mandhan Introduction Exodontia is a branch of dentistry that deals with extractionremoval of teeth An ideal extraction is defined as the painless removal of whole toothroot with minimum trauma to the investing tissue so the wound heals uneventfully ID: 908119
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Slide1
Exodontia
By
–
swati
mandhan
Slide2Introduction
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.
Slide3Techniques 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
Slide4Indications
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.
Slide5Contraindications
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.
Slide6Systemic 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
Slide7Systemic 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
Slide8Armamentarium 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.
Slide9Armamentarium 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.
Slide10Maxillary 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.
Slide11Maxillary 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.
Slide12Maxillary Forceps
Maxillary Anterior Forceps
Maxilary Premolar Forceps
Maxillary Left Molar Forceps
Maxillary Right Molar Forceps
Maxillary Residual Root Forceps
Slide13Mandibular 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.
Slide14Mandibular Forceps
Mandibular Canine and Incisor Forceps
Mandibular Bifurcated Molar Forceps
Cowhorn Forceps
Mandibular premolar Forceps
Mandibular Molar Forceps
Slide15Instruments 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.
Slide16Characteristics 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.
Slide17Commonly 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.
Slide18Commonly 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.
Slide19Mechanical 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.
Slide20Lever Principle
Slide21Mechanical 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.
Slide22Mechanical 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.
Slide23Indications 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.
Slide24Preoperative 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
Slide25General 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
Slide26General 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
.
Slide27General 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
Slide28Steps 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.
Slide29Steps 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
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
Slide31Complications 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.
Slide32Post-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.
Slide33THANKS FOR WATCHING