Exodontia: Slides Flashcards
Last tooth in arch is mobilized with…
Straight elevator
What is ALWAYS used when performing and extraction
Gauze throat pack
How many steps are there in a routine extraction
5
All should be considered, but some can be skipped in certain situations
What is general step 1 of an extraction
Loosen soft tissue
What instrument(s) do you use to loosen soft tissue
1 Woodson Elevator
Periosteal elevator (Moldt #9)
What is step #2 of a routine extraction
Luxate tooth with elevator
What instrument is used to Luxate tooth
Usually the small straight elevator #301
What should be used as a fulcrum
The bone, not the adjacent teeth
What is step 3 of a routine extraction
Adapt Forceps to Root
Seat lingual beak first
Position beaks apically under soft tissue
Grasp root
Keep beaks of forceps parallel to root
Sub steps to General Step 3 (Adapt Forceps to Root)
As beaks are worked ______, bone ______ and movement of tooth out of socket may even begin
apically, expands
What is step 4 of a general extraction
Luxate tooth with forceps
- Strong apical pressure
- Slow, firm pressure
- Buccal first and most (usually), alternate buccal and lingual pressure
- Always apical pressure, with some combo of
Luxation
Rotation - Reapply apical pressure
Substeps of General Step 4 (Luxate tooth with Forceps)
What is general step 5 in a routine extraction?
Remove tooth from socket
- Gentle traction, usually toward buccal
- Luxation or rotation must first
expand socket
Disrupt periodontal ligament - Teeth are never removed by “pulling”
Substeps of General Step 5 (Remove tooth from socket)
What does socket debridement mean
Remove granulation tissue with curette
Irrigate if debris is present
- Debride if needed
- Check for sharp bone margins, smooth if needed (bone file/Rongeur)
- Trim excess gingiva
- Place gauze for pressure over extraction site
- Consider suture if papillae significantly loosened
Steps of Closure
General Order of Extraction
Maxillary First
Posterior First
Most difficult (First or Last?)
Symptomatic teeth first if an doubt re: ability to complete procedure in a single setting
What can occur if you over-luxate the tooth?
Buccal plate fracture
Root fracture
What direction are you moving the tooth when you talk about traction
Incisally out of the socket
- No absolutes, just general principles
- Position self based on good ergonomics and ability to apply controlled, effective forces
- Palm up and palm down grip on forceps both have applications
- Patient position may vary with chair design
- Most operators stand, though some are effective with seated technique
General Rules for Patient and Operator Positioning
General Guideline for Patient Positioning for Maxillary Teeth
Patient semi-reclined so that maxillary oclusal plane is about 60 degrees to the floor
height should be at elbow level
General Guidelines for patient positioning for mandibular teeth
Patient somewhat upright, so that lower occlusal plane is nearly parallel to floor
Height adjusted so the arms are comfortable bent (could be elbow level or below)
Specific technique for Mx First Premoalrs
Gentle buccal/palatal luxation
Specific technique for Mx 2nd Premolars
Rotation and Traction
Specific technique for Mx Molars
- Luxate molar to buccal first
- Luxate to palate
- Repeat
- Eventually unseat the palatal root
- Deliver the tooth to the buccal
Specific Techniques: Mandibular Incisors to 2nd Bicuspid
Combination of apical pressure, rotation, traction
Usually minimal luxation is used
What should be balanced in exodontia
Controlled force and Finesse
Specific techniques: mandibular molars
What instruments should be used
Cowhorn forceps if there is a clearly developed furcation
Otherwise, use universal forceps
Specific Techniques:
- Squeeze to seat into furcation
- Pump to begin to raise tooth out of socket
- Subtle figure 8 motion to complete delivery
Special technique for cowhorn forceps
- Keep clear field of vision
- Protect teeth and soft tissues (watch lip impingement by instruments)
- irrigate during bone removal
- support jaw
- Pass instruments
- General emotional support for patients
Role of the Assistant
How would the assistant help keep a clear field of vision
Retraction
Suction
Light adjustment
- Prepare patients for expected course
- Identify potential complications
- Provide a point of contact
Purpose of Post-op Instructions
Give both written and orally
- Mild to moderate pain
- increased with flap or bone removal
Post-op instructions for pain and swelling
What drugs should be used to manage post extraction pain
OTC analgesics are appropriate for simple extractions
mild narcotic combinations for surgical flaps, bone removal, difficult extractions, low pain threshold patients
- Narcotic analgesics are now recognized as gateway to heroin use
- Amount of oral narcotics in circulation is staggering
- Be part of the solution, not the problem
Reasons to avoid over-prescribing opiods
- Little of none for simple extractions
- Little to a lot for flaps, bone removal
- Ice to face 20 minutes on/20 off for 24 hours
- Keep head elevated
- Swelling peaks after 48 hrs then should decrease
Swelling post-op
- Should be minimal
- A little blood mixed with saliva may look like more than it is
- Gauze pressure
- Repeat if necessary throughout first day, call if bleeding persists
- Expect some slight ooze first 24 hours
Bleeding post-op
- Soft, cool foods for the first day, avoid hot liquids
- Chew gently in surgical area for several days (avoid if possible)
- Avoid anything that could dislodge clot (sucking on food or wound, smoking)
Diet, post-op
- Avoid rinsing for the first day
- Rinse mouth with warm salt water several times a day beginning day after surgery
- Brush gently/may need to avoid surgical site for first few days
OHI post-op
Instructions for rinsing mouth with warm salt water several time a day
- 1/2 tsp salt in 8 oz
2. Hold in mouth, swish gently, spit and repeat
- Avoid vigorous exercise on day of surgery
2. May resume usual activities as tolerated
Activity, post-op
Activity restriction for simple extractions
rarely more than 24-36 hours
Activity restriction for surgical extraction
several days
- none is best
- Cutting back is second best, the less the better
- greatly increases risk of dry socket of alveolitis
No smoking post-op
- Rare, post-op antibiotics are not warranted in healthy patients
- Prophylactic antibiotics appropriate in some
- Continuing antibiotics (post-op) appropriate in others
4
Post-op infection instructions
When should patients call you back after extraction
- If swelling is increasing rather than decreasing after 48 hours
- Induration, skin erythema, persistent fever, difficulty swallowing or opening
Increase in pain after 3-5 days
Lack of improvement after 3-5 days
Worsening taste or odor in mouth
Patients should be instructed to call and return for re-eval if these signs occur
Signs of Dry Socket
Patients must be able to contact doctor
Answering service
Cross coverage
Include phone number in written instructions
Point of contact
What should you always do after surgery or long, difficult procedures?
Call your patient to check on them
