Principles of uncomplicated exodontia Flashcards
ESSENTIALS OF EXODONTIA
(5)
- Finesse
- Dexterity and Skill
- Controlled force
- Firm steady pressure
- Knowledge of what to treat and what to refer out
PRE-EXTRACTION PREP
- Medical history
- Physical examination
- Radiologic evaluation
- Informed consent
- Surgical plan
- Pain, anxiety control
- Patient and surgeon preparation
SURGEON & PATIENT PREP
* UNIVERSAL PRECAUTIONS
(6)
- Over coat/garment
- Mask
- Surgical gloves
- Hair out of surgical field (cap or hair tie)
- Eye protection
- Patient drape
BASIC PREPARATION
(4)
- PROFOUND anesthesia is required
- Check for signs and symptoms
- If patient says they are not numb…BELIEVE THEM
- Extractions should be painless and relatively quick
- If patient says they are not numb…BELIEVE THEM
(2)
- May have to distinguish pain with pressure which often is difficult for patients
- LA results in loss of pain, temperature, and touch. But DOES NOT anesthetize
proprioceptive fibers, thus potentially can feel intense pressure
COMMON INJECTIONS
MANDIBLE
- Inferior alveolar nerve block
- Gow-Gates block
- Akinosi block (closed mouth)
- Long buccal block
- Mental nerve block
- PDL injection
- Intrapulpal injection
COMMON INJECTIONS
MAXILLA
- Posterior superior alveolar block
- Middle superior alveolar block
- Anterior Superior alveolar block
- Infraorbital Nerve block
- intraoral and extraoral approaches
- Greater palatine
- Nasopalatine nerve block
- V2 block*
LOCAL ANESTHESIA
* 2% Lidocaine w/ 1:100k epi →
* 3% Mepivacaine plain →
7 mg/kg or 3.2 mg/lb
6.6 mg/kg or 3.0 mg/lb
- Epi limit for healthy adult →
- Epi limit for cardiac patients →
0.2 mg (works out to 11.76 cartridges of 1:100k epi)
0.04 mg (works out to 2 cartridges of 1:100k epi)
OPTIONS FOR THE ANXIOUS PATIENT
* TLC most important concept
(2)
- Proper explanation of procedure
- Assurance that sharp pain will not be felt, but significant pressure will still be present
Basic pharmacologic option available
(3)
- Pre-operative oral sedation (valium)
- Nitrous oxide analgesia
- Intravenous Sedation
- Fentanyl, versed, propofol, ketamine
INDICATIONS FOR TOOTH REMOVAL
* SHOULD BE COMPLETED BY GENERAL DENTIST PRIOR TO ORAL
SURGERY CONSULTAITON
* OMS is a CONSULTING service
(3)
- We do not determine restorability of teeth
- All options for treatment should be discussed prior to OMS consultation
- If patient asks what could be done other than extraction, the patient should be sent back to general
dentist for treatment discussion
Extractions are non-reversible, and if there is a questions about the procedure, the patient is
not fully informed
INDICATIONS FOR TOOTH REMOVAL
- Caries
- Pulpal necrosis
- Periodontal disease
- Orthodontic reasons
- Malpositioned teeth
- Fractured teeth
- Impacted teeth
- Supernumerary teeth
- Teeth associated with pathology
- Radiation therapy
- Teeth involved with jaw fractures
- Financial issues
CONTRAINDICATIONS FOR TOOTH REMOVAL
(5)
- Severe uncontrolled metabolic issues
- Uncontrolled lymphoma/leukemia
- Pregnancy in 1st and 3rd trimester
- Uncontrolled Blood/Bleeding disorders
- Uncontrolled cardiac issues
- Uncontrolled lymphoma/leukemia
(2)
- Concern for infection due to
nonfunctioning white cells - Bleeding concern due to nonfunctioning
platelets
Uncontrolled cardiac issues
(4)
- Unstable angina
- Recent MI
- Malignant hypertension
- Uncontrolled dysrhythmias
CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Access to tooth
(3)
- Small mouth, limited opening
- Posterior more difficult to visualize
- Severe crowding
CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Mobility of tooth
* Periodontally involved teeth –
greater than normal mobility
* Increased amount of bleeding due to overgrowth of granulation
tissue
* Soft tissue management is more problematic
* Root fractures unpredictable
Less than normal mobility
(2)
- Hypercementosis at root
- Ankylosis
CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Condition of crown
(2)
- Extensive carious lesions causing destruction
of crown during delivery with forceps - Similar with excessively large restorations
- Endodontically treated roots over time cause
brittle root structure prone to root fracture
during extraction attempt
Check condition of adjacent teeth crowns
- Large restorations or crowns could be
damaged with improper luxation or forceps
use
RADIOGRAPHIC EXAMINATION OF TEETH
* Need a periapical radiograph that is properly:
(3)
- EXPOSED – proper contrast
- POSITIONED – entire tooth structure visualized
- PROCESSED – developed and fixated
- Less of a concern with advent of electronic radiographs
Department policy for impacted third molar
evaluation is an —
radiograph of good diagnostic quality
ORTHOPANTOMOGRAM (PANO)
Relationship of associated vital structures
* Maxillary molars –
* Mandibular molars –
* Mandibular premolars –
(2)
sinus position
Inferior alveolar canal position
mental foramen position
- Can easily be confused with a periapical abscess
- Careful when creating and reflecting FTMP flap
Configuration of Roots
(6)
- Number of roots and length
- Curvature
- Divergence
- Shape
- Associated pathology: Abscess, hypercementosis, external and internal
root resorption - PDL space
RADIOGRAPHIC EXAMINATION OF TEETH
* Condition of surrounding bone
(2)
- Increased bone density vs decreased bone density
- As patient’s age, bone becomes less medullary →more cortical, thus more dense
SURGEON & PATIENT PREP
* UNIVERSAL PRECAUTIONS
- Over coat/garment
- Mask
- Surgical gloves
- Hair out of surgical field
- Cap or Hair tie
- Eye protection
- Patient drape
SURGEON & PATIENT PREP
- Sterile drape over patient
- Antiseptic mouth rinses
- Oral pharyngeal partition!!
- No throat pack →immediate failure during comp exams
- Sterilized instruments and equipment
CHAIR POSITION
* Standing vs sitting
* Choose the position that allows you:
- To feel comfortable
- The maximum amount of control over the forces being sued
- Good visualization and access
- Free hand for ancillary tasks
- Does not block the light source
SURGEON POSITION
- Keep feet firmly planted on the floor
- Keep elbows in close to body
- Keep forceps, hands, wrist, and lower arm in a straight line
- Transmit the force with the more stable and powerful upper arm and shoulder and not
the wrist or hands
FORCEPS EXTRACTION
* Frequent errors:
(4)
- Chair is too high
- Operator blocks out light
- Elbows flailing
- Bending over or craning neck
Elbows flailing
- Increased stress on deltoids and trapezius muscles
- Causes fatigue which could potentiate mistakes at the end of the workday
Bending over or craning neck
- Causing potential career ending neck and back problems
MAXILLARY EXTRACTIONS
(4)
- Operator in front position
- Chair recline so maxillary occlusal plane is 60º to 90º to the
floor - Mouth at level of elbow
- Patient’s head turned towards or away operator to degree
necessary for appropriate visualization
MANDIBULAR EXTRACTIONS
(5)
- Patient in more upright position
- Mandibular occlusal plane parallel to floor
- Chair will be lower than for maxillary extractions
- Mouth at level of elbow
- Patient’s head turned towards or away operator to degree
necessary for appropriate visualization
REAR EXTRACTION POSITION
ADVANTAGES
(5)
- Underhand grip allowing operator to use
more powerful biceps instead of weaker
forearm - Keeps elbows tight to body
- Less light obstruction
- More effective support of mandible for
free hand - Easier for assistant to see
REAR EXTRACTION POSITION
DISADVANTAGES
(3)
- Acceptable technique for mandible,
MORE DIFFICULT for maxilla - View of field is upside down
- Causes operator to rely more on “feel”
than direct vision - Especially with maxilla
PRINCIPLES
(3)
- The LEVER
- The WEDGE
- The WHEEL AND AXLE
THE LEVER
* — are used primarily as levers
* —CLASS lever system
Elevators
FIRST
THE LEVER
Mechanical advantage:
(2)
- Long lever arm with short effector arm
- Transforms small force and large movement to small movement and large force
THE WEDGE
(3)
- Wedge can be used to expand, split, and displace portions of
the substance that receives it - Elevators wedged into PDL space expanding bony socket as
well as displacement of root toward occlusal surface - Forceps seated below crestal bone to aid in crestal bony
expansion
THE WHEEL AND AXEL
(3)
- More closely identified with use of Cryer elevators
(flag elevator) - Handle serves as the axel
- Tip of elevator serve as the wheel and engages and
elevates the root from socket
DENTAL ELEVATORS
(3)
- Used to LUXATE teeth, not to remove them
- Minimizes root fracture
- Requires fulcrum point
RULES FOR LUXATION
(5)
- Never use adjacent tooth as fulcrum, UNLESS the tooth is also
to be extracted - Never used the buccal/lingual plates at the gingival line as
fulcrum - Always use finger guards to protect the patient in case elevator
slips - Be certain that the forces applied by the elevator are under
control - Elevator tip should exert pressure in the right direction
STRAIGHT GOUGE ELEVATORS
* The ONLY elevators that use all 3 principles
(3)
- Lever
- Wedge
- Wheel and Axel
FORCEPS
* The PRIMARY instrument for
removal of teeth
FORCEPS’
Goals:
(3)
- Expansion of bony socket by movement of the tooth against alveolar socket
- Separation of the PDL attachment
- Removal of tooth from socket
FORCEPS FORCES
(5)
- Apical
- Buccal
- Lingual
- Rotational
- Traction
FORCEPS FORCE
(4)
- Apical force
- The first force applied
- Used on all teeth
- Seat forceps beak on firm root structure
- Seat forceps beak on firm root structure
(2)
- Expands crestal bony cortex
- Displace center of rotation as apically as possible
Seat forceps beak on firm root structure
* Expands crestal bony cortex
* Displace center of rotation as apically as possible
(2)
- Reduces apical root fracture
- If fulcrum is too high, there is increased force placed on
apical region of root →root fracture
FORCEPS FORCE
* Buccal force
- After apical force applied
- Most frequently used to expand socket
- Buccal plate usually thinner than palatal or lingual plate
- Possible to fracture buccal plate without expansion of socket if
large buccal force and thin alveolus present
FORCEPS FORCE
* Lingual force
(2)
- Similar to buccal force, but with lingual/palatal bony expansion
- Rare to get lingual plate or palatal plate fracture with this force
FORCEPS FORCE
* Rotational force
(3)
- Create internal expansion of socket
- Best application is teeth with single conical roots
- Least chance to fracture bony plates, roots, or tooth
FORCEPS FORCE
* Traction force
- Limited to the final phase of the extraction process
- To deliver the tooth
- Should be very minimal force
- If proper bony expansion and PDL disjunction achieved with
previous applied force
PRE-EXTRACTION PREP
- Medical history
- Physical examination
- Radiologic evaluation
- Informed consent
- Surgical plan
- Pain, anxiety control
- Patient and surgeon preparation
PRE-PROCEDURE PREP
- Proper chair position
- Mandibular occlusal plane parallel to floor
- Maxillary occlusal plane 60º to 90º
- Universal precautions
- Instrument selection
- Discussion with faculty
Closed extraction technique
- Simple extraction →elevators and forceps
- Most frequently used technique for extraction
- Always attempted first
Fundamentals for a proper extraction
(3)
- Adequate visualization and access
- You can’t complete what you can’t see
- Unimpeded path for removal
- Controlled force to luxate and remove tooth
PROCEDURE FOR CLOSED EXTRACTION
* Steps for closed extraction
- Loosening gingival attachment
- Luxation with elevator
- Proper adaptation of forceps
- Luxation of tooth with forceps
- Removal of tooth from socket
ROLE OF OPPOSITE HAND
- Reflect cheek, lips, possibly tongue
- Stabilize patient head
- Support lower jaw
- Prevent damage to TMJ
- Support alveolar process
- Feel cortex expanding
- Stabilize neighboring dentition
Maxillary incisors
(2)
- Primarily rotational
- # 13 forceps
- Maxillary canine
(4)
- Longest tooth
- Combination of all 5 forces (mild rotational)
- Fracture buccal plate very common
- Upper Universal #150 forceps
Maxillary 1st premolar
- Highest chance of all premolars to have multiple
roots - Buccal force > palatal force
- Want to break buccal root instead of palatal
root - Avoid rotational force
- # 150 forceps
Maxillary 2nd premolar
- Thick, blunt root
- Usually relatively simple extraction
- # 150 forceps
Maxillary Molars
- Can be difficult due to large divergent roots and
proximity of sinus - Apical force, with slow steady buccal force with
less palatal force (buccal plate thinner) - # 150 vs #88 R/L vs #53 R/L
Maxillary 3rd molar
- One tooth that can be frequently removed with
elevators only
Mandibular anterior teeth
- Apical →buccal & lingual (equal pressure) →
rotational →labial traction - Roots and buccal bone fracture very easily
- Be sure the smooth sharp areas of bone
- Lower universal #151 vs #13 Ash forceps
Mandibular premolars
- Next to max central incisors & max 2nd premolars,
lower premolars are among the easier to extract - # 151 vs #13
- Apical →buccal & lingual (equal force) →
rotational (short and conical roots) →buccal
traction
Mandibular molars
- Like max first molar, can be the most difficult of all teeth
to deliver - Long, strong, divergent roots
- Buccal and lingual bone more dense
- Roots may converge at apex (“locking” tooth into place)
- # 23 Cowhorn forceps vs #17
COWHORN FORCEPS USE
- Seat lingual beak first, then buccal beak
- Can easily crush crestal lingual cortex and inadvertently severe lingual nerve
- Lingual nerve is on average ~ 2.5 mm medial and inferior to lingual cortex crest
- ~15% lingual nerve is oriented superior to lingual cortex crest
- Push beaks apically
- Pumping motion vs Rocking motions vs gentle rotational movements
- Squeeze handles together as beaks come together in the bifurcation
- Figure of 8 motion
- Occlusal plane of tooth will elevate above remaining mandibular occlusal plane
- Gradual traction to deliver
DECIDUOUS TEETH
- Roots are long and thin
- Easy to fracture
- If unable to retrieve small root segment, leave
it in place and advise the parent - If deciduous molar roots grasp around
permanent crown, tooth should be surgically
sectioned - DO NOT CURETTE SOCKET
- Do not want to damage permanent bud
underneath
POST EXTRACTION CARE FOR SOCKET
- If periapical pathology is present, curettage is indicated
- If no pathology, no need for forceful curettage
- Smooth any sharp areas of bone around alveolar socket
- Irrigate socket, usually with normal saline
- Suture if indicated (if mucosa does not lay passively to
alveolus) - Place 4x4 gauze over socket
- Instruct patient to bite for 1 hour, FIRMLY
- Most common cause of post-operative bleeding from not
putting enough pressure over socket
