Exodontia Flashcards
What are the indications for an extraction?
- pulpal pathology- irreversible pulpitis (unrestorable teeth)
- periodontitis
- orthodontic- malposition of teeth in the arch
- focus of infection
- unsplintable/unmanageable trauma
- impacted or unerupted teeth (e.g. ectopic canines)
- cysts/tumours
Give an example of an odontogenic tumour
Moniocular bone invasive tumour
How can an odontogenic tumour be managed?
can be treated with a local resection at best
When obtaining consent for an extraction, what must you include in your consent delivery ?
- why they are having the treatment
- the implication of not having the treatment
- what treatment options are available
- all possible serious adverse effects of each treatment
- the more likely but less serious effects
What are the types of consent forms available?
- patient agreement
- parental agreement
- patient/parental agreement
- healthcare professionals
What pre-checks are required before performing an extraction?
- right patient
- consent checked and confirmed
- adequate LA
- assistant
- infection control
What are some “redflags” for extractions ?
- diabetes and hypertension- immunocompromised- risk of infection
- pt on steroid therapy- immunocompromised- risk of infection
- pregnancy
- active infection
- bleeding disorders
- radiation therapy- bone health?
Outline the equipment required for an extraction
- mouth mirror
- probe (use to check LA)
- tweezer
- gauze pack (wet to prevent dislodging of the clot)
- LA syringe
- elevators
How can you identify maxillary forceps?
if the beak of the forecep is along the long axis of the handle
How can you identify mandibular forceps?
if the beaks are perpendicular to the long axis of the handles
Outline the anatomy of a forcep
- blades/beaks [there is a beak on the blade of forceps]
- hinge
- handles
How are beaks of a forcep configured?
they are configured in a way that can engage the root of the tooth
beaks are also configured to take into account the morphology of the crown. For instance, deciduous teeth are more bulbous due to short cervical-incisal length
How are beaks configured for deciduous teeth?
curvature of the forceps for a deciduous tooth is greater (compared to curvature of forceps in permanent teeth)
more curved teeth require more rounded beaks
Briefly describe the nature of single rooted teeth
- rounded
- oval
- often have a longer bucco-lingual dimension
- not as wide mesiolingually
Describe the furcation observed in mandibular molars
- one side bifurcation
- bucco-lingual bifurcation
Describe the furcation observed in maxillary molars
- bifurcation on both buccal as well as palatal roots
Based on root morphology, for every bifurcation, what must be present on the blade of the forcep?
there must be beak on the blade of the forcep for every bifurcation
How would you determine whether you are holding a left or right posterior forcep?
- beak to cheek rule
- the beak must face upwards
- the beak must face the cheek and not towards the palate
- the beak must engage the buccal furcation !
Upper forceps with a slight curve can be used for extracting…
premolars
What are the steps for forcep engagement on a tooth?
- application of forceps
- dilation of socket
- disengagement of tooth
- restoration of socket
- bitepack
Outline the steps of an extraction procedure
- patient position
- operator position
- infection control
- steps with forceps
- POI
Outline recommended patient positions for a maxillary extraction
- supine position- gives tactile feedback
- patient at 45 degree angle; should be no higher than the shoulder, as low as reasonably possible, at elbow levels
How should the clinician be positions for an upper teeth extraction? Include other conditions for extraction
- operator in front and to the right of patient
- steady stance
- operator MUST support alveolus
- tooth to be extracted should be AT shoulder height of operator
- patient head retroclined at 45 degree
- area is full visible and well illuminated
How should the clinician be positioned for a lower left extraction? Include other conditions for extraction
- operator in front of and to right of patient
- steady stance
- supporting alveolus
- tooth to be extracted should be at elbow height ot the operator
- patient head almost vertical
- visible and well illuminated
How should a clinician be positioned for a lower right extraction? Include other conditions for extraction
- operator can stand behind and to the right of patient
- or in front on the left between (1-3 o’clock)
- steady stance
- supporting alveolus
- tooth extracted at elbow height of operator
- patient head almost vertical
- visible and well illuminated
What is the first step in an extraction?
Sever or loosen the soft tissue attachment surrounding the teeth
Detachment of the tooth from the gingiva at least up to septal bone
detachment of junctional epithelium to allow placement of the forceps to the cervical 1/3 of the root cementum
What instruments can be used to sever the soft tissue attachment of a tooth?
straight and curve desmotomes
What are the main ways for holding forceps
horizontal grasp
vertical grasp
Describe how forceps should be applied to the tooth
- pushed along the long axis of the tooth
- (after seperation of gingiva from tooth) blades should be forced onto the root cementum under the gingiva using apical thrust
- maintain apical pressure throughout the extraction to engage the root
Describe an acceptable forcep contact with the root
should be intimate
forcept should be completely disipated allong the tooh
A full embrace
What kind of forcep contact is unacceptable for forcep engagement with the root?
a one-point conact
there must be at least a 2 point contact
What is the role of the opposite hand of the operator?
- supporting and stabilising the lower jaw
- support the alveolar process and provide tactile information to the operator regarding the expansion of the alveolar process during the luxation period
What hand positions are available for the operators opposing hand?
pinch grasp
mandubular sling grasp
How would you position the opposing hand for a lower extraction?
thumb can be used to support the lower border of the mandible
What is the aim of the dilation of the socket?
expand the alveolus and shear the periodontal ligaments
What is the primary movement of a forcep?
apical thrust
What is the secondary movement of a forcep?
bucco-palatal??
buccal movement
Why must apical pressure be maintained throughout the extraction?
to continue to engage the root
Why do we not rock the tooth palatally?
this is because the palata bone is compact and does not expand
thus it is likely to fracture
Why are we able to get away with a bucco-palatal movement in children?
their bone is more elastic
What is the wedge principle?
application of the blade of an elevator between the tooth and the bone parallel to the long axis of the tooth
Where should the centre of rotation be when extracting incisors? Why ?
should be as away from the crown as possible
increases the chance of the alveolus expanding on both sides
How should the tooth be disengaged?
- traction should be away from the apical region
- slight rotation to free gingival attachment
- avoid tearing mucosa
- use of elevators to ease gingivae
- do not squeeze you palm!
- do not squeeze the tooth
*
List the secondary movements
- buccal pressure
- palatal pressure (discussed breaking of compact bone previously)
- rotation- single rooted tooth- figure of 9
- traction- pulling when you know tooth is reasonably mobile
Following an extraction, how do you restore the socket?
- after checnking the root apex and the socket to ensure no fragment is left behind
- compress the alveolus
you want the epithelium to migrate over the clot that has formed in the socket.
The clot is then slowly broken down; the connective tissue and bone can be laid down
How long does it take bone to heal?
6 months
What are the mechanical principles for tooth extractions ?
- expansion of the bony socket
- use of fulcrum or lever
- inserion of wedge or wedges
- wheel and axel
What are the uses of elevators ?
- to reflect periosteum
- luxate the tooth (dislodge)
- luxate and remove tooth where forcep engagement is not possible
- remove fracture or carious tooth
- remove interradicular bone
- to remove fractured tooth
What is the anatomy of an elevator?
- blade
- shank
- handle
The bigger the handle of an elevator…
the more force can be used
What is the appropriate hand grip for an elevator?
modified pen grip
Where should the tip of an elevator rest?
on the fulcrum
What are the principles for use of an elevator?
- never use adjacent tooth as fulcrum
- never use buccal or palatal plate as a fulcrum
- direction of use should be correct
- always use finger guards to protect soft tissue
- alwasy elevate from mesial side of th tooth
- the concave or flat surface of the elevator should face the tooth/root not being elevated
What is an appropriate fulcrum for elevator use?
the interdental alveolar bone
Why shouldn’t you use the adjacent tooth as a fulcrum?
- can cause subluxation of tooth
- pushes tooth down, can lead to periapical ischaemia
What are the principles of extractions?
- wedge principle
- lever principle
- wheel and axel principle
Further elucidate the wedge principle
wedges is placed along the long axis of the tooth if it is conical; the force gets trasmitted in the opposite direction
Give the instances where the wedge principle is useful
- the beaks of the extraction forceps are used as a wedge (beaks placed along the long axis)
- then a straight elevator is used to luxate a tooth from its socket
What are the classifications of elevators?
- straight- couplands
- triangular -cryers
- pick type - warwick james, apexo
What is the process for root fragment removal with no flap present?
remove with forceps or elevators
What is the process of root fragment removal with a flap present?
- bone removal
- remove with forceps or elevators
What is a lever?
simple machine used to lift heavy objects with minimal effort
What are the components of a lever?
- effort
- fulcrum
- load
Briefly describe where the components are located in a second class lever
- fulcrum located at other end of the bar opposite to th input
- output load is at a point between the fulcrum and input forces
What is a root tip?
more than 1/3 of the root
5mm of the root
What technique can be used to remove a loose root tip?
forcibly irrigate with saline
remove with suction or apex elevator
loosen with explorer or elevator, forcibly irrigate with saline
What techiques can be applied to removed attached root tips?
- loosen with explorer or elevator
- extend bone removal from alveolar crest
- using a curved flap, approach root tip through performing endodontic apical surgery
In a root elevation technique, what can be used to remove a root tip wth an exposed root canal?
endodontic file; used as an anchor to lift the root out
