Exodontia (Simple Extraction) - PDF

1 Exodontia (simple extraction or forceps extraction) Painless removal of the whole tooth, or root, with minimal trauma to the investing tissues, so that the wound heals without post operative complications Types of exodontia Closed Intra-alveolar extraction (forceps, elevators)...

1 Exodontia (simple extraction or forceps extraction) Painless removal of the whole tooth, or root, with minimal trauma to the investing tissues, so that the wound heals without post operative complications Types of exodontia Closed Intra-alveolar extraction (forceps, elevators) Opened Transalveolar extraction (flaps)  Factors Complicating Extraction Restricted area by lips & cheeks Proximity to vital structures e.g., maxillary sinus Tongue Movements interfere with proper forceps and inferior dental canal) Oral cavity communication with Pharynx, Larynx Movements of the TMJ that need proper support by operator left hand Adjusting the positions of the operator, patient & dental chair, 3. For maxillary extraction: to achieve: a. Dental unit is tilted backward so that Maximum convenience to the patient & operator maxillary occlusal plane is 45-60° to Best visibility & accessibility to the operator the floor (semi-supine to supine) Maximum amount of force with least effort during extraction b. Height of dental unit: height of A. Patient and dental chair positions maxilla is between operator's shoulder 1.The patient should be seated comfortably in dental unit & elbow 2. The patient's head, neck and trunk should be in one straight line, without head bending (forward or backward): – To avoid excessive strain on neck muscles – To provide proper visibility of the oral cavity 5 4. For mandibular teeth extraction: a. Dental unit height: mandible is at or below the operator's elbow level b. The patient should be positioned more upright, so mandibular occlusal plane is // to the floor when the mouth is opened widely 5. When extracting lower right posterior teeth, the operator should stand to the back right side of the patient & tilt the dental unit backwards for better accessibility and visibility 6  B. Operator position 8 o'clock position: when To avoid abnormal strain at weight bearing articulations extracting all upper teeth & lower teeth Stand erect, with equal distribution of body weight on both feet Feet apart Except Operator's arms, back & wrists should be straight, & arms should be in close contact to his body Allowing him to deliver force with arm & shoulder 10 o'clock position: when extracting the lower right rather than his hand posterior teeth Neck may bent minimally After forceps application is not necessary 7 to have perfect vision of the field 8 1. Badly decayed tooth 2. Advanced periodontal 3. Teeth related to These teeth can be diseases (More than ½ of pathologic lesions alveolar bone loss) (cyst, tumors) treated by endodontic ttt. However, if tooth maintenance comprises surgical removal of the lesion, the tooth should be extracted. 9  4. Malposed teeth 5. Orthodontic reasons 7. Retained deciduous teeth 6. Preprosthetic extractions that don’t respond to 8. Impacted teeth orthodontic ttt & traumatize adjacent structures if teeth interfere with the design 10 of prosthetic appliances 9. traumatized teeth such as: 10. Root resorption a. Un-restorable fractured teeth 11. Pre-radiation therapy: Teeth in the direct b. Teeth involved in fracture line, which interfere field for radiotherapy to the jaws (treatment of with fracture reduction or those that prevent proper malignant tumors), may be removed fracture healing when they get infected prophylactically before the start of radiotherapy, because extraction after radiation cause necrosis of jaw bones (osteoradionecrosis) which lead to loss of large segment of jaw 11 12 1. Systemic contraindications a. Severe uncontrolled metabolic diseases (diabetes, renal e. Bleeding disorders (thrombocytopenia, failure,….) hemophilia, anticoagulants, …) b. Uncontrolled leukemias & lymphomas: Potential side effects f. Pregnancy is a relative contraindication (2nd include infection from ineffective white cells & excessive trimester is stable) bleeding from insufficient platelets g. Drugs (corticosteroids, chemotherapy, c. Severe uncontrolled cardiac diseases: (uncontrolled Angina immunosuppressive) pectoris & recent myocardial infarction) h. Epilepsy patient d. Uncontrolled hypertension: Persistent bleeding, acute myocardial insufficiency, and cerebro-vascular accidents may occur because of stress caused by extraction 13  Acute dentoalveolar abscess is 2. Local contraindications not contraindication to – Previous radiation therapy (ORN) extraction, the most rapid – Teeth located within a malignant tumor (Dissemination resolution of this abscess is of malignant cells) obtained when the tooth is – Tooth in vascular lesions (central hemangioma or AV removed as early as possible malformation) (after antibiotic injection) – Acute pericornonitis: around an impacted mandibular 3rd molar should delay extraction until the pericoronitis is treated. Otherwise, the risk of surgical infection rises 14  Preoperative assessment (Medical & dental history)  Take history of : General disease - previous difficulty with extraction  Clinical examination Tooth accessibility (mouth opening) The upper & lower teeth on the side of complaint ST inflammation, swelling & oral hygiene Crown condition & degree of tooth mobility 15 Radiographic evaluation o Ideally any tooth to be extracted should be Roots configuration: number, shape curvature, root canal radiographed (practically impossible) treatment (RCT) o Only recommended if: Condition of the surrounding bone: height, density, apical 1. History of difficult or failed extractions pathology 2. Close approximation to MS or IAC Vital structures: successors, IAC, MS 3. All impacted or malposed teeth 4. Heavily restored, badly decayed or Endodontically treated 5. When any bone disease is suspected 6. Teeth that have been subjected to trauma  Radiographs Intraoral Extra oral Periapical Occlusal used when intraoral films cannot be taken due to pathological condition leading to trismus. orthopantomogram Postero- Lateral Oblique (OPG) anterior for examination of the for buccolingual localization root and the apical tissues of impacted teeth  Patient preparation A napkin should be put across the patient's chest to decrease the risk of contamination Before extraction, patients rinse their mouths with antiseptic mouth rinse (chlorhexidine). This ↓ the amount of bacteria in the patient's mouth, which helps to reduce the risk of postoperative infection 18 19  Two beaks constructed of stainless steel or cobalt chromium alloys Joint composed of 3 parts Two handles Lower forceps Upper forceps 20 Two handles: One Joint – Serrated to avoid slippage during extraction Rigid & strong – Of suitable size to rest comfortably in operator’s hand Provide free movement for easy function – Long enough to provide strong & steady extraction Stable & free from rocking movement movements that may cause tooth fracture – Must be suitable in shape and design to suit the area of the It must be lubricated with sterile oil tooth extraction Serrated handles Small joint Large joint 21  Blades vary in width, length and curvature to Two blades (beaks): accommodate the different shapes of teeth Must be sharp enough (not knife sharp) to be introduced under the gingival margin, without causing contusion of soft tissues Must be of proper angulation with a space, to avoid crushing the tooth Blades have inner serrations Any error in forceps adaptation to the tooth will cause: – Slippage of the instrument – Injury to adjacent teeth – Tooth fracture 22 23 Extraction set of forceps Consists of 7 forceps Upper anterior, premolar, Lt and Rt molars forceps They differ from each other in: Lower anterior, premolars, molars forceps Shape of blades to fit the different In addition to: shapes of roots Bayonet forceps Angles between handles & blades Jocky forceps allow maximum accessibility to the upper right and left Cow horn forceps and lower tooth to be extracted Cow horn forceps 24  Curve ==== Accessibility They have their handles in line with the blades 25 Upper anterior forceps (straight) Root Forceps Straight handles For removal of upper anterior remaining roots No angle between handles & blades o Wide spaced blades: for extraction of 1 & 3 (accessible for single rooted upper o Narrow pointed blades: for extraction of 2 & anterior teeth) upper anterior remaining roots Blades are mirror image o When extracting several adjacent teeth including canine, it is advisable to remove the canine before 2 or 4 as their loss will weaken the labial bone 26 Upper premolar forceps Handles are angled in opposite direction to the blades to allow: B P 1. Correct alignment of blades to the tooth (accessibility) 2. Avoid the handles pressing on the lower teeth or lip, as happen with straight forceps 3. Allow the instrument to sit more comfortably in the palm of the hand Blades are mirror image, sharp, with rounded end 27 Upper molar forceps 6 & 7 have 2 buccal roots & single palatal root Buccal blade has projecting tip that fits between buccal roots, while palatal blade is smooth with no projecting tip (Blades are not mirror image) Handles & blades are curved as upper premolar forceps, to provide correct alignment of blades on tooth (accessibility) Because of handles curvature & asymmetric beaks, two separate forceps are needed for the right and left sides Right Left 28  Jocky forceps Bayonet forceps For extraction of 8 (single conical root) Very narrow, long, rounded end and Blades: broad, smooth & offset from the mirror image blades that are offset from handle in a distal direction, for proper the handle in a distal direction alignment on the tooth Use: removal of remaining roots of There is a double angle between maxillary molars and rudimentary the blades and the handles wisdom (separated roots) It is used, due to the difficult accessibility Double angle between blades and handles by the forward movement of the coronoid Distal offset of bayonet & jockey: allow operator to reach process when the mouth is opened the posterior aspect of the mouth while the forceps blades remain in the correct position 29 Upper cow horn forceps Design variation of maxillary molar forceps With longer accentuated, pointed buccal beak. Use: maxillary molars with badly decayed crowns The sharply pointed beak may reach deeper into the tri-furaction 30 Right Left  Blades at right angles to handles Blades are mirror image Anterior Premolar Molar Cow horn All types of lower forceps can be used on either side of the mouth (i.e. no right and left forceps). 31 Lower anterior & roots forceps Lower premolar forceps Similar to lower anterior forceps, but: Beaks: narrow pointed (that Have broader, smooth, & spaced beaks meet at their tips) Used for extraction of lower premolars Use: Extraction of lower anterior teeth & lower remaining roots 32  Lower molar forceps Lower Cowhorn forceps Buccal & lingual Have long, accentuated, pointed buccal & projecting tip Lower molars have mesial & lingual beaks distal roots. So both buccal & Use: mandibular molars with badly decayed lingual blades of lower molar crowns forceps have projection tip to Pointed beaks engagelower molar furcation, this creates force against the alveolar bone be engaged in the bifurcation crest & forces the tooth superiorly out of the socket (double wedge action) M D Cowhorn forceps often split the roots, enabling the separated roots to be extracted 33 more easily  Basic principles for forceps technique Beaks should be seated as far apically as possible Beaks should be // to the long axis of the tooth Excess force should be avoided Mechanical principles involved in tooth extractions 1. Expansion of the bony socket 2. Insertion of wedges Achieved by using the tooth as a dilating instrument By inserting forceps beaks (act as wedges) between root & bony socket, a deep apical grip leads to bone expansion, forcing the tooth out of socket 34 35 A. Forceps handling (Grasp) Hold the forceps in the palm of right hand with Curved side the thumb finger supporting it at its joint In upper premolar & molar forceps, the curved side of handles should rest on palm of hand Forceps should be gripped as near as possible to the free ends of the to apply maximum force In lower forceps the hand must be placed above the forceps 36 Maxillary forceps Mandibular forceps Placing the index finger inside the handles Weak force and Low control Greater force and Low control 37 In lower forceps the hand must be placed above the forceps B. Retraction and support In extraction of maxillary teeth: Retract and protect the lip and cheek and support the alveolar process of the maxilla using the fingers of the left hand in a pinch grasp Alveolar bone fracture can be detected at an early stage thus altering the extraction technique to prevent the removal of bone with the tooth 38  In extraction of the mandibular teeth: Sling grasp The fingers of the left hand are used for retraction and protection of cheek, lip and tongue, alveolar bone support and for supporting the mandible in a sling grasp, to counteract the forces of extraction to prevent injury of TMJ Right side: Left side: Lt index finger: buccally left index finger: buccally reflecting cheek reflecting cheek Thumb finger: lingually reflecting tongue. Second finger: lingually A mouth prop should be used when removing lower Three fingers are positioned reflecting tongue. under chin teeth to minimize trauma to TMJ Thumb is under chin39 C. Tooth grip Role of parallelism: The blades should be // to the long axis of the tooth, to distribute the Apical (initial) movement: force the blades of the forceps forces to the root under the gingival tissues, down the periodontal ligaments, untill the blades grip the root at or below the cemento-enamel junction Correct alignment Poor alignment Not at the crown will concentrate forces at the points of below CEJ to avoid tooth fracture contact, leading to root fracture 40  Inner surface of forceps blade should snugly fit the root surface (firm grip) For convenience, apply the blade to less accessible side of the tooth (lingual or palatal) then to the other side (buccal) Don't allow the forceps to slide along the tooth surface to avoid injury Extraction movements should be: Start with the side of least resistance Reasonable force is applied. Slow, steady, gradually  force in B-L direction Allow bone to expand and Cutting the PD ligaments attachment 41  Little finger is placed on the inside of the D. Extraction movement handles to facilitate forceps adjustment on 5 major motions that the forceps can apply to the tooth luxate the teeth and expand the bony socket: The little finger should then be moved to 1. Apical pressure A outside the handles as the tooth is gripped to 2. Buccal pressure B join the other fingers, and then extraction 3. Lingual pressure L movement is started 4. Rotation R 5. Traction T 42 1. Apical pressure A Improper apical grip 2. Buccal pressure B: (Wedging) lead to apical fracture (outward movement): results Expand the crestal bone. in buccal plate expansion & Displace the tooth occlusally. detaching the lingual 43 periodontal ligament  4. Rotation R: Once the tooth becomes luxated, rotatory movement is performed for complete detachment of periodontal ligament Teeth with single conical roots 1 & 5, without additional movements 3. Lingual pressure L: (inward movement) long standing remaining roots, because their results in lingual plate expansion & alveolar structures undergo resorption & are detaching the buccal periodontal ligament replaced with granulation tissues Internal socket expansion Tear P.L. attachment 44  Extraction force should be held for several 5. Traction T: for delivering the seconds to allow bone expansion tooth from the socket after bone expansion Jerky movements cause fracture because it Traction should be directed outward does not allow socket expansion to: Avoid traumatizing the opposing teeth Avoid slipping the tooth from the traction is buccally forceps (aspirated or swallowed) Figure of eight movements: a 4 has two tapered BP roots (easily combination fractured): only Traction with minimal B-P B, L and R movements, performed 45 in a dynamic fashion Uses of the left hand Pinch grasp (upper jaw), sling grasp (lower jaw) Compression of dilated socket after extraction, to soft tissues retraction: tongue, cheek, & lips (improve decrease the size of the blood clot (rapid access & vision) (protection from injury by forceps) uncomplicated healing) Protection of adjacent teeth Stabilize the patient's head during extraction Support & stabilize TMJ (counteract extraction forces to Remove broken filling, tooth fragments ….. prevent dislocation) Detect sharp edges or loose bone fragments Support alveolar bone around the tooth Provide tactile information, toward changes in the alveolar process during extraction 46  Anatomical factors influencing forceps movement 1. Thickness of alveolar bone on buccal & b. Mandibular alveolar bone: lingual sides: Anterior buccal bone till the region of 1st molar is a. Maxillary alveolar bone: Buccal side is thinner than lingual bone, so must stress on buccal thin, while palatal side is thicker. stress movement (B > L). stress should be placed on buccal on buccal movement (B>P) as buccal movement (B>L). bone is easier to expand In 7, 8 , the buccal bone is thicker than lingual bone, (external oblique ridge) so must stress on lingual movement (B < L) General rule: initial extraction movement is toward the side of less resistance. In case of extensive caries, movement starts at the side of caries due to alveolar resorption at that side 47 2. Shape of roots Round, ovoid, single root or multi roots e.g. round conical root extracted with rotation Linguobuccal movement Rotatory movement round & conical 48  Immediate post-extraction care Examine the socket for the following: Squeeze socket using thumb & index finger to: Any tooth fragment, broken filling or pieces of calculus – Decrease the socket orifice: for proper Sharp projecting bony septae should be trimmed with organization of the blood clot rongeur or bone file to avoid infection & postoperative pain – Prevent the entrance of saliva loaded with Inspect soft tissues for any laceration food debris & MO into the socket Amalgam fragment – To prevent bony undercuts Clean patient's lips & face from any blood Dismiss the patient after examining the socket for abnormal bleeding Bony septae Do not curette the socket 49 Postoperative instructions Avoid any hot food, drinks and mouth washes (for the first 12 hrs to prevent bleeding Verbal Written Start cold, soft food & drinks 2 hrs after extraction Bite on cotton or gauge for one hour, this pressure Do not disturb extraction site by putting fingers or results in hemostasis. The gauze should fit into the tongue on it space that occupied by the crown of the tooth Avoid the use of straw after surgery Don’t spit or rinse (1st day of extraction) Do chewing away from extraction site No physical activity for 24 hours. 50  No smoking Cold compress with ice packs to the face, after Avoid brushing teeth near extraction site prolonged surgical procedure for the rest of the Use warm saline wash after 24 hrs for next 3-5 days 3 day times/day ((1/2 teaspoon of salt in a cup of warm water) Instruct the patient to call you if there is after meals and before bed, to keep the area clean) excessive bleeding, swelling, severe pain, and Analgesics, for pain relief (e.g., acetaminophen or fever ibuprofen) 51  Primary Teeth Deciduous teeth are easier to extract than permanent teeth. But some factors may complicate extraction: Limited access as mouth is small. Developing premolars are enclosed within the roots of deciduous molars so they are liable to damage Deciduous molars have thin resorbed roots. Also, caries invades roots, making forceps grip difficult 52 These difficulties require some modification to extraction technique in children: Smaller forceps have narrower & shorter When this happens, the partially formed tooth should blades (to not endanger the successors) be carefully freed from the primary roots and replaced Care must be taken not to place the beaks of in the alveolus, the soft tissues are then sutured over forceps deep down on the deciduous molars the alveolus to hold the bone and the tooth in position. roots because of great possibility of removing the partially formed permanent teeth. 53  Slow buccal pressure with minimal rotation Consider primary molar sectioning: If the roots of deciduous molars encircle the premolar tooth bud If fracture of deciduous roots occurs, do not curette the socket. It is better to leave small fragments to undergo resorption rather than endanger the permanent premolar After extraction, examine the roots to differentiate between resorption and fracture 54