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Exodontia
- 1. Exodontia Submitted by Soumya Mishra M.D.S ORAL AND MAXILLOFACIAL SURGERY
- 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.