Extraction of teeth Flashcards
Some indications for extraction of teeth
- Periodontal disease
- Pulpal disease
- Pathological lesions surrounding the teeth
- Crown and root fracture
- Before radiation therapy
- Orthodontic indications
- Supernumerary teeth
- Impacted teeth
- Malposition of teeth
- Teeth in bone fracture lines
- Caries
Systemic contraindications for extractions
- Severe anxiety
- Haemophilia/other coagulopathies
- Uncontrolled diabetes
- Uncontrolled hypertension and cardiac diseases
- Ongoing radio-chemotherapy
- Medications that affect immune system/delay healing
Particular attention should be paid to following medications
- Anticoagulants
- Cancer medication
- Glucocorticoids
- Immunosuppressants
Local contraindications of extractions
- Acute inflammation or infection(if from pulpal diseases can be resolved by extractions)
- Lower third molar with pericoronitis
- Radiation therapy
Reasons why operation contraindicated after radiation therapy
- Necrosis of bone(some cancer meds also cause necrosis of bone after extraction)
- Delayed healing
- Dehiscence
Clinical features evaluated before extraction
- Condition of crown
- Tooth and root mobility
- Access to perform extraction
- Pathology of pulp and surrounding tissues
Importance of radiographic assessment pre extraction
Evaluates difficulty of extraction by assessing:
- Root anatomy
- Pathology in surrounding bone
- Ankylosis or hyper-cementosis of root
- Proximity of molars to sinus in maxilla
- Position of mandibular canal(relation to third molars)
- Position of mental foramen(where flap is raised to remove premolars)
Most common radiograph for extractions
Periapical
Radiographs for assessing impacted teeth
- Panoramic
- Scanogram
- Cone beam
Sinus rupture results in
Oroantral communication
Preoperative mouth rinse can be done with
Chlorhexidine
Patient position for extraction of Maxillary teeth
- Patient mouth at same height as dentist shoulder
- 120 ° angle between dental chair and floor
- Occlusal surface of maxillary teeth at 40 ° when open compared to horizontal
Patient Chair position for extraction of mandibular teeth
- 110 ° angle between chair and floor
- Occlusal surface of mandibular teeth parallel to floor when mouth open
Surgeon position for extraction with forceps for maxillary teeth
-Infront or to the side of the patient
Surgeon position for extraction with forceps for mandibular teeth
- Right posterior and anterior teeth→ behind patient
- Left mandibular teeth→ in front of patient
Two stages of extraction
- Tooth separated from surrounding soft tissues→ Desmotome or elevator
- Tooth extracted from socket→ forceps or elevator
Desmotome use
- Pen grip with dominant hand
- Positioned at bottom of gingival sulcus to sever PDL
- Continuous motion from mesial to distal→ buccally then lingually/palatal
- Non dominant hand→ index finger and thumb positioned on buccal and palatal
Elevator Function
Push or reflect gingiva→ allows extraction forceps to grasp tooth beneath cervical line
Extraction technique with forceps
- Beaks of forceps at cervical line of tooth→ parallel to long axis of tooth
- Gentle initial buccal then lingual/ palatal movements
- Gradual increase in pressure first at buccal(bone thinner and more elastic)
- Rotational force if roots single and conical
- Slight traction to facilitate extraction but not used at final stage
- Final movement → Maxilla=buccal and curved outwards and upwards
→ Mandible=Buccal direction and curved outwards and downwards
Extraction technique of maxillary central incisor
- Initial gentle labial and palatal movements
- Increase in force first at labial
- Rotational forces permitted due to conical root
- Slight traction
Extraction technique of maxillary lateral incisor
- Labial and palatal movements with forceps
- Rotational forces not permitted(thin root curved distally)→only very slight rotation at final stage with traction
Extraction technique of maxillary canines
- Labial/palatal movements with increasing pressure
- Rotational movements not permitted due to distally curved root→ if used very slight w/ alternating buccopalatal pressure
- Final extraction movement labial
Extraction technique for maxillary first premolar
- Initial buccal and palatal movements
- Rotational movements not permitted→ 2 roots w/ slight curve
- Final movement buccal
Extraction technique for maxillary second premolar
- Same technique as first premolar
- Easier due to one root
- Final movement buccal
Anatomy to consider during extraction of maxillary molars
- Three diverging roots(longest root palatal and two buccal roots w/distal curve)
- Tooth firmly anchored to alveolar bone and buccal surface reinforced by extension of zygomatic process
- Strong force required for extraction
- Risk of oroantral communication→ root tips close to sinus
Extraction technique for maxillary first and second molars
- Initial buccal and palatal pressure w/ emphasis on buccal
- increasing pressure w/ final movement buccal w/ upwards curved movement
Extraction technique for maxillary third molar
- If roots conical (fused)- simple w/ buccal pressure mostly to avoid thin palatal alveolar process fracture
- If 3 or more roots→ buccal pressure w/ slight palatal pressure
- Final extraction movement buccal
-
Extraction technique of mandibular incisor teeth
- Extraction easy→ thin alveolar bone and roots not firmly attached to alveolar bone
- Labial and lingual movements w/ increasing pressure
- Roots slightly curved esp. lateral→ slight rotational movement only
Extraction technique of mandibular canines
- Same movements as incisors
- Harder to extract than incisors→ longer root and curvature of root tip
- Final movement labial curved outwards and downwards
Extraction technique of mandibular premolars
- Buccal/lingual movements
- Final extraction movement outwards and downwards
- Easy extraction as roots straight and conical
Anatomy to consider for mandibular first molar
-Two roots(mesial and distal)
Mesial root larger, more flattened and curved distally
-Distal root straighter, narrower and more rounded
Anatomy to consider for mandibular second molar
-More easily removed despite denser bone→ roots smaller and less divergent(often fused together)
Extraction of mandibular first and second molars
- Forceps as apical as possible beneath cervical line→ beaks parallel to long axis
- Initial gentle buccal and lingual pressure
- Gradual increase in force and final movement buccal
Anatomy to consider for Extraction of mandibular third molar
- Two roots w/ similar morphology to other molars→ smaller and fused in conical shape w/ wide distal divergence
- If one or two roots converge and curve in same direction→ straight elevator can be used
- Lingual bone very thin compared to alveolar bone(unyielding in third molar area)
Extraction technique for mandibular third molar
- Buccal/lingual pressure
- Main force in lingual area to mobilise tooth
- Careful pressure to avoid fracture in area of lingual plate
Risk involved in extraction of deciduous teeth
May extract bud of permanent tooth(especially under deciduous molar as crown short0
How to avoid extraction of underlying tooth bud
Beaks of forceps placed on mesial or distal area of tooth and not central(furcation area)
Extraction technique of elevator
- Held in dominant hand w/ index finger along blade
- Used buccally(not lingual/palatal)
- Concave surface contacts mesial or distal
- Alveolar bone used as fulcrum
- In maxillary posterior teeth- perpendicular to long axis and in rest→ perpendicular, parallel or at angle
Protective measure during elevator use
Cotton wool or gauze between finger and palatal to avoid injury if elevator slips
Post extraction care of socket
- Periapical curette used at bottom of socket(removes granulation tissue preventing cyst)
- If sharp and bony edges-ronguers forceps or bone file to smooth alveolar margin
- Haemostasis aided by pressure on socket w/ gauze for 30-45 min
Post operative instructions
- Rest
- Analgesia
- Edema
- Bleeding
- Antibiotics
- Diet
- Oral hygiene
