objectives and principles of exodontics - class

EXTRACTION OF TEETHDENTAL FORCEPS

TOOTH EXTRACTION….Defined

The ideal tooth extraction is the painless removal of the whole tooth, or tooth root, with minimal trauma to the investing tissues, so that the wound heals uneventfully and no postoperative prosthetic complication is created.

BASIC REQUIREMENTS FOR EXTRACTION

1. A good radiograph2. Adequate Anaesthesia3. Appropriate instruments4. Adequate illumination5. Good & efficient assistance6. Suction apparatus

DENTAL FORCEPS

Dental Forceps are used for the actual removal of tooth from its socket after it has been slightly loosened.

The handles of the forceps are designed for a palm grasp position and may have a hook on one handle to provide additional leverage by placement of the little finger.

The term ‘Universal’ means that the forceps may be used

* either on the left or right side of one dental arch * or it may be used on the maxillary or

mandibular arch. The beaks of the forceps are designed to

fit the convexity (curve) of the crown and onto the cementum of the tooth root.

These have two blades with sharp edges to cut the periodontal fibres.

The blades are wedge-shaped to dilate the socket and are hollowed on their inner surface to fit the roots.

  They are made in various sizes, separate for adults and children and a pair may be selected which fit snugly round the roots and have even contact with the cementum over a wide area.

  One- or two-point contact of forceps on tooth, is bad as it prevents the tooth being gripped firmly.

The beaks of the forceps should engage only the roots and never the crowns of the teeth

The blades are hinged which allows them to close and grasp the root.

The handles act as a lever which gives the operator a mechanical advantage. The farther from the blades the surgeon grasps the handles the less effort he will have to make to apply force to the tooth.

In order to drive the forceps blade straight up along the long axis of the tooth the shape of the handle is varied.

Lower forceps have handles at right angles to the blades.

Upper forceps are straight for anterior teeth and cranked ( at an angle) for the posteriors.

For the upper third molars the beaks as

well as the handles are bent

Method of holding the Upper Forceps. Note the grip and position of the blades on root, not crown.

Method of holding the Lower Forceps

The crown of this mandibular molar tooth has been grasped in the forceps resulting in its fracture – the root of the tooth is required to be gripped.

Incorrect alinement and application of forceps blade to teeth – one or two point contact is bad, as it prevents the tooth from being gripped firmly eg upper premolar.

Lower Incisor

DENTAL ELEVATORS

Dental forceps are the best instruments for general use in extraction removal of teeth; therefore it is necessary to become proficient in the use of forceps before mastering the use of elevators.

Each manufacturer has his own particular design with the result that there are many that are superfluous .

There are a few fundamental designs in elevators, the use of which should be mastered by the dental surgeon.

Indications for use of Elevators

Elevators are used to luxate & remove teeth which cannot be engaged by the beaks of the forceps, such as

1. Impactions and malposed teeth.2. To remove tooth roots on account of

fractures/caries3. To loosen teeth prior to application of forceps.4. To split teeth that have been grooved for

splitting before removal.5. To remove intra-radicular bone.

Dangers in the use of Elevators

Elevators should be used with utmost caution because of danger of :

1. Damaging or even extraction of adjacent tooth.2. Fracture of the maxilla/mandible/alveolar process.3. Plunging the point of the elevator into the soft

tissues with possible perforation of blood vessels & nerves.

4. Perforating the maxillary antrum or forcing a root/ maxillary third molar tooth into the antrum.

5. Forcing the apical third of the root of the lower third molar into the mandibular canal /or through the lingual plate of the mandible into the sublingual space.

Rules when using Elevators

The following rules should be observed whenusing elevators:

1. Never use an adjacent tooth as a fulcrum unless that tooth is to be subsequently extracted.

2. Never use the buccal plate at the gingival line as a fulcrum, except where a odentectomy is performed, or in the third molar region.

Rules when using Elevators

4. Never use the lingual plate at the gingival margin as a fulcrum.

5. Always use a finger guard to protect the patient,in case the elevator slips.

6. When cutting through the interdental bone,take care not to engage the root of the adjacent tooth,thus inadvertently forcing if from its alveolus.

OBJECTIVES AND PRINCIPLES OF EXODONTICS

SCRUPOLOUS ADHERENCE TO THESE PRINCIPLES COUPLED WITH ADEQUATE KNOWLEDGE OF DENTOALVEOLAR ANATOMY IS A MUST

These objectives are :1. To gain adequate access and get a secured

grip on the tooth.2. To apply controlled force in a predetermined

direction.3. To sever the dentoalveolar bondage or

attachment with minimal trauma.4. To safely deliver the tooth in toto out of the

socket with minimum pain and discomfort to the patient.

5. 5. Uneventful healing.

1. Adequate Access

Difficulty may experienced if a good light source is not available focusing on the surgical field.

Access & workability can be improved by …If anaesthesia is adequate …Bleeding is under control …If the surrounding tissues are

protected away from surgical field.

2. Application of Controlled Force1. Do not use force as a test of your physcical

strength.2. Injudicious application f force results in #

tooth / jaw bone3. It is safe to stop surgical movement of

forceps if any abnormal resistance is felt4. In such situations, a radiograph is a must to

see the cause of resistance – it can be either due to

i accessory roots ii unfavourable curvature of root iii fusion of roots with bone(

ankylosis)/adjoining teeth iv locking with adjoining teeth.

3.

3. To Sever the Tooth attachment with Atraumatic Technique1. The attachment of the tooth can be

severed by forces like rotational or pendulum movements.

2. The sole objective is to sever the periodontal fibres without damaging the adjoining structures

3. The rotational movement is rocking in the longitudinal axis of the tooth

4. The pendulum movement is by rocking in the medial –lateral direction ie buccolingually or buccopalatally.

  4. Safe delivery of the Tooth. The objective here is to deliver the

tooth in toto / one piece out of the socket through an uninteruppted path of removal.

This should be done with minimum pain or discomfort to the patient without causing any complications.

 5. Uneventful Healing

The healing of the extraction socket must be without discomfort or complications

The discomfort, if any could be because of underlying systemic condition like Diabetes, Vitamin deficiency or debilitating diseases of systemic origin

INDICATIONS FOR EXTRACTION OF TEETH

In general, indications for removal of teeth are based on :-

1. Dentoalveolar pathology2. Feasability / otherwise to restore the

dental, periodontal tissues3. Patients willingness & motivation to

undertake the type of treatment4. Economic and time factor considerations.5. Universally dental caries & periodontal

diseases account for 85 – 90 % of extractions

1. Periodontal disturbances: most common cause of extraction - depends on success of periodontal therapy - pts attitude towards conservation of teeth - economic/time factors

2. Dental caries : tooth extensively damaged –unrestorable – sharp margins repeatedly ulcerate mucosa.

3. Pulp pathology: if RCT not possible / amenable

4. Apical pathology: teeth fail to respond to all consevative measures eg teeth involved in a cyst.

5. Orthodontic reasons:

Therapeutic extractions to gain space for realignment of teeth eg premolars/molars

Malposed teeth – if difficult to realign them

Serial extractions – mixed dentition period-extraction of deciduous teeth undertaken in a chronological order to prevent malocclusion & provide space for permanent teeth in a sequential way.

6. Prosthetic considerations:

A few selected teeth may have to be extracted for better design and efficient prosthesis

The patient may request the extraction of the few remaining teeth to enable him to have complete dentures.

7. Supernumery teeth:

These may be - malpositioned or unerupted, - may predispose to

malocclusion, - periodontal problems, - facial pain or bone pathology.

8. Impactions:

Retention of unerupted teeth beyond their chronological eruption may be a cause of

- vague facial pain, - periodontal problems of adjoining

teeth, - TMJ problems, - cysts & pathological # of the jaws. Impacted teeth may predispose to

anterior overcrowding of teeth.

 9. Teeth in Line of Fracture: This has been controversial issue over

the last so many years. The present thinking is that the tooth in

line of # should be extracted, if a) it is a source of infection at site of

# b) the tooth itself is fractured c) the retention of the tooth may

interfere with reduction / healing of the #

10. Teeth in relation to bony pathology

These are indicated for extraction eg, if they are involved in cyst formation, neoplasms or osteomyelitis.

Careful evaluation is required, if there is any chance for properly guiding the tooth to erupt into normal occlusion, especially in children

11. Root Fragments:

They may remain asymtomatic for a long time and their removal should be evaluated carefully.

Sometimes the roots may cause ulceration of the tongue or they may lie submucosally producing recurrent ulceration under the denture

Some roots may be infected, painful & may be involved in initiation of bone pathology eg osteomyelitis, cyst or neoplasm

At times the root may lie near the neurovascular bundle & the patient may complain of facial pain or numbness

Generally, many very small broken root fragments remain asymptomatic and can be left alone provided its not infected, all other roots fragments are indicated for removal.

As age advances patients become medically compromised, hence root removal is indicated as soon as it is diagnosed.

12. Teeth prior to Irradiation.

Irradiation is one of the treatment modalities for oral carcinomas.

Previously as a prophylactic method, all teeth in the region of irradiation used to be extracted.

Currently, precautions are taken to conserve teeth & if good oral hygiene can be maitained, routine prophylactic extraction of teeth is not encouraged.

Only teeth which cannot be kept in a sound condition require extraction.

13. Focal Sepsis.

At times teeth may apparently appear sound, but radiological evaluation is a guiding factor if any teeth are to be considered as foci of infection.

In such cases the weightage is in favour of underlying systemic diseases/problem such as facial pain, skin problem, uncontrolable opthalmic problem.

In such conditions, doubtful teeth are extracted instead of tryng to conserve them.

14. Aesthetics:

Teeth requiring attention for esthetic reason due to compelling reasons like marriage and job opportunities,– but because of the paucity of time it may not be possible to improve esthetics either conservatively or surgically.

In such situations doubtful teeth are extracted and replaced by immediate dentures, in a shorter time.

15. Economic / Financial cosiderations: It sometimes so happens that the

patient & dental surgeon are faced with financial constraints, although the conservation of the tooth is possible.

In such cases extraction may be the only alternative and the benefit of doubt is left to the discretion of the patient.

CONTRAINDICATIONS FOR EXTRACTION OF TEETH

Even if the tooth is indicated for extraction, certain factors make the tooth contraindicated for extraction. T here may be relative or absolute contraindications.

The contraindications may be due to systemic or local factors

The presence of absolute systemic contraindications indicate that this group of diseases exist in an uncontrolled state.

No attempt should be made to thrust extraction on these patients – eg

1. Metabolic disorders like diabetes2. Cardiac probems with failure3. Leukemia4. Renal failure5. Liver disorders like cirrhosis of liver.

On the other side of the coin are conditions which are examples of relative contraindications - that is, the extraction of teeth is deferred till such time the underlying problem has been attended to and the patient is medically fit to undergo the extraction.

In such patients the underlying condition is to be treated by way of precautions so that complications do not arise due to extraction.

1. Diabetes and Hypertension2. Patients on steroid therapy3. Pregnancy4. Bleeding disorders5. Medically compromised patients6. Local contraindication-presence of

uncontrolled infection7. Extraction of teeth in recently irradiated

patients

PRE-OPERATIVE ASSESSMENT

It is always wise to assess the patient on the following aspects.

  Systemic Evaluation Clinical Examinatrion Radiological Ivestigation

The basic aim & objective of these pre-op assessment is to decide:

1. The choice of anaesthesia2. Whether the patient can withstand GA3. Whether the patient can withstand the

trauma of surgery.4. Any abnormalities in the pateient

general health prior to surgery5. The choice of pre-medication6. On the treatment plan that will suit or

benefit the patient the most.

A. SYSTEMIC ASSESSMENT

1. A thorough medical history - bleeding disorders - on anticoagulants – immuno/medically compromised patients.

2. Difficulties encountered in previous extractions

3. Any limitations of mouth opening4. State of oral hygiene –for smooth post op

recovery.

B. CLINICAL EXAMINATION

The tooth to be extracted & also the adjoining structures which will provide valuable information:

The general cleanliness of the patients mouth and oral hygiene are noted.

Whenever necessary and possible, pre – extraction scaling should be performed, in neglected mouths – so that chronic inflammation is eliminated, and to hasten early healing & to avoid calculus or other infected material being swallowed / inhaled especially during extraction under GA.

In addition to this, also carry out the examination of

thetooth to be extracted & adjoining structures providesvaluable information.

1. Access to the tooth, range of mouth opening, location & position of the tooth in the arch –

malposed tooth - difficulty in positioning the instrument for extraction.

2. Tooth mobility-periodontal disease, underlying pathology.

3. Anatomy of the Crown – examine under proper light

* carious destruction of the crown * shape, position, long axis and size of

crown * presence of large restorations * attrition of the crown * presence/absence of adjoining teeth

and their condition * nonvitality * state of supporting structures.

C. RADIOLOGICAL ASSESSMENT

Clinical examination is incomplete without a intra-oral periapical radiograph of the region – it is indicated in

1. History of ‘difficult’ or unsuccessful extraction

2. Crown with extensive caries, large restorations, non vital or malposed tooth

3. Abnormal resistance during forcep extraction

4. Teeth in close proximity to important anatomical structures5. Attritioned teeth in elderly patients6. If tooth is partially or completely

unerupted 7. Solitary tooth in the jaw without

adjoining teeth8. When underlying bone pathology

suspected

Radiographic evaluation

Radiographic evaluation will yield the following information

1. All necessary features of the crown2. Any alteration in the number, size,

shape & configuration of root morphology

3. Status of the alveolar bone like bone level around root, hypercementosis, gemination sclerosis, of bone or ankylosis

4. Presence of any apical or bony pathology

5. Proximity to important anatomical structures, will forewarn the operator about the possibility of nerve damage, oro-antral fistula or # of the maxillary tuberosity.

It is therfore,better to take precautions rather than face intra-operative complications

CHOICE OF ANAESTHESIA The choice of anasesthesia will depend

upon the patients medical history and level of cooperation.

There are a variety of surgical factors that may indicate the use of

LOCAL or GENERAL Anaesthesia, or SEDATION however, in general here

are some…

LOCAL ANAESTHESIA Safe & most commonly employed method

LA is best for: 1. Procedures taking less than 45 minutes 2. Single operative site in the mouth 3. Readily accessible areas of the mouth

GENERAL ANAESTHESIA

GA is best for:1. When there is acute or subacute infection,

because an injection may cause a flare up of infection

2. Complicated procedures of unpredictabe duration

3. Multiple operative sites4. Working in areas of the mouth with difficult

access ( eg palate )1. In young children and nervous patients.

SEDATION

Sedation is reduction/abolition of physiologic and psychological response to stress of surgery without loss of conciousness, cooperation or protective responses.

Used as an adjunctive measure to LA to help patients comfort during surgery.

There are 3 methods of administering sedation

1. Oral – for nervous patients - oral diazepam 2 - 5 mg – night before & 1 hour prior to surgery

2. Inhalation –use of nitrous oxide through a nasal mask.

3 Intravenous – the most efficient, effective and predictable method of sedation –requires close monitoring. Drugs commonly used are Benzodiazepines ie Diazepam & midazolam