Extractions Flashcards
Objectives of extractions
Dilatations of bony socket to allow for tooth removal
Disjunction of PDL around tooth
Removal of tooth with minimal damage to adjacent structures
Factors complicating exos
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
Types of extraction
Simple (forcep +/- elevators)
Surgical (transalveolar extraction, flaps, bone removal +/- tooth sectioning)
Sequence of simple extractions
Anesthesia
Removal of tooth
Hemostasis
Post=op management
Sequence of surgical extractions
Anesthesia
Raise flap
Remove bone
Section tooth if necessary
Removal of tooth
Hemostasis
Post-op management
Post-op instructions
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
Positioning
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
Parts of forcep
Beak
Neck
Handle
Upper anterior forceps
Thin, straight, tips dont completely come tgt, no beak
Upper 1st and 2nd molars
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!
Upper 3rd molar
Double curve for better reach
Upper roots
Sharper and thinner straight or curved forceps, can close fully
Lower anteriors and premolars
90 degree head, no beak, doesnt close fully
Lower molars
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
Lower roots
90 degrees, thin and sharp, doesnt close fully
Purposes of forceps
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
Forcep motions
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
Elevators
Coupland
Warwick James
Cryers
Others
Winged elevators hug the root so less likely to slip
Coupland
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)
Warwick James
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
Cryers
Sharp!
Similar to warwick james, can elevate with narrow engagement
Also good for roots cos can cut PDL
Root pick
Long thin and sharp end
Reasons for fracture
Improper technique
Dense bone
Fragile roots
Damaged tooth (RCT, pulpless, gross aries, preexisting fracture)
How to remove roots
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
How to remove multrooted teeth
Coupland to loosen if necessary
Apply forceps
If v difficult can separate roots and deliver roots individually
Complications of elevators
Injury to adjacent tooth, antrum, soft tissue or operator
After extraction actions
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
Complications
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
Alveolar osteitis
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
Managing prolonged bleeding
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
Oral-antral communication
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
Tooth displaced into sinus
Caldwell Luc procedure, make hole at canine region to see inside sinus while removing
