles in which excessive force is

required to luxate the teeth .this excessive
force may result in the fracture of the
mandible
 Malposed teeth ,impactions,unerupted
teeth and supernumerary teeth
 Ankylosed roots found only in elderly
patients)

 When the forces used to remove the

mandibular teeth results in dislocation of
condyles
 When the customary force fails to produce
any luxation.


Steps in odontectomy









Pre operative assessment
Administration of local anesthesia
Incision
Elevation of mucoperiosteal flap
Bone removal
Delivery of the tooth or root
Toileting or debridement of surgical site
Suturing or wound closure


Principles of mucosal incisions
 1.should not be placed on the operative

site but on the undisturbed area.
 2.incisions should avoid blood vessels
 3.maintain good blood supply to the flapso give incisions parallel to major vessels
 4.minimize number of side cuts


 5.incise to have broader base
 6.no incision on thinned mucosa
 7.around the teeth in the gingival crevice
 8.integrety of the interdental papillae

should be maintained (avoid interdental
papillae)


 9.releasing incisions should be made if

necessary (should be in smooth curve
with primary incision)
 10. single stock (to elevate both mucosa &
periosteum for mucoperiosteal flaps)


THE TERM LOCAL FLAP INDICATES:
A SECTION OF SOFT TISSUE THAT
1.IS OUT LINED BY A SURGICAL INCISION
2.CARRIES ITS OWN BLOOD SUPPLY
3.ALLOWS SURGICAL ACCESS TO
UNDERLYING TISSUES
4.CAN BE REPLACED IN THE ORIGINAL
POSITION
5.CAN BE MAINTAINED WITH SUTURES AND
IS EXPECTED TO HEAL WITHOUT ANY
PROBLEM.

DESIGN PARAMETERS FOR
FLAPS
1.
2.

3.

4.

BASE- BRODER THAN FREE MARGIN
SUFFICIENT SOFT TISSUE
REFLECTION –TO PROVIDE
NECESSARY VISUALIZATION
ENOUGH FLAP REFLECTION TO
PERMIT THE RETRACTOR TO HOLD
THE FLAP WITHOUT TENSION
LONG,STRAIGHT INCISION-BETTER
THAN-TORN,SHORT INCISION

FLAP DESIGN CONTD
6.FULL THICKNESS FLAP
- MUCOSA
- SUB MUCOSA
- PERIOSTEUM
7.INCISION ON INTACT BONE ONLY
8.TO AVOID VITAL STRUCTURES
MANDIBLE: LINGUAL AND MENTAL N.
MAXILLA: NASOPALATINE AND
GREATER PALATINE A

Needles
According to the shape :
1/4circle,3/8circle,1/2circle,3/4circle,straight with curved
end, straight
 According to the shape of the cutting edge :
Tapered, cutting, reverse cutting.
 According to the material :
Carbon steel, stainless steel
 According to presence or absence of eye:
Swaged, eyed, spilt eyed.



Principles of suturing
 1.needle holder should be grasped ¾ from

the point
 2.needle should enter perpendicular
 3.needle should be passed following the
curve.
 4.suture should be placed at equal
distance (2-3mm) from the incision &at
equal depth.

 5.needle should be passed from free to

fixed.
 6.thinner to thicker
 7.Deeeper to superficial
 8.distance of penetration > distance from
the tissue edge.


 9.tension free closure

 10.suture should be tied for approximation

not blanched.
 11.knot should not be placed over the
incision line.
 12.sutures should be placed 3-4mm apart.
 13.avoid dog ear.


SUTURE MATERIALS
A SUTURE IS A STRAND OF MATERIAL
USED TO LIGATE BLOOD VESSELS
AND TO APPROXIMATE TISSUES
TOGETHER
AIM IS TO BRING TISSUES
TOGETHER AND HOLD THEM IN
POSITION UNTIL HEALING HAS TAKEN
PLACE.

 Ideal suture material should have :











adequate strength
good handling properties
knot tying characteristics
should be sterilized
evoke little tissue reaction.

3-0 to 7-0 ,more number of zeroes –smaller diameter of
the strain
5-0&6-0: skin closure in head &neck
3-0&4-0:for intraoral mucosal incisions
Sutures can be:monofilament,braided,gut.

Classification of suture material:



Biologically derived materials :




1.absorbable:eg:plain catgut, chromic catgut
2.non absorbable:eg:silk ,cotton



Synthetic materials:



1.Absorbable;eg;polyglycolic acid,polyglactic 910(vicryl)
2.non absorbable:eg;nylon,dacron,polypropylene
stainless steel,tantalum,titanium.












Different types of suturing methods :
1.interrupted suture
2.continous suture
3.locking continuous suture
4.mattress suture
5.figure of 8 suture
6.sub cuticular suture.













Catgut: derived from sheep intestinal sub mucosa or bovine
intestinal serosa
Kit gut-string of dancing master’s fiddle
Least tensile strength
Packed in isopropyl alcohol –to prevent enzymatic
degradation(organic material)
Quick rinse before use in saline
Absorbed by proteolytic degradation &phagocytosis-considerable
inflammation
40-6- days –complete absorption
intraorally remove- 3-5 days
Chromic catgut-chromic salts are added before spunning,
grounding& polishing
They increase tensile strength ,resistance to absorption &knot
retaining capacity, decrease tissue reaction










2.Collagen: grinding the native collagen of deep flexor
tendons of cattle ,increase absorption-not widely used
3.polyglycolic acid&glycolactin 910:resorbed by
hydrolysis, synthetic polymer decreases reaction
Polylgycolic acid: is hydroxyacetic acid in presence of
heat &catalyst forms linear chain polymer
Polyglactin 910:a copolymer of glycolide &lactide
derived from hydroxyacetic acid &lactic acid respectively
Strongest absorbable suture
Degradation products-decrease tissue reaction
Can be used as non absorbable sutures intraorally (5-7
days)
Difficult in tying the knot

 Have

to wet with saline
 suggested knot of polyglacolic acid
&polyglactin 910 is first row- 3 throws,2
&3 rows-two ties in opposite direction
 Subcuticular area-general usage


Non absorbable sutures


1. silk: organic substance, resorbs after 2 years, most popular for
intraoral use
Braided ,moderate tissue reaction ,does not imitate
adjacent
tissues, excellent handling properties
Lowest rank in knot holding cpacvity,2nd –tensile strength



2.nylon:braide ,monofilamentous(skin suture) has memory



3.cotton &linen : fibers twisted into piles



4.metal : stainless steel or titanium, monofilamentous or braided


KNOT TYING
BASICALLY: instrument tie and one or two hand tie
TYPES OF KNOTS:
1.square knot:two knots-opposite directions..ex;nylon,poly
propelene,pga and gut.
2.surgeon’s knot:two throws in one direction for first knot
and one throw for second knot in opposite direction.ex;
synthetic and pga
3.granny knot: two knots in the same direction and third
in the opposite direction

POST OPERATIVE CARE
DEBRIDEMENT
COMPRESSION OF THE EXPANDED
SOCKET
SUTURE IF NEEDED
PRESSURE PACK
PROPER INSTRUCTIONS
ANALGESICS AND ANTI INFLAMMATORY
DRUGS
ANTIBIOTICS FOR 5 TO 7 DAYS
PERIODICAL REVIEW IF NEEDED

Operative complications
 Fracture
 Causes:

of the tooth:

 Teeth that has been devitalized

 Mechanical obstruction :hypercementosis,

curvature of the root

 Decision to leave or remove broken root

pieces


 Injuries

to the adjacent teeth:
 Loosening of teeth
 Avulsion of an adjacent tooth
 Fracture of the crown
 Extraction

of wrong tooth

 Fracture

of alveolar bone

 Fracture

of tuberosity

 Maxillary sinus perforation
 Root displaced into the sinus
 Root displaced into the submandibular

space

 Gingival and mucosal lacerations
 Injury to the inferior alveolar nerve

 Hemorrhage
 Subcutaneous emphysema
 Temporomandibular joint trauma


Postoperative complications
 Hemorrhage
 Primary hemorrhage
 Secondary hemorrhage
 Ecchymosis and hematoma
 Swelling

 Septic

periostitis

 Alveolar

osteitis(dry socket)

 Prevention

of postoperative pain

 infection


Healing of extraction wounds






Hemorrhage and clot formation
Organization of the clot by granulation tissue
Replacement of granulation by connective tissue
and epithelialization of the wound
Replacement of the connective tissue by coarse
fibrillar bone
Reconstruction of the alveolar process and
replacement of the immature bone by mature
bone tissue


HEMOSTATIC BIOMATERIALS
 GEL FOAM-GELATIN FOAM
 OXYCEL-OXIDIZED CELLULOSE
 SURGICEL-OXIDIZED REGENERATED

CELLULOSE
 BONE WAX-BEES WAX,OLIVE
OIL,PHENOL
GELFOAM-MANUFACTURED FROM
DENATURED ANIMAL SKIN COLLAGENMECHANICAL SCAFFOLD

OXYCEL AND SURGICEL-WILL REACT
CHEMICALLY WITH BLOOD TO FORM
AN ARTIFICIAL CLOT
-SHOULD BE APPLIED DRY
BONE WAX-ONLY TO ARREST BONE
BLEEDERS
-MECHANICAL OBSTRUCTION


MECHANICAL WOUND
CLOSURE
LIGATING CLIPS
2. SURGICAL STAPLE
TISSUE ADHESIVES: N-BUTYL CYANO
ACRYLATE
-EPOXY RESINS
-POLY URETHANES
1.


Electro surgery
cusel, cushing & bovie
 1.medical diathermy: two electrodes are used


Heat is produced when current is passed
through the tissues



Large electrodes-dispersive



Small electrode-active (heat is generated at the
smaller electrode as the current is uneven)

Its effects:
 1.dehydration
 2.warming

of the tissues

 3.coagulation
 5.tissue

destruction

2.Electrodessication
(electrofuluguration):
 Oscillations

of the current used

 When

electrode is in contact with the
tissue- desiccation occurs)

 When

away –sparkle causes superficial
burn or carbonization


3. ELECTROCOAGULATION:
 Heat causes coagulation
 Promotes coagulation &burns &seals the
edges of the blood vessels
4. Electrocautery:
 high current wire passes heat causes burn
 Tissue effects: no significant difference
between the scalpel


Techniques
 1.The

active electrode should passed
through the tissues as quickly as possible
in a brush stroke movement with no
pressure

 2.A

continuous rapid movement is
important because delay in one area will
cause tissue burning

 3.Allowing

time between the strokes will
allow heat to dissipate7produce less
damage

 4.Active

electrode should not come into
contact with the periosteum or bone

 5.When

used as a coagulation device it is
better to adjust ht machine at low current
to avoid necrosis &slough

 6.Electrode

may be applied directly or
indirectly (via a hemostat or forceps) to the
bleeding tissue

Complications of electrocautery
 Explosion

of volatile anesthetic gases
 Burns at sites remote from the surgery
 Ignition of dry sponges in the mouth
 Burning of the endotracheal tube
 Ventricular fibrillation
 electrocution


Cryosurgery
 Involves application of cold to the tissue to

freeze &destroy

 Decrease of temperature causes necrosis in

vascular &connective tissues

 Less cellular –less susceptible to freezing


Factors effecting damage
 1.rate
 2.

of cooling

final temperature

 3.time

spent at the frozen site

 4.rate

of thawing

 5.

the medium it takes place

Effects of freezing
 1.formation

of extra cellular ice
 2.concentration of extra cellular solutes
 3.decrease in intracellular water
 4.cell shrinkage
 5.concentration of intracellular solutes
 6.cell membrane damage
 7.formation of intracellular ice

Clinical applications:
 1.cancer

growth
 2.brain tumors
 3.vascular anomalies including
heamangiomas
 4.caracts
 5.premalignant lesions
 6.mucous membrane tumors
 7.intaosseous tumors
 8.ameloblastoma 9.aneurysmal bone cyst.

 Cryosurgery
 Most

units:

expensive –liquid nitrogen
 Carbon dioxide ,nitrous oxide, Freon
 For tissue necrosis:-20 for 4-5 min.-80 for
4-5 min (intramucosal)
 Disadvantage:
 no

specimen for histological examination

Thank you
Leader in continuing dental education


Exodontia /certified fixed orthodontic courses by Indian dental academy

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