Extractions

Question 1

Objectives of extractions

Answer 1

Dilatations of bony socket to allow for tooth removal
Disjunction of PDL around tooth
Removal of tooth with minimal damage to adjacent structures

Question 2

Factors complicating exos

Answer 2

Medical conditions
Restricted mouth opening (tumour, infection under mouth muscles, myalgia, joint problems, guarding)
Gag reflex
Lips and cheek tightness
Anatomical features (IDN for lower molars so cannot curette abscess, max sinus perforation for upper molars, blood vessels in floor of mouth, root configuration increasing fracture risk)
Condition of tooth and bone (RCT and heavily restored teeth are v brittle, tilted teeth harder to extract)
Adjacent crowns and restorations

Question 3

Types of extraction

Answer 3

Simple (forcep +/- elevators)
Surgical (transalveolar extraction, flaps, bone removal +/- tooth sectioning)

Question 4

Sequence of simple extractions

Answer 4

Anesthesia
Removal of tooth
Hemostasis
Post=op management

Question 5

Sequence of surgical extractions

Answer 5

Anesthesia
Raise flap
Remove bone
Section tooth if necessary
Removal of tooth
Hemostasis
Post-op management

Question 6

Post-op instructions

Answer 6

Bite on gauze for 30 mins, change if still bleeding
No rinsing or spitting for 24h to allow for complete clot retraction
Avoid strenuous activities, drugs and alcohol for 48h (avoid increased BP)
Take medication if pain
OHI
If lots of bleeding go A&E or clinic after hours
Brief on likely complications, like if close to sinus warn not to suck on straws, blow balloons, go diving/flying, pinch nose and sneeze etc

Question 7

Positioning

Answer 7

Maxilla - max occlusal plane 45-60 degrees to floor, 3 inches below shoulder

Mandible - occlusal plane parallel to floor, lower than or equal to elbow level

Question 8

Parts of forcep

Answer 8

Beak
Neck
Handle

Question 9

Upper anterior forceps

Answer 9

Thin, straight, tips dont completely come tgt, no beak

Question 10

Upper 1st and 2nd molars

Answer 10

Straight, beaked for buccal furcation, split into R and L side

Thick palatal root
Deliver buccally along path of insertion of palatal root
Check for oral-antral perforation!

Question 11

Upper 3rd molar

Answer 11

Double curve for better reach

Question 12

Upper roots

Answer 12

Sharper and thinner straight or curved forceps, can close fully

Question 13

Lower anteriors and premolars

Answer 13

90 degree head, no beak, doesnt close fully

Question 14

Lower molars

Answer 14

90 degree head, beaked on both sides to engage B and L furcations

Bifurcated/divergent
Mesial root more commonly fractured as it is slender and curved
Deliver with CONTROLLED buccal lingual motion

Question 15

Lower roots

Answer 15

90 degrees, thin and sharp, doesnt close fully

Question 16

Purposes of forceps

Answer 16

Tear away gingival attachment, expand socket and remove tooth

Engage root not crown, parallel to long axis
Deep firm grip, apical movement with rotation/bucco-lingual movement

Avoid hitting opposing tooth

Question 17

Forcep motions

Answer 17

Apical - grip as apically as possible to avoid fracture, can even use elevators to create more apical space
Buccal
Lingual
Rotational - for anteriors and mand premolars because single rooted
Tractional - buccal delivery

Question 18

Elevators

Answer 18

Coupland
Warwick James
Cryers
Others

Winged elevators hug the root so less likely to slip

Question 19

Coupland

Answer 19

Straight with a wedge shaped end

Like pencil sharpener, push and wiggle rotationally, use one finger to support next tooth to avoid loosening wrong tooth and DONT USE BONE OR ADJACENT TOOTH AS FULCRUM

Use left hand to guard and support by holding alveolar bone near tooth

1 (small) then 2 (medium) then 3 (large)

Question 20

Warwick James

Answer 20

Bent head, kinda like big curved plastic 6
Useful for raising flaps and extracting upper 8s
Can hug 8s from mesial interproximal space to torque it out

Question 21

Cryers

Answer 21

Sharp!
Similar to warwick james, can elevate with narrow engagement
Also good for roots cos can cut PDL

Question 22

Root pick

Answer 22

Long thin and sharp end

Question 23

Reasons for fracture

Answer 23

Improper technique
Dense bone
Fragile roots
Damaged tooth (RCT, pulpless, gross aries, preexisting fracture)

Question 24

How to remove roots

Answer 24

Use root forceps to rotate and pull
Can use luxators to create more space around root for engagement of root forceps by using a circular cutting motion

Question 25

How to remove multrooted teeth

Answer 25

Coupland to loosen if necessary
Apply forceps
If v difficult can separate roots and deliver roots individually

Question 26

Complications of elevators

Answer 26

Injury to adjacent tooth, antrum, soft tissue or operator

Question 27

After extraction actions

Answer 27

Debride if can (mand molars cannot cos of IDN)
Compress sockets
Examine surgical field (sharp edges, bleeding, loose fragments) and extracted tooth (tooth extracted in toto? bone?)
Suture if necessary

Question 28

Complications

Answer 28

Immediate
> LA failure
> failure to move tooth
> Fracture of tooth, alveolus, mandible
> damage to soft tissues, adjacent teeth
> oral antral perforation
> displacement of teeth, e.g. upper posteriors into max sinus or mand into lingual pouch, or swallowed tooth
> hemorrhage
> TMJ dislocation
> trismus due to infection or injection into muscles causing fibrosis
> nerve damage
> excessive bleeding

Delayed
> excessive pain/swelling
> prolonged bleeding
> dry socket
> osteomyelitis
> infection
> delayed healing
> paresthesia
> chronic pain
> necrosis

Question 29

Alveolar osteitis

Answer 29

Most common complication of 8s
Breakdown of fully formed blood clot prior to maturation into granulation tissue due to excessive compressive force, washing, or traumatic extraction
Exposes bone that is normally covered by a fibrin clot, causing pain as nerves are irritated by air, food, bacteria etc
Usually presents as dull throbbing pain starting 2-3 days after extraction, foul taste and malodour
Socket grey, brown clot, exposed bone
Increased risk in smokers, oral contraceptives, trauma, vaping
TREAT by irrigating with chlorhex or saline, cleaning with gentle debridement, putting obtundent dressing like alvogyl, repeat if necessary

Question 30

Managing prolonged bleeding

Answer 30

Often due to lack of compliance, reinforce instructions
Go to medical history to see if pt is taking any blood thinners etc or if they have risk factors like hemophilia
Infection?

Mx: Identify source, take local measures like irrigation to clean, pressure pack and apply hemostatic like surgicel cellulose mesh and spongiostan gel. Suture and apply tranexamic acid

Question 31

Oral-antral communication

Answer 31

Posterior max teeth
Bulbous roots can cause bone breakage upon removal
Pathologies that breach bone
Pneumatization or close proximity

Inspect socket, see if got hole, see if mirror mists, cotton roll flutters, or if got hole, irrigate to see if pt feels anything in nose, or palpate with probe (??)

Treatment:
> small <2mm then will j heal by itself
> big then need surgery (graft or flap surgery), take fat from buccal flap and pull over, rotate flap from palate, or bring up tongue flap

If dont do surgery quickly can get sinus infection

Question 32

Tooth displaced into sinus

Answer 32

Caldwell Luc procedure, make hole at canine region to see inside sinus while removing