Final Revision Flashcards
Proper tooth removal:
- does not require a large amount of strength
- the tooth should not be pulled from bone
- it is gently lifted from its socket
- controlled force in a manner
Excessive force may:
- injure local soft tissue
- damage the surrounding bone and teeth
- fracture the crown
- make the extraction more difficult
- increase the patient’s intraoperative and postoperative discomfort and anxiety
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local anesthesia:
even with profound LA patients will still experience discomfort from:
- is required to prevent pain during extractions
- eliminates sensation from the pulp, periodontal ligament, and adjacent soft tissues
-patients will still experience discomfort from pressure placed on the TOOTH, surrounding tissues, and JAW JOINTS during most extractions
The surgeon must remember that the patient will need to distinguish between:
sharp pain and the dull feeling of pressure when determining the adequacy of anesthesia
-it is difficult
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INDICATIONS FOR REMOVAL OF TEETH:
•Caries
- most common
- The extent to which the tooth is carious and is considered non-restorable is a judgment call to be made between the dentist and patient
•Pulpal Necrosis
-result of a patient declining endodontic treatment or
of a root canal that is tortuous, calcified, and untreatable by standard endodontic techniques
•Periodontal Disease
- excessive bone loss and irreversible tooth mobility found
- HYPERMOBILE teeth should be extracted
•Orthodontic Reasons
- orthodontic correction of crowded dentition with insufficient arch length
- most commonly extracted teeth are the maxillary and mandibular premolars but also mandibular incisors
•Malposed Teeth
- If they traumatize soft tissue and cannot be repositioned by orthodontic treatment
- maxillary third molar, which erupts in severe buccal version and causes ulceration and soft tissue trauma of the cheek
- hyper-erupted because of the loss of teeth in the opposing arch
•Cracked Teeth
- cracked crown or a fractured root
- can be painful and is unmanageable by a more conservative technique
- sometimes cracked teeth have already undergone endodontic therapy in the past
•Impacted Teeth
-if a partially impacted tooth is unable to erupt into a functional occlusion because of inadequate space, interference from adjacent teeth, etc
•Supernumerary Teeth
- are usually impacted
- may interfere with eruption of succedaneous teeth and have the potential for causing their resorption and displacement
•Teeth Associated with Pathologic Lesions
- odontogenic cysts
- the tooth or teeth can be retained and endodontic therapy performed
•Radiation Therapy
- removal of teeth that are in the beam of radiation therapy
- however, many of these teeth can be retained with proper care
•Teeth Involved in Jaw Fractures
- patients who sustain fractures of the mandible or the alveolar process
- if the tooth is injured, infected, or severely luxated from the surrounding bony tissue or interferes with proper reduction and fixation of the fracture !!
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CONTRAINDICATIONS FOR REMOVAL OF TEETH
SYSTEMIC:
-Uncontrolled leukemia and lymphoma
•infection as a result of non-functioning white cells and
•excessive bleeding as a result of an inadequate number of platelets
-Uncontrolled Cardiac diseases: severe myocardial ischemia such as UNSTABLE ANGINA PECTORIS and
patients who have had a RECENT MYOCARDIAL INFRACTION
-Malignant hypertension
-Uncontrolled cardiac dysrhythmias
-Pregnancy: middle trimester safe
-Variety of medications usage (caution needed)
LOCAL:
- History of therapeutic radiation for cancer: extractions performed in an area of radiation may result in osteoradionecrosis, and therefore, the extraction must be done with extreme caution
- Teeth that are located within an area of Tumor !!!!!!!!!
Acute infection is NOT a contraindication to extraction but it may be difficult to extract b/c:
•the patient may NOT ABLE FOR WIDE OPEN MOUTH
•it may be DIFFICULT TO REACH a state of PROFOUND LA
Access to the Tooth - Examine:
- the extent to which the patient can open the mouth
- the location and position of the tooth to be extracted within a dental arch
- the condition of the crown •If large portions of the crown have been destroyed by caries, the likelihood of crushing the crown during the extraction is increased, thus causing more difficulty in removing the tooth
- large amalgam restorations (produce weakness in crown)
the forceps are applied as far apically as possible to grasp the root portion of the tooth instead of the crown for such conditions
ALSO
-the condition of adjacent teeth
If adjacent teeth have large restorations, the surgeon should use:
elevators with extreme caution because fracture or displacement of the restorations may occur
The patient should be informed before the surgical procedure about possible damage to these restorations during the process of obtaining informed consent.
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It is essential that proper radiographs be taken of any tooth to be removed
periapical radiographs:
panoramic radiographs:
a) Radiographs should probably be retaken before surgery when they are taken..:
b) Radiographs taken for mandibular premolars should always include:
periapical radiographs:
information concerning the tooth, its roots, and the surrounding tissue
panoramic radiographs:
for impacted teeth as opposed to erupted teeth
- adequate penetration and good contrast
- properly positioned so that it shows all portions of the crown and roots of the tooth under consideration without distortion
- the relationship of the root structures of adjacent teeth must be known (be careful if adjacent roots are close to the root being removed)
a) older than 1 YEAR should probably be retaken before surgery
Radiographs that are taken, but not available during surgery, are of limited value
b) MENTAL FORAMEN
inferior alveolar canal in relationship with the roots of mandibular molars:
- Such extractions may lead to injury of the canal and cause damage to the inferior alveolar nerve
- CBCT images are often useful in these circumstances
The first factor to evaluate in radiographic assessment of the tooth to be extracted is
the number of roots on the tooth to be extracted
-is known before the tooth is extracted, an alteration in the plan can be made to prevent fracture of any additional roots
must know
- the curvature of the roots and the degree of root divergence
- the shape of the individual root (long roots with severe and abrupt curves or hooks at their apical end are more difficult lo remove)
- the size of the root (short roots are easier to remove)
- evidence of hypercementosis (aging effect)
- evidence of caries extending
- internal or external root resorption
- evaluation of previous endodontic therapy (there may be ankylosis or the tooth root may be more brittle)
The principle of universal precautions states that:
all patients must be viewed as having blood-borne diseases that can be transmitted to the surgical team and other patients
- To prevent this transmission, surgical gloves, surgical mask, and eye wear with side-shields are required
- the surgical team should wear long-sleeved gowns, which should be changed when they become visibly soiled
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for successful completion of the extraction - critical are:
It allows the surgeon to keep the:
The positions of the patient, the chair, and the operator
•The best position is one that is comfortable for the patient and surgeon, and allows the surgeon to have maximal control of the force that is being delivered to the patient’s tooth through the elevators and the forceps
The correct position allows the surgeon to keep the ARMS CLOSE TO THE BODY AND PROVIDES STABIITY AND SUPPORT
- It allows the surgeon to keep the wrists straight enough to deliver the force with the ARMS AND SHOULDER and not with the fingers or hand
- The force delivered can be controlled in the face of sudden loss of resistance from a root or fracture of the bone
Position errors
The most common error dentists make in positioning the dental chair for extractions is to have
Another frequent positioning problem is for the dentist to
- the chair too high
- lean over the patient and put his or her face close to the patient’s mouth
This forces the surgeons to operate with their shoulders raised, thereby making it difficult to deliver the correct amount of force to the tooth being extracted in the proper manner
It is also tiring to the surgeon
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For a maxillary extraction, the chair should be _ so that maxillary occlusal plane is _:
The height of the chair should be such that patient’s mouth is:
tipped backward
the maxillary occlusal plane is at an angle of about 60 DEGREES TO THE FLOOR
The height of the chair should be such that patient’s mouth is AT OR SLIGHTLY BELOW OPERATOR’S ELBOW LEVEL
maxillary right quadrant:
patient’s head should be turned toward the operator
maxillary anterior arch:
patient should be looking straight ahead
maxillary left quadrant:
patient’s head is turned slightly toward the operator
For a mandibular extraction:
the chair should be:
the occlusal plane should be:
in a more upright position so that when the mouth is opened wide, the occlusal plane is parallel to the floor
surgeon’s arm inclined downward to a 100 degree angle at the elbow
right posterior teeth:
patient’s head should be turned acutely toward the surgeon
left posterior teeth:
surgeon should stand in front of the patient, but the patient’s head should not turn so acutely toward the surgeon
anterior region:
surgeon stands at the side of the patient, who looks straight ahead
-Some surgeons prefer to approach mandibular teeth from a posterior position (left hand supports the mandible but it requires that the forceps be held opposite the usual method)
Sitting position for maxillary extractions
patient is positioned in a semi-reclining position
(similar to that used when the surgeon is standing)
patient should be lowered as far as possible so that the level of the patient’s mouth is as near as possible to the surgeon’s elbow
maxillary anterior and posterior teeth are similar to standing extractions - patient is reclined back 60 degrees
-surgeon can work from the front of the patient or from behind the patient
•It should be noted that the surgeon and the assistant have hand and arm positions similar to those used when the surgeon is in the standing position
Preparation for Extraction - Patients
a minimal draping with a sterile drape placed across the patient’s chest
For extraction of the mandibular teeth the surgeon should stand from:
right posterior and anterior teeth:
left posterior teeth:
from behind
from front
The approach from behind gives the surgeon
great visibility of the extraction site and it allows the surgeon to be in a comfortable and stable position
mechanical principles and simple machines:
- the lever
- the wedge
- the wheel and axle
Elevators are used primarily as:
An example of the use of a lever to remove a tooth:
Levers example - used as:
as levers
•A lever is a mechanism for transmitting a modest force-with the mechanical advantages of a long lever arm and a short effector arm—into a small movement against great resistance -The first-class lever transforms small force and large movement to small movement and large force
-used as a STRAIGHT ELEVATOR
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Wedge
The beaks of the forceps act as _ to expand alveolar bone and displace the tooth in the occlusal direction
- The beaks of extraction forceps are usually narrow at their tips and they broaden as they go superiorly
- When forceps are used, a conscious effort must be made to force the tips of the forceps into the periodontal ligament space at the bony crest to expand the bone and force the tooth out of the socket
The beaks of the forceps act as WEDGES to expand alveolar bone and displace the tooth in the occlusal direction
The wedge principle is also useful when a STRAIGHT ELEVATOR is used to luxate a tooth from its socket
An elevator is wedged into the periodontal ligament space, which displaces the root toward the occlusion and out of the socket
wheel and axle
triangular, or pennant-shaped elevator
When one root of a multiple-rooted tooth is left in the alveolar process, the pennant-shaped elevator Cryer is positioned into the socket and turned
HANDLE serves as the AXLE
ELEVATOR acts as a WHEEL
The primary instruments used to remove a tooth from the alveolar process are
what is their use?
- Elevators:
- Forceps:
the elevator and extraction forceps
- Elevators help in the luxation of a tooth
- Forceps help in the bone expansion and disruption of periodontal attachments
Forceps can apply five major motions to luxate teeth and expand the bony socket:
First, apical pressure Second, buccal pressure Third, lingual or palatal pressure Fourth, rotational pressure Fifth, tractional force
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Apical pressure of the forceps on the tooth during extraction causes:
BONY EXPANSION
-the center of rotation of the tooth is displaced apically
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The chance of fracturing the root apex during extraction increases if:
the center of rotation is HIGH and a LARGE amount of force is placed on the apical region of the tooth
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Buccal force:
Excessive force can fracture:
Buccal pressures result in expansion of the buccal plate, particularly at the crest of the ridge
Excessive force can fracture BUCCAL BONE or cause a fracture of the APICAL PORTION OF THE ROOT
Lingual or palatal pressure
is similar to the concept of buccal pressure but is aimed at expanding the linguocrestal bone and,
at the same time, AVOIDING EXCESSIVE PRESSURES ON BUCCAL APICAL BONE
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Rotational forces/pressures:
useful for which roots?
rotates the tooth, which causes some internal expansion of the tooth socket and tearing of periodontal ligaments
Teeth with single, CONICAL ROOTS and those with roots that are not curved are most liable to luxation by this technique
Teeth that have other than conical roots or that have multiple roots—especially if those roots are curved—are more likely to fracture under this type of pressure
tractional forces
useful for delivering the tooth from the socket once adequate bony expansion is achieved
Teeth should not be pulled from their sockets
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Buccal Vs Palatal bone and the forces applied on maxillary teeth:
Because maxillary buccal bone is usually thinner and palatal bone is a thicker cortical bone
-maxillary teeth are usually removed by STRONGER BUCCAL FORCES and less strong palatal forces
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In the mandible incisors, canines, and premolars are removed with what force?
In the mandible molars are removed with what force?
strong buccal force and less strong lingual pressures
STRONG LINGUAL PRESSURE first
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Closed technique extraction:
- also known as:
- used when:
Open technique extraction
- also known as:
- used when:
Closed:
- most frequently used, with any type of surgery
- also known as: ROUTINE TECHNIQUE
Open:
- also known as: surgical/flap technique
- used when: excessive force needed, a substantial amount of the crown is missing or covered by tissue or when access to the root of a tooth is difficult
- The correct technique for any situation should lead to an atraumatic extraction
- the wrong technique commonly results in an excessively traumatic and lengthy extraction
3 fundamental requirements for a good extraction
(1) adequate access and visualization of surgery field
(2) a free pathway for the removal of the tooth, and
(3) the use of controlled force to luxate and remove the tooth
For the tooth to be removed from the bony socket, it is usually necessary to:
- expand the alveolar bony walls to allow the tooth root a free pathway
- tear the periodontal ligament fibers that hold the tooth in the bony socket
-with the use of elevators and forceps as levers and wedges with steadily increasing force
5 general steps to make the closed extraction procedure:
- Step 1 involves loosening of the soft tissue attachment from the cervical portion of the tooth
- Step 2 involves luxation of the tooth with a straight elevator entered perpendicular to tooth
- Step 3 involves adaptation of the forceps to the tooth
- Step 4 involves luxation of the tooth with forceps
- Step 5 involves removal of the tooth from the socket
The purpose of loosening the soft tissue from the tooth is twofold:
(1) it allows the surgeon to ensure that profound anesthesia has been achieved
2) soft tissue is loosened to allow the elevator and tooth extraction forceps to be positioned more apically, without interference from the gingiva
Elevator blade position:
- the inferior portion of the blade:
- the superior portion of the blade:
- the inferior portion of the blade rests on the alveolar bone
- the superior portion of the blade is turned toward the tooth being extracted
-Strong, slow, forceful turning of the handle moves the tooth in a posterior direction, which results in some expansion of alveolar bone and tearing of the periodontal ligament
if the patient does not have a tooth posterior to the tooth being extracted or if it is broken down to an extent that the crowns do not inhibit movement of the tooth, the elevator can be turned in the:
in the opposite direction and more vertical displacement of the tooth will be achieved, which can possibly result in complete removal of the tooth
Forceps beaks position:
which beak is situated first?
The lingual beak is usually seated first and then the buccal beak
-Care must be taken to confirm that the tips of the forceps beaks are beneath the soft tissue and not engaging an adjacent tooth
Forceps handles are grasp at their:
ends to maximize mechanical advantage and control
If the tooth is malposed in such that the usual forceps cannot grasp the tooth without injury to adjacent teeth, which forceps should be used?
other forceps with narrower beaks
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The beaks of the forceps must be held:
parallel to the long axis of the tooth
The left hand is responsible for:
- reflecting the soft tissues of the cheeks, lips, and tongue to provide adequate visualization of the area of surgery
- helps to protect other teeth from the forceps, should release it suddenly from the tooth socket
- helps to stabilize the patient’s head during the extraction process
The assistant helps the surgeon to:
- visualize and gain access to the operative area by reflecting the soft tissue of the cheeks and tongue so that the surgeon can have an unobstructed view of the surgical field
- suction away blood, saliva, and the irrigating solutions used during the surgical procedure
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For maxillary left anterior teeth the:
left index finger of the surgeon should:
left thumb of the surgeon should:
the left index finger of the surgeon should REFLECT LIP AND CHEEK tissues
the thumb should rest on the palatal alveolar process
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Maxillary incisors extraction:
Alveolar bone is:
Expansion of alveolar process will be:
steps:
Alveolar bone is thin on the labial side and heavier on the palatal side
-The forceps are seated as far apically as possible for all extractions
Expansion of alveolar process will be in LABIAL direction
steps: luxation is begun with labial force slight palatal force is used rotational tractional movement
Rotational movement should be minimized for the:
lateral incisor
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Maxillary canines extraction:
The initial movement is:
The INITIAL movement is APICAL and THEN to the BUCCAL aspect, with return pressure to the PALATAL
Then delivered in the labial-incisal direction with a slight rotational force
If root fracture does occur, a mobile root tip can be removed more easily than:
one that has not been well luxated
Maxillary premolars extraction:
The initial movement is:
The initial movement is apical and then to the buccal aspect, with return pressure to the palatal, rotational and last is tractional movement
-for first premolars: no rotational force due to 2 roots!!!
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Maxillary molars extraction:
which molar is more easily extracted?
The dentist must minimize palatal force because this is the force that fractures the:
for maxillary first molar is preferable to fracture which root?
use strong buccal and palatal pressures, with stronger forces toward the buccal than toward the palate
no rotational force due to 3 roots
second molar is more easily extracted than first molar
-the erupted third molar is also frequently extracted by the use of elevators alone
The dentist must minimize palatal force because this is the force that FRACTURES PALATAL ROOT
preferable to fracture a BUCCAL ROOT rather than a palatal root
periapical lesion or debris:
a) If a periapical lesion is visible on the preoperative radiograph and there was no granuloma attached to the tooth when it was removed, the periapical region should be:
b) If any debris is obvious then:
The socket should be debrided only if necessary
If neither a periapical lesion or debris is present, the socket should not be curetted
If teeth were removed because of periodontal disease, there may be an excess granulation tissue around the gingival cuff.
If this is the case, special attention should be given to removing this granulation tissue with a curette, tissue scissors, or a hemostat
the bone should be palpated through the overlying mucosa to check for any sharp, bony projections
a) be curetted with a periapical curette to remove the granuloma or cyst
b) it should be gently removed with a curette or suction tip
