Exodontia By – swati - PowerPoint Presentation

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Exodontia

By

–

swati

mandhan

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Introduction

Exodontia is a branch of dentistry that deals with extraction/removal of teeth. An ideal extraction is defined as the painless removal of whole tooth/root with minimum trauma to the investing tissue, so the wound heals uneventfully.

Removal of teeth only requires fine and controlled forces.

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Techniques of Dental Extractions

Intra-alveolar extraction/Conventional extraction:

Removal of tooth /roots by using specially designed forceps and elevators. This method cannot be used in root deformities and Grossly decayed crown or root.

Transalveolar extraction: Carried out by planning surgical flap technique with alveolar bone removal and tooth sectioning of a tooth/root.

Stobie Technique:

Extraction of multiple Mandibular anterior teeth using dental elevators for teeth extraction.

Intra-Alveolar Extraction

Transalveolar Extraction

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Indications

The extraction of teeth is usually carried out as a last resort for the therapeutic or prophylactic purpose.

Unrestorable teeth which may be affected due to following reasons:

Severe Carries: Seen in 49% cases. endodontic treatment  is not possible either due to technical or economics reason

Serial periodontal disease sign in 41% of cases

Severe  attrition aberration erosion

Acute or chronic colpitis or pulpal necrosis due to trauma

Over retained deciduous teeth blocking the eruption of permanent tooth

Supernumerary tooth

Malposed teeth

Impacted teeth

Tooth in the fracture line:  Only if the fracture tooth is a source of infection for root fracture is there.

Tooth directly involved in Pathology: cyst, tumor.

Teeth with cracked tooth syndrome

For orthodontic treatment:  crowding and malposed teeth

For prosthetic purpose

Supra erupted tooth

Teeth Causing chronic trauma to the soft tissue of oral cavity.

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Contraindications

It is usually classified as due to systemic and local regions: further divided as relative and absolute contraindications.

Relative contraindications suggest that the patient can be improved by proper medication and following certain treatment protocols.

Absolute contraindications

if ignored, then simple extraction may turn into fatal or life threatening event for a patient.

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Systemic Contraindications

Relative Contraindication:

Cardiovascular System: Rheumatic heart disease, Coronary heart disease, Myocardial infraction, Congestive Cardiac Failure

Blood dyscrasias: Anemia, Leukemia, Agranulocytosis

Uncontrolled Diabetes

Uncontrolled Hypertension

Nephritis

Toxic Goiter

Jaundice, Cirrhosis of liver

Bleeding disorder: Hemophilia

Acquired Coagulopathies and Anti-platelets drugs

Neurological disorders: Epilepsy

Adrenal insuffiencincy

Respiratory System: Asthma, COPD, Pulmonary Tuberculosis

Patient on long term Corticosteroids

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Systemic Contraindications Contd.

Physiological Contraindication:

Pregnancy: First and last trimester are more crucial period. All the dental invasive procedures should be avoided, unless severe infection warrants the emergency treatment.

Extraction during menstruation period: High circulating Estrogen levels may cause excessive bleeding.

Extreme Old-age: Compromised body physiology as well as physical and mental condition should be handled with utmost care.

Relative Contraindication:

Acute Generalized Periodontitis, Acute Necrotizing Ulcerative Gingivitis (ANUG).

Acute Pericoronitis

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Armamentarium Used for Exodontia

Extraction Forceps:

These are designed to grasp and deliver the teeth from the sockets.

The forceps design is based on crown shape, root shape, tooth size and location in the mouth.

Each forceps has two handles, a hinge joint and two beaks.

The handles must be of suitable size, to rest properly in the operator’s palm. The handles act as a lever, which gives mechanical advantage.

If the handles are held far from the beak, less efforts are required to apply the force during extraction.

The beaks are applied along the long axis of the tooth:

Below CEJ in Mandibular teeth

Above CEJ in Maxillary tooth

A Firm grip on the tooth is established prior to give movement to forceps.

The hinge joint allows the beak to open, close and grasp the root. The joints should have free movement for easy manipulation.

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Armamentarium Used for Exodontia

Forceps design styles:

American Pattern: Hinge is directed horizontally with the handles of the forceps.

English pattern: Hinge is directed vertically to the handles of the forceps.

Forceps used for Maxillary and Mandibular teeth are different in design.

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Maxillary Extraction Forceps

Maxillary Anterior Forceps

: They have identical beaks that are closed, straight, flat and broad. The handles are straight, not curved.

Basic Forces:

Maxillary Central incisors – Labial movement, Mesial rotation

Maxillary Lateral incisors – Labiopalatal movement, removal in labial direction

Maxillary canines – Labiopalatal movement, removal in labial direction

Maxillary Premolar Forceps

: They have identical beaks that are concave and facing the operator and are broad and open.

Basic Forces:

Buccopalatal movement, removal in buccal direction.

Maxillary Molars

: Beaks of these forceps are not identical. One of them is rounded while the other is pointed. The pointed beak engages the buccal groove between the buccal roots and the other beak engages the palatal surface above the CEJ. The handles have concavity on the inner side and convexity in the outer.

Basic Forces:

The First and Second molars are extracted by giving buccopalatal movements and removal in buccal direction.

The third molar is extracted by giving buccal movements and Distal rotations.

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Maxillary Molars Forceps

Maxillary Cowhorn Forceps

: these forceps have unidentical beaks, one of which has a single pointed tip and other bifed pointed tip. The single pointed tip engages the furcation and other tip engages the palatal root. They are used for teeth where there is extensive destruction of crown but the trifurcation of root is intact.

Maxillary Anterior Root Forceps

: They have identical straight, slender and closed beaks, used for extraction of root stumps.

Maxillary Posterior Root Forceps

: They are similar to Anterior forceps but have curvature towards the operator for access posteriorly.

Bayonet Forceps:

They have identical pointed, angulated and closed beaks. According to the thickness of beaks, they can be classified a Thick beak and Thin beak Bayonet forceps.

Maxillary Third Molar Forceps:

The handles are extra long and the beaks are angulated shaped.

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Maxillary Forceps

Maxillary Anterior Forceps

Maxilary Premolar Forceps

Maxillary Left Molar Forceps

Maxillary Right Molar Forceps

Maxillary Residual Root Forceps

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Mandibular Forceps

They are designed such that handles and beaks are at right angle to each other.

Mandibular Anterior forceps:

They have identical, broad, short and closed beaks.

Basic forces: central and lateral incisors: labiolingual and mesiodistal movement and removal in the labial direction.

Cuspid: labiolingual movement and removal in the labial direction.

Mandibular Premolar forceps

: They have identical broad open beaks that are longer than the beaks of anterior forceps.

Basic forces: buccolingual and mesiodistal movements.

Mandibular Molar forceps

: They have identical, broad, stout open beaks with a pointed tip.

Basic forces: buccolingual movements and removal in the buccal direction.

Mandibular Cowhorn forceps:

They have identical, open, short and pointed beaks that resemble the horns of a cow. They are used to remove grossly carious mandibular molars with extensive destruction of the crown.

Mandibular Root forceps

: these

forceps

have identical, slender beaks are closed. It is used for removal of root stumps of all the mandibular teeth.

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Mandibular Forceps

Mandibular Canine and Incisor Forceps

Mandibular Bifurcated Molar Forceps

Cowhorn Forceps

Mandibular premolar Forceps

Mandibular Molar Forceps

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Instruments used to Luxate the Tooth

Elevators: the dental elevators are used to luxate/ elevate the teeth from the socket prior to application of the forceps. The elevator has three components:

Handle:

This is usually large in size to facilitate a good grip on the instrument while working.

Shank:

It connects the handle to the blade. The shank should be strong enough to withstand the forces.

Blade:

The blade of the elevator is the working tip. It is used to transmit forces to the tooth, root and bone.

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Characteristics of Elevator

Elevator has no joint, needs a fulcrum to work and has to be wedged.

Blades can vary in size and shape and depending on that the elevator are classified as:

Depending on the working tip shape:

The straight or gouge type

The triangular type

The pick type

According to the use of elevator designed to remove:

The entire tooth: straight elevator hospital pattern, Coupland elevator.

The roots broken at gingival margin: Apexo elevator, Coupland elevator.

The roots broken off halfway to the apex: Curved hospital pattern, winter elevator.

Apical third of root.

According to form:

Straight or gouge type: all types, wedge type, Miller, Pott elevator.

Curved right and left Cryer's Apexo elevator.

Angulated or triangular: Right and left Cryer's or pennant type.

Cross bar: Handle at right angled to the shank, winter elevator.

Pick type: Crane pick, Root tip pick.

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Commonly Used Elevators

Straight Elevators:

They are the most common types used for the luxation of teeth. The Blade has a concave surface or one side that faces the tooth to be elevated.

Hockey stick or London Hospital Elevator:

This elevator is similar to the Cryer’s elevator with the working blade at an angulation to the shank ,but the blade is straight rather than triangular and has a convex and a flat surface.

Apexo elevator:

These are state animated that resemble the Cryer’s elevator but has a biangulated and sharp straight working tip. They are paired Elevators for mesial and distal roots

Cryer’s elevator:

 Cryer’s elevator is a straight elevator with the triangular blade. The working tip is angulated with one convex and another flat surface.

Uses: For extraction of root stumps,

For extraction of Mandibular molar root stump when both the roots are present.

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Commonly Used Elevators Contd.

Winter’s elevator:

Winter’s elevator is a crossbar elevator.  the shank is at right angle to the handle.  the working tip is at an angle to the Shank. The Blade has a convex and a flat surface.

Uses: To luxate the mandibular molar teeth.

Winter Cryer’s elevator

: As the name suggests the elevator is a crossbar elevator with the triangular blade.

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Mechanical Work Principles

There are three work principles applicable to the dental elevators.

They are:

Lever Principle

Wedge Principle

Wheel and Axle Principle

Lever Principle

:

This is the most commonly used principle. In this, the Fulcrum is located between the input effort and the output load/resistance. In order to gain mechanical advantage, the effort arm must be longer than the resistance arm.

Use of lever principle while using

Forceps

:  While extracting a tooth, controlled force is delivered in a predetermined direction. The effort of power is represented by handles of forceps.

Use of lever principle while using

Elevators:

  This principle is also used when elevators are used, where modest force is transmitted at long power arm or handle, so that the mechanical disadvantage is derived at short-weight arm. 

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Lever Principle

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Mechanical Work Principles Contd.

Wheel and Axle Principle:

  The mechanical device consists of a wheel attached to an axle or central pole, where torque is applied to the wheel winds a rope or chain onto the axle. The wheel and axle principle is actually a modified form of lever principle. A light force applied to a crank handle onto the side of a wheel creates a torque about the axle centerline to lift heavy load. Greater the diameter of the wheel, more is the mechanical advantage.

The principle is applicable to crossbow and Cryer’s

elevator

where mechanical advantage is 4.6.

To remove the teeth using

forceps

, it engages labial/buccal and lingual/palatal aspects of a tooth and then force is applied in the form of an arc to the handles, which results in the rotation of a tooth in the socket.

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Mechanical Work Principles Contd.

Wedge Principle

:

It consists of two movable inclined planes, which meet and form a sharp angle. The effort is applied to the base of the plane and the resistance has its effect on the slant side. A wedge can be used to split, expand or displace the portion of a substance that receives force. Mechanical advantage of a wedge is 2.5.

The wedge

elevator

is forced between the root and the bone, parallel to the long axis of the tooth . Warwick James elevator can displace the roots toward the occlusal plane out of the socket.

The dental

forceps

also take the advantage of this principle. The narrow tip is first introduced below CEJ  and the broader portion of the week is gradually inserted further by expanding the bone.

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Indications for the use of Elevators:

To luxate

multirooted

teeth prior to the forceps application

To luxate, remove teeth that cannot be engaged by the beaks of forceps 

To remove fractured root stumps or apical tips.

Rules to be followed while using the Elevators:

Hold the elevator with palm grip

Never use the adjacent tooth as fulcrum

Never use the buccal and lingual palate as fulcrum

Always use finger guard to protect the soft tissues if the elevator slips.

Always elevate from the medial side of the tooth.

The concave or flat surface of elevator faces the tooth/root to be elevated,  follow the root curvature.

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Preoperative Assessment

Taking History Of:

General Disease

Nervousness

Resistance to inhalational anaesthesia

Previous difficulty with extraction

Oral Hygiene Status of Patient:

Oral Prophylaxis

Antiseptic mouth rinse

Clinical Examination of Tooth

Clinical Examination of Oral Cavity

– Any Prosthesis

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General Arrangement

1. Position of Operator:

Stand erect, Equal distribution of weight on both feet

Force delivery – with arm and shoulder, not with hand

Application of force without stress to shoulders and back

Generally on right hand side

For right posteriors – Back side

Operating box

2. Position of Patient:

Make the patient comfortable on dental chair

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General Arrangement Contd.

3. Height of Dental Chair:

Maxillary teeth –

8 cm or 3 inch below the shoulder of operator.

Mandibular teeth –

16 cm or 6 inch below the elbow of operator.

4. Angulation of the chair:

Maxillary teeth

– 45-60 degrees

Mandibular teeth

– Parallel or 10 degrees

5. Light:

Good Illumination

6. Role of Opposite Hand:

Reflection of Soft Tissue

Protection of other teeth

Stabilisation of patient’s head

Supporting Alveolar bone or Mandible

Tactile Information

Compress Socket

Deliver the whole tooth, root, dislodging filling

.

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General Arrangement Contd.

7. Role of Assistant:

Helps the surgeon to gain access & visualise the field.

Suction

Protect the teeth of opposite arch

Support the head

Support the mandible

Psychological & emotional support

Avoid Casual, offhand comments

Increase Patient’s anxiety

Decrease Patient’s Cooperation

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Steps to Carry out Simple Extraction

Step 1 (Severing/loosening the soft-tissue attachment around the tooth):

Separating the tooth from the alveolar bone along with crestal and principal periodontal fibres, and gingival papilla is carried out by using moon’s probe for specially designed straight or curved desmotome or periosteal elevator.  it also helps to access the depth of local anesthesia.

Step 2 (Luxation of tooth with a dental elevator)

(Optional step):

Usually straight elevator is used, which is inserted perpendicular to the tooth into the interdental space after reflection of interdental papilla. Slow strong, forceful turning of the elevator is carried out with the inferior portion of the blade resting on the alveolar bone and the superior portion of the blade is turned toward the tooth to be extracted.

Step 3 (adaptation/application of the forceps to the tooth):

 

Expansion of bony socket:

Bone is relatively elastic, so it is possible to expand the bony socket by inserting the beaks of forceps below CEJ over the root.

Rules to be followed:

 Proper selection of a dental forceps is a must. After placing the left hand in the position, the clear view of tooth is obtained. Tips of the forceps’ beaks are inserted parallel to the long axis. Lingual beak is inserted first and then buccal beak.

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Steps to Carry out Simple Extraction Contd.

Step 4 (major movements of  forceps for luxation of tooth):

Apical pressure/ force during introduction of dental forceps:

 This is the first force generated, by giving a firm vertical pressure up and down the long axis of tooth. the peaks of the forceps are forced into periodontal ligament space.

Labial/Buccal pressure

: It produces expansion of buccal cortical plate

Lingual/Palatal pressure

: It expands the lingual cortical plate

Tips

: The major portion of the force is directed toward the thinnest/weakest bone. Thus in maxilla and all teeth in the mandible, accept lower molars, the major movement is labial/buccal. First the pressure is always applied on less accessible side of tooth. In case of cervical caries, first movement is directed towards carious portion. The next movement is then toward the opposite direction with slow, deliberate, strong pressure.

Rotational Pressure:

Wheel and axle principle for the teeth with single/conical root.

Step 5 (removal of tooth from socket):

Tractional force is used for final delivery of tooth out of socket.

The operator should use different movements were different teeth extraction

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Complications of tooth extraction

Intraoperative Complications (Immediate):

Failure to luxate/ remove the tooth

Fracture of a tooth. alveolus, mandible, maxillary

tuberosity

Mucosal laceration/puncture wounds on gums,  lips, tongue & floor of mouth

Luxation/removal of adjacent tooth

Displacement of root/tooth in facial space, maxillary sinus, lingual pouch

Aspiration of tooth/root

Nerve injury

Haemorrhage - Primary

Temporomandibular joint (TMJ) dislocation/Subluxation

Late Complications:

Chronic Osteomyelitis/osteoradionecrosis

Nerve Damage: Anaesthesia/paresthesia

Chronic Pain

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Complications of tooth extraction contd.

Postoperative Complications (Delayed complications):

Haemorrhage

: Reactionary, secondary

Pain

Dry socket: Alveolar osteitis

Postoperative edema/swelling

Hematoma/ecchymosis

Infection

Tristmas

Systemic Complications:

Syncope

Fits

Respiratory obstruction

Hyperventilation

Myocardial infarction etc. 

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Post-extraction care:

Inspect the socket: Remove the debris, bone or tooth fragments

Irrigate the site with saline

Compress the alveolar bone with from finger pressure

Curette out the granulation tissue from the socket and excess granulation tissue around gingival cuff

Trim/smoothen any sharp edges from alveolar margin with bone file

Ensure hemostasis

Suture, if required

Medications: Antibiotics/analgesics.

Instructions to the patient:

Moist pressure pack to be held with gentle pressure for at least 30 minutes

No spitting/gargling/smoking

Avoid hot food/alcohol for at least 24 hours

Only liquid/semisolid/soft diet.

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