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DEPARTMENT OF

ORAL & MAXILLOFACIAL SURGERY


RUNGTA COLLEGE OF DENTAL SCIENCES & RESEARCH
KOHKA, BHILAI

MODERATOR -

PRESENTED BY
DR. SHEETAL KAPSE

1st YEAR, P.G. STUDENT

DR.
DR.
DR.
DR.

SUNIL VYAS
M. SATISH
DEEPAK THAKUR
MANISH PANDIT

EXODONTIA
rinciples, techniques & complication

INTRODUCTION
Science the earliest period of history of the extraction of the tooth
has been considered a very formidable procedure by the
layman, & it is because of the horrifying experiences associated
with the tooth extraction in the past that even today the removal
of a tooth is dreaded by a patient almost more than any other
surgical procedure.
Many patients suffer from extractionfobia & are often difficult to
care for, despite modern methods of anesthesia.
Many dentists still believe that speed is essential when extracting
the teeth.

DEFINITION
The ideal tooth extraction is
The painless removal of the whole tooth, or
root, with minimal trauma to the investing tissues, so that
the wound heals uneventfully & no post-operative
prosthetic problem is created.
(Geoffray L Howe)

HISTORY
OF
EXODONTIA

The 1st dentist was an EGYPTIAN


HESI RE (31002181BC)

The history of dental extraction forceps is


very old and goes back to the time of
Aristotle (384 to 322 BC) where Aristotle
described the mechanics of oral surgery
forceps . This was over 100 years before
Archimedes studied and discussed the
principles of the lever.

Dental history arabic dentist


cauterizing dental pulp

Curing a Toothache with


FireThe fumes from

The Martyrdom of St. Apollonia,


shows the torturous extraction of
teeth

German Traveling Dentist

The Italian "Oral Surgeon" That


Traveling Dentist in a Dutch VillageEffortlessly Removes Jawbones

until the 16th century, dedicated dentists did not exist


and dentistry was practiced by general physicians
and barbers.

A number of tools were invented for performing this


procedure.

Dental Pelican, which was invented in the 14th


century by Guy de Chauliac and used until the late
18th century.

The instrument is a combination


of the attributes of the an
extracting forceps and a toothkey
1843 to 1863

In the 20th century, the key was


replaced by the forceps, which

INDICATIONS
OF
EXODONTIA

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

11.
12.

Allen 1994 caries in 48.8% cases abscess


Periodontal diseases in 40.7% cases to prevent alveolar ridge
resorption
Tooth with necrosed pulp & periapical lesion not responding to
endodontic treatment
Over retained deciduous tooth but take radiograph first
Orthodontic purpose
Prosthetic purpose
Unrestorable tooth
Impacted tooth
Supernumerary tooth
Grossly decayed 1M / 2M make room for 3rd molar
HOTZ & SMITH
Tooth in fracture line
Teeth directly involved by cyst & tumor

13.

Teeth in the area of therapeutic irradiation

14.

Teeth acting as foci of infection


ex. bacterial endocarditis
- rheumatic fever

RICHARDS (1932) bacteremia after infected tooth extraction

OKELL & ELLIOTT (1935) STREPTOCOCCUS VIRIDANS in


blood stream (75% of 40 patient)
Use of local anesthetic solution (vasoconstrictor) infection

rate of spread of

CONTRAINDICATIONS

It may be judicious to delay the extraction until certain


local or systemic condition corrected or modified.

In the era of antibiotics acute infection of odontogenic


origin are not considered as absolute contraindication of
immediate extraction.

NUG / HERPETIC GINGIVOSTOMATITIS spread of


infection & greater degree of systemic reaction.

Previously irradiated area (within 1 year) less trauma


+ pre & post-op antibiotic prophylaxis

Other relative systemic contraindications

Acute blood dyscrasias

acute leukemia ,

agranulocytosis,

Untreated coagulopathies congenital or acquired


Adrenal insufficiencies
Within 6 months of myocardial infarction

CONTRAINDICATIONS :
A. Absolute : Central Haemangioma. May cause
uncontrolled bleeding.
A-V malformation.
B. Relative :
When some precautions have to be taken.
1. Local Acute cellulitis.
ANUG.
2. Systemic Uncontrolled Diabetes Mellitus,
Hypertension.
Bleeding disorders.
Cardiovascular diseases.
Liver disorders.
Patients on long-term steroid therapy.
Teeth that have undergone radiation [6

PRINCIPLES
OF
EXODONTIA

THE MECHANICAL
PRINCIPLES
Expansion of bony socket
specially for forcep extraction
sufficient tooth structure
elastic bone (children)
multiple small fractures of buccal
cortical bone
1.

Use of a lever & fulcrum


remove the tooth/root along the path of least
resistance
basic factor governing the use of elevators

THE MECHANICAL PRINCIPLES

2.

The insertion of
wedge or wedges
between tooth-root
& bony socket wall

3.

Wheel & axle principle

Forces applied during


extraction of tooth

PREOPERATIVE
ASSESSMENT

Take history of
1. general disease
2. nervousness
3. resistance to inhalational anesthesia
4. previous difficulty with extraction

Oral hygiene status of the patient


oral prophylaxis
antiseptic mouth rinse

Clinical examination of the tooth

Clinical examination of the oral cavity- any


prosthesis

PREOPERATIVE RADIOGRAPHS

Indications
i.
H/O difficult & attempted extractions
ii.
Resistance to forcep extraction
iii.
Planning to remove the tooth by dissection
iv.
Close approximation with important anatomical structures
v.
Abnormal root pattern third molars, in standing premolars, misplaced canine
vi.
Tooth having periodontal problem & some sclerosis hypercementosis
vii. Trauma to tooth fracture of tooth, roots & alveolar bone
viii. Isolated & Unopposed maxillary molars
ix.
Partially erupted, unerupted tooth & retained roots
x.
Delayed erupting or having abnormal crown
xi.
Condition indicating dental or dentoalveolar deformities
osteitis deformans - hypercementosis
cleido-cranial dysosteosis - hooked root
therapeutic irradiation
osteopetrosis

CHOICE OF ANESTHESIA
General factors
LOCAL
ANESTHESIA

GENERAL ANESTHESIA

5-10 min.
uncooperative patients

30-45 min.
No pre-op preparation
Respiratory tract disease
Cardiovascular diseases

Local
factors

Acute infection at the site of injection


Hemangioma

STERILIZATION

Is defined as
removal of all micro-organisms from a given
object.

Hands of operator
Instruments
Operation area
Engines, lights & chairs are inevitably sources of crossinfection.
Use the sterile gauze /cloth to change the position of
light.

GENERAL ARRANGEMENT
1.

Position of the operator


- Stand erect , equal distribution of weight on
both feet
- Force delivery with arm & shoulder not with hand
- application of force without stress to shoulders &
back

- generally on right hand side


- for Right posteriors back side
- operating box

GENERAL ARRANGEMENT

2.

Position of the patient


make the patient comfortable on
dental chair

3.

Height Of Dental Chair


maxillary teeth 8 cm / 3 inch below
the shoulder level
of operator
mandibular teeth 16 cm / 6 inch
below the elbow of
operator

GENERAL ARRANGEMENT

4.

Angulation of the chair


maxillary teeth 45-60
degree
mandibular teeth parallel
or 10 degree

5.

Light
good illumination

6.

Role of opposite hand

Reflection of soft tissue


Protection of other teeth
Stablization of patients head
Supporting & stablizing the mandible
Supports alveolar bone
Tactile information
Compress socket
Deliver the whole tooth, root, dislodged
filling

.
.
.
.
.
.
.

7.

Role of assistant

Helps the surgeon to gain access & visualize


the field
Suction
Protect the teeth of opposite arch
Support the head
Support the mandible
Psychological & emotional support
Avoid casual , offhand comments
increase patients
anxiety
- decrease
patients cooperation

.
.
.
.
.
.

PRINCIPLES
OF
TOOTH REMOVAL

Clear access to & vision of the surgical field.

Use of controlled force

Unimpeded path of removal

EXTRACTION
PROCEDURES

What we do in
extraction of a tooth
????

Separation of tooth from alveolar bone


with crestal & principal periodontal
fibers.

Alveolar expansion

Bleeding is arrested by pressure pack.

Separation of Tooth from


Soft Tissues

Severing Soft Tissue Attachment


The straight and
curved desmotomes

Reflecting Soft Tissues

Chompret elevators;
a straight, and b curved

Techniques
of
exodontia
A.

Intra-alveolar extraction

(closed

technique)

B.

Transalveolar extraction (open


method)

intra-alveolar
extraction
1.

forcep Technique

2.

elevator Technique

1. Forcep Technique

Commonly used

Not used in hypercementosis


- root deformities
- grossly decayed crown
- grossly decayed root
- brittle root

Advantages - least trauma


- gingival fibers reduces the size of
extraction orifice
so promotes healing

Basic principles for forcep


technique
1.
2.
3.

Beaks should seated as far apically as


possible
Beaks should be parallel to the long axis of
tooth
Excess force should be avoided.

HOW TO HOLD THE


FORCEP
Thumb just below the joint
Handle in palm
Little finger inside the
handle

Adaptation of blade

Buccally & lingual parallel to long axis of tooth.


Forced through periodontal membrane, towards apex.
Firm pressure.
1st apply on less accessible side of tooth under direct
vision
2ndly on other side
Cervical caries - 1st movement towards carious part

IT IS SAID THAT Time spent in careful application of


forcep blades to the radicular
portion of tooth is never wasted.

Displacement of tooth from


socket

Pressure applied by the operator by moving his


trunk from hips not from elbow.

Movements linguobuccal & buccolingual


loos
- firm, smooth & controlled

remov
rotatory / figure
of 8
al

Maxillary buccal bone is thinner buccally removal of


teeth

Mandibular buccal bone till molar is thinner - buccally


removal of teeth

Mandibular buccal bone in molar region is thicker lingually removal of teeth

Socket compression

Avoid soft tissue laceration

Maxillary incisors

Maxillary canine

In multiple extraction cases canine should be


extracted prior to extraction of incisors, as
prior extraction of incisors weakens the labial
cortex.

Maxillary premolars

Maxillary

molars

MANDIBULAR INCISORS

MANDIBULAR CANINE

Heavy bladed forceps


are used.

MANDIBULAR PREMOLARS

MANDIBULAR

MOLARS

Extraction of deciduous
teeth
Factors
1.
2.

So use fine blades

Permanent successors Warwick james


elevators can be
Limited access
used

Extraction of deciduous molar with


forceps. Forceps are positioned
mesially or distally on the crown and

2. Elevator technique

Works on lever & fulcrum principle

It forces the tooth / root along the line of withdrawal


R/G

Fulcrum bone or adjacent tooth

Elevator grasping

Application
in periodontal space
450 to long axis of tooth

Placement of gauze between finger


and lingual side, for protection from
injury in case the elevator slips

Point of application

Application of elevator
Buccally
Mesially
distally

Movement
rotate the elevator along its
long axis

a During luxation of a tooth,


the alveolar ridge is used as a
fulcrum, not the adjacent tooth.
b Incorrect
placement of the instrument.
c Photoelastic model
showing extraction of the third
mandibular molar using a
straight elevator. Using the
adjacent tooth (second molar) as
a fulcrum creates great tension
around the tooth, with a risk
of injury to tissues surrounding the

Extraction of Single-Rooted Teeth


with Destroyed Crown

Positioning of straight elevator on the distal


surface of the root, either perpendicular to,
or at an angle to the root

Removal of the root of mandibular premolar


with the special instrument (endodontic filebased action) for root extraction

Extraction of multi-rooted
Teeth with Destroyed Crown

Separation of roots of the


mandibular first molar with
fissure bur

Extraction of Multi-Rooted Teeth


with Destroyed Crown
Roots of mandibular first
molar. Extraction is
accomplished by sectioning
roots using a straight elevator

Positioning of the elevator and the fingers of the left hand for
separation of molar roots

Using an elevator with T-shaped handles to remove


intraradicular bone

Extraction of Root Tips

Diagrammatic illustrations showing luxation of


the root tip of the mandibular second premolar,
using
double-angled elevators

MESIAL ROOT OF A
MANDIBULAR MOLAR

Technique for removing the tip of a mesial


root of a mandibular molar. Removal of
intraradicular bone
and luxation of the root tip using a doubleangled elevator

Removal of the tip of the distal root of a


maxillary molar

REMOVAL OF ROOT TIP

Removal of the root tip using an endodontic


file. After the endodontic file enters the root
canal, the root tip is drawn upwards by hand
(a), or with a needle holder (b)

AFTER CARE

Irrigation of the socket


Squeezing of the socket
Mouth rinsing with warm bland water
for once
Suturing if require
Moist gauze pack
Medication
Post extraction instructions verbal &
written

Transalveolar extraction (open


method)

INDICATIONS 1.
2.
3.
4.
5.

Intra-alveolar attempt is failed


Retained roots in proximity with maxillary sinus &
not accessible to forcep
History of difficult or attempted extraction
Heavily restored tooth
Geminated / dilacerated tooth

Radiograph showing abnormal root pattern

Hypercementosed / ankylosed tooth

Fusion of
teeth

Dens in dente of maxillary left canin

Deciduous mandibular molar, whose


roots
embrace the crown of the
succedaneous premolar. Risk of
concurrent luxation with the simple
extraction technique.

Main components of transalveolar extraction


1.

Design of mucoperiosteal flap

2.

Method to be used to deliver the tooth / root from


socket

3.

Bone removal used to facilitate tooth / root removal

Design of mucoperiosteal flap


Base broad

Raise to render the operative site


clearly visible & accessible
Suture should not be placed over
blood clot

Obliteration of buccal sulcus


should be avoided

INCISION

Sharp scalpel
Firm pressure
Mucousa + periosteum
Avoid Button hole formation in case of
sinus
Incision of sufficient length at once

REFLECTION OF FLAP
Austins
retractor

Minnesota retractors for


retraction of the cheek and
tongue

Bone removal

To expose root/tooth
Facilitated by large flaps
Provides point of application
After tooth/root removal remove all sharp edges &
bone prominences
Instruments used -

dental burs

Round / rose head provides less clogging, better control.


It doesn't cut the tooth that easily
Should not contact soft tissue
Avoid overheating
Postage stemp method
then join with chisel

TOOTH DIVISION

Different line of removal for different roots


Divide the root from furcation area
Make space for application of forcep / elevator
Osteotome / burs

REMOVAL OF TOOTH OR
ROOT

Engage the elevator in a notch on side of root


If notch is not present then create it with round bur
directed at 450 angle to the long axis of root.

AFTER CARE

Irrigation of the socket


Suturing
Moist gauze pack
Medication
Post extraction instructions verbal &
written
Recall after 48 hours

SUTURE REMOVAL

Normally 7 days
Within 2 days if it was for control of
hemorrhage

OAC repair 10 days

Removal of maxillary molar

Steps in the surgical extraction of an intact


maxillary first molar. Reflection of the envelope
flap, sectioning of two buccal roots from the
crown (a), removal of the crown together with
the palatal root, and then finally
removal of the mesial and distal roots (b)

hypercementosis at the root


tip

An L-shaped incision is made and the flap is


reflected. The buccal plate covering the surface of
the root is removed, and the tooth is extracted
using forceps

Hypercementosis at the
distal root tip

a, b. Surgical extraction of a
mandibular molar
with hypercementosis at the distal
root tip. The envelope
flap is reflected, part of the buccal
plate is removed, and the
tooth is sectioned buccolingually at
the crown as far as the
intraradicular bone

Extraction of the mesial portion of the


tooth,
which includes the crown and root
Widening of the alveolus with a round
bur, so
that removal of the root is possible
without fracturing the bulbous root tip

Root of a maxillary first premolar.

The surgical technique is indicated for its removal

Radiograph of roots of the mandibular first molar.


The surgical technique is indicated for their removal

Root of a maxillary first


premolar.

RUBBER BAND
EXTRACTION
INDICATIONS
1. Patient Under Coverage of BISPHOSPHONATE
2. Hemophilic patients
PROCEDURE

Root canal treated and split mandibular molar


during exfoliation process. Note extrusion of
mesial root.

Dentin bulge (arrows)


preventing elastics from
sliding apically.

Atraumatic Teeth Extraction


in
Bisphosphonate-Treated
Patients
2008 American Association of Oral and
Eran Regev,
DMD, MD,* Joshua
Lustmann, DMD,
Maxillofacial
Surgeons
and RizanJNashef,
DMD
Oral Maxillofac
Surg 66:1157-1161, 2008

0278-2391/08/6606-0011$34.00/0
doi:10.1016/j.joms.2008.01.059

Sockets immediately after exfoliation of

Specific consideration for extraction


under general anesthesia

Take careful history

Take care of airway, support of mandible &


position of patients head

The dental surgeon should never act as


both operator & anesthetist.

PREPARATION FOR
ANESTHESIA
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Accompanying person
No driving
6 hrs of NPO
Emptying the bladder
Loose the tight clothing
Patient Comfortable in
dental chair
Head slightly extended
Mandible should be parallel
to floor
Arm & leg position of patient
Waterproof apron
Hearing of patients each
breath

Preoperative
consideration
1.
2.
3.
4.
5.

Identify the tooth


All prosthesis are removed
All instruments should be keep ready
Larger the anesthesia increase risk of
anoxia & aspiration
Ideal time 5-10 min.

Special arrangements
1.

Dental prop

2.

Mouth gauge

3.

Mouth pack

4.

Efficient suction
apparatus

5.

Tracheostomy kit

Modification of
extraction technique
1.
2.
3.
4.
5.

Tooth priorities
Avoid excess force to mandible
Soft tissue injury should be avoided
Postpone remove pulp if it is
exposed
Fractured root v/s resorbed root

Co-operation
between dentist
&
anesthetist

HEALING
OF
EXTRACTION SOCKET

5 Stages 1.

Hemorrhage & clot formation 1-2 days

2.

Organization of clot by granulation tissue 3-7 days

3.

Replacement of granulation tissue by connective tissue


& epithilialization of wound 4-35 days

4.

Replacement of connective tissue by coarse fibrillar


bone 6-8 weeks

5.

Reconstruction of alveolar process & replacement of


immature bone by mature bone tissue

Factors influencing the


healing
1.
2.
3.
4.
5.
6.

Infection
Size of wound
Blood supply
Resting of part
Foreign bodies
General condition of the
patient

TECHNOLOGICAL
ADVANCEMENT
IN
EXTRACTION
TECHNIQUES

Technological Advances in Extraction Techniques


and Outpatient Oral Surgery
Adam Weiss, DDS*, Avichai Stern, DDS, Harry
Dym, DDS
Department of Dentistry and Oral and Maxillofacial Surgery, The
Brooklyn Hospital Center,
121 Dekalb Avenue, Brooklyn, NY 11201, USA
* Corresponding author.
E-mail address: aweissdds@gmail.com
KEYWORDS
Powered periotome Polyurethane foam Piezosurgery
Immediate implants Orthodontic extrusion Bone grafting
Physics forceps
Dent Clin N Am 55 (2011) 501513
doi:10.1016/j.cden.2011.02.008 dental.theclinics.com
0011-8532/11/$ see front matter 2011 Elsevier Inc. All rights
reserved.

1.
2.
3.
4.
5.
6.

Powered
periotome
Piezosurgery
Lasers
Coronectomy
Orthodontic
extrusion
Physics forceps

Powered periotome
Powertome Assisted
Atraumatic Tooth Extraction

The Journal of Implant &


Advanced Clinical Dentistry
Jason White, Dan Holtzclaw,
Nicholas Toscano
September 2009 Volume 1,
No. 6

Powered periotome

Precise extraction of tooth


Preserves bone & gingival architecture
Option for immediate implant placement
Mechanism of WEDGINNG & SEVERING
Severs the periodontal ligament
Multirooted teeth requires sectioning.

Presurgical radiograph of
Case 1.

Rotational movement of root with forceps

Powertome blade advanced in


a sweeping fashion.

Atraumatic removal of the tooth

Presurgical clinical presentation Powertome blade advanced down PDL

Extracted segments of maxillary canine

Presurgical clinical presentation


Presurgical radiograph

Motorized periotome _Powertome_ for atraumatic extractions - YouTube.flv

Piezosurgery

Piezosurgery is an innovative bone surgery technique that produces


a modulated ultrasonic frequency of 24 to 29 kHz, and a
microvibration amplitude between 60 and 200 mm/s.

The amplitude of the vibrations created allows a very clean and


precise surgical cut.

It works selectively, without harming soft tissues such as nerves and


blood vessels even with accidental contact with the cutting tip.

The surgical control of the device is effortless compared with


rotational burs or oscillating saws because there is no need for an
additional force to oppose rotation or oscillation of the instrument.

Despite the longer time of the procedure, the investigators also


noted that the piezoelectric osteotomy reduced postoperative
facial swelling and trismus.

Uses of piezosurgery device to cut and elevate a precisely defined


bone lid on the lateral cortex of the mandible to provide access to
the teeth needing extraction or even a lesion that needs to be
excised. The bone window is then elevated with the help of a
curved osteotome.

After the visual confirmation of an undamaged IAN and adjacent


tissues, the bone lid is placed back into its original position and
fixated with absorbable miniplates.

piezosurgery flaples extraction of lower first molar in severe ankylosis with kaps microscope - YouTube.flv

LASERS FOR
EXTRACTION OF
IMPACTED TEETH

For the surgical extraction of the teeth, the covering bone was first
ablated, layer by layer, using the Er:YAG laser.

In the case of the fiber-optic Er:YAG [erbium:yttrium-aluminum


garnet ], laser the fiber is closely guided around the teeth, creating
a narrow gap with minimal bone loss.

The benefits of laser therapy include the creation of a bloodless


surgical field and thus improved visualization during surgery,
decreased postoperative pain, and limited scarring and contraction.

Time consuming, sound and smell, significantly inhibition the


laser cutting because of the overall volume of irrigation and blood
covering the bone surface.

Orthodontic extrusion

Third molars in close proximity to the IAN have a significant


negative impact on recovery for pain and oral function.

The advantage of this technique is that the risk of direct trauma


to the nerve is eliminated, due to both the increased distance
between the roots and the mandibular canal and the decreased need
for surgical manipulation during the extraction.

A potential problem with this technique is soft tissue damage from


impingement on the mucosa of the cheek and the gingiva.

In addition, working in this area of the mouth presents great


difficulty, and the action of the masseter muscle leads to cheek
compression against the orthodontic appliances.

This technique will be of no value for a tooth that cannot move


because of ankylosis.

This technique should be used only in carefully selected cases in


conjunction with an orthodontist, being certainly difficult, time
consuming, and not always successful.

STAGED REMOVAL OF
HORIZONTALLY IMPACTED THIRD
MOLARS TO REDUCE RISK OF
INFERIOR ALVEOLAR NERVE INJURY
J Oral Maxillofac Surg 68:442446, 2010

Staged Removal of Horizontally Impacted


Third Molars to Reduce Risk of Inferior
Alveolar Nerve Injury
Luca Landi, DDS,* Paolo Francesco Manicone, DDS,
Stefano Piccinelli, DDS, Alessandro Raia, DDS, PhD, and
Roberto Raia, DDS

2010 American Association of Oral and Maxillofacial


Surgeons
0278-2391/10/6802-0032$36.00/0
doi:10.1016/j.joms.2009.07.038

Panoramic radiograph at initial consultation. The


mandibular
third molars are mesially impacted with the roots
close to
the alveolar canal.

Postoperative radiograph after the right


mandibular
third molar was surgically sectioned. The
space distal to the second molar would
allow mesial migration of the impacted
tooth.

Postoperative radiograph after second sectioning of


the right mandibular third molar. A pulpotomy has been
performed.
More space was created distal to the right mandibular
second
molar to allow further migration

3 months after odontectomy.


The third molar moved
mesially.
However, the mesial root was
still in contact with the
alveolar canal.
A second sectioning was
required.

Periapical radiograph obtained 2 months


after second sectioning. At that time, the
roots were away from the alveolar canal,
and a riskless extraction could be
scheduled.

Physics forceps

The Physics Forceps uses first-class level mechanics to atraumatically


extract a tooth from its socket.

One handle of the device is connected to a bumper, which acts as a


fulcrum during the extraction.

Together the beak and bumper design acts as a simple first-class lever.

A squeezing motion should not used with these forceps. By contrast, the
handles are actually rotated as one unit using a steady yet gentle
rotational force with wrist movement only.

Once the tooth is loosened, it may be removed with traditional


instruments such as a conventional forceps

GMX-100A - Upper Anterior - Extracts Teeth 6 to 11


GMX-200 Lower Universal Extracts Teeth 18
to 31

GMX-100R - Upper Right - Extracts Teeth 2 to 5

GMX-100L - Upper Left Extracts Teeth 12 to 15

Dental Extraction Forceps - Extraction Forceps - Physics Forceps Price - Forceps Dental Extraction.flv

Coronectomy oral
surgerys answer to
modern day
conservative dentistry
V. Patel, S. Moore and C. Sproat
BRITISH DENTAL JOURNAL VOLUME

Refereed Paper
209 NO. 3 AUG 14 2010
Accepted 29 April 2010
DOI: 10.1038/sj.bdj.2010.673
British Dental Journal 2010;
209: 111114

Coronectomy is a technique
1*,3Oral and Maxillofacial Surgery, Oral and Maxillofacial that should
Department, Guys Hospital, Floor 23, Great Maze Pond,
London, SE1 9RT; 2Restorative Dentistry, Guys Hospital, be considered for mandibular
Floor 26, Great Maze Pond, London, SE1 9RT
third molars
*Correspondence to: Dr Vinod Patel
Email: vinod.patel@hotmail.co.uk
when it is felt there is an
increased risk of
injury to the inferior dental
nerve.

Coronectomy can be beneficial but success requires both good patient selection
and operator technique.

Renton et al.reported no IDNI in 58 successful Coronectomy patients and a


19% IDNI rate in those having traditional extractions.

Leung et al. showed nine (5%) patients in the control group presented with
IDNI, compared with one (0.06%) in the Coronectomy group.

Hantano et al. reported that in the extraction group six patients (5%) suffered
IDNI, of which 3 patients were diagnosed with permanent injury, where as in
the Coronectomy group one patient (1%) complained of altered sensation postoperatively which resolved within one month.

The retrospective analysis of ORiordan consisted of 52 patients that


underwent Coronectomy. In this study there were 3 cases of transient IDNI
which showed resolution one week post operatively. One patient developed
permanent IDNI, which was thought to be as a result of perforation of the canal
due to operator error rather than the Coronectomy technique itself.

1, deviation of the canal

3, periapical radiolucent area

5,darkening of roots

2, narrowing of the canal

4, narrowing of root;

6, curving of root

7, loss of lamina dura of canal

Coronectomy: A, cutting crown


below cement-enamel junction
(arrow);

B, trimming cutting surface to


less than 3 to 4 mm below
alveolar crest.

Radiographic imaging
showing pre and
post coronectomy of the
right mandibular
third molar (48)

IMPLANT DRILLS FOR EXTRACTIONS PRIOR


TO IMMEDIATE
IMPLANT PLACEMENT

To avoid traumatizing the surrounding bone during elevation,


implant drills were placed in the root canals to thin the root walls
giving way to extraction with the application of much less force,
thereby decreasing the chance of traumatizing the thin buccal bone.

COMPLICATIONS OF
EXODONTIA

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

FAILURE TO ACHIEVE ANESTHESIA / TOOTH


REMOVAL
FRACTURE OF TOOTH / SURROUNDING STRUCTURES
DISLOCATION
DISPLACEMENT OF TOOTH / ROOT
EXCESSIVE HEMORRHAGE
DAMAGE TO HARD & SOFT TISSUES
POSTOPRATIVE PAIN
POSTOPERATIVE SWELLING
TRISMUS
OROANTRAL COMMUNICATION
SYNCOPE
RESPIRATORY ARREST
CARDIAC ARREST
ANESTHETIC EMERGENCIES

FAILURE TO ACHIEVE
ANESTHESIA / TOOTH REMOVAL

Faulty technique
Inadequate solution
Test the efficacy of anesthesia
Tooth could not be removed with intra-alveolar or
trans- alveolar procedure.

FRACTURE OF TOOTH
Crown / root
Grossly carious
Tooth with Endodontic treatment
Improper application of forcep
One point contact
Slip off of forcep
Excessive force
Hurry
Tooth with divergent roots /hypercementosis
Then trans-alveolar method is indicated

Remove all the root fragments except


1.

5 mm & requires excessive bone removal well tolerated.


(Simpson 1958)

2.

Apical 1/3 rd of palatal root of maxillary molars &


requires excessive bone removal

If removal is indicated inform the patient


radiograph
If root is left in place pulpectomy should be performed.

FRACTURE OF ALVEOLAR BONE


Causes
Excessive inclusion of bone within the forcep beaks
Extraction of incisors before canine
Intact versus torn periosteum

FRACTURE OF MAXILLARY TUBEROSITY

Generally during extraction of maxillary 3rd molars


Pneumatization of maxillary air cells
Gemination

Management

i.
ii.

Preoperative radiograph is essential


Raise the mucoperiosteal flap
Separate the tooth & bone from gingiva
Mattress Suture
10 days
If tuberosity is excessively mobile
Splint the tooth for 6-8 weeks
Sectioning the crown & pulpectomy.

FRACTURE OF ADJACENT TEETH

Heavily restored adjacent teeth in the line of


withdrawal
Abutment teeth
When used as fulcrum

FRACTURE OF OPPOSITE TEETH

Uncontrolled force
Under general anesthesia gauge & props
intubation

FRACTURE OF MANDIBLE
Causes
Excessive / incorrectly applied force
Pathologic fracture
Senile osteoporosis
Precautions
Peroperative radiograph
Splint febrication
Exraoral support

management
Inform the patient
Reduce the fractured segment

DISLOCATION OF ADJACENT TOOTH

When used as fulcrum


Improper use of elevators
Give support to adjacent tooth from other hand
Dont apply the elevator mesial to 1st molar

Management
Place the tooth in socket & splint it

DISLOCATION OF
TEMPOROMANDIBULAR JOINT
Causes
Excessive / incorrectly applied force
Improper use of mouth gauge
Management
Senile osteoporosis

Reduce it immediately
Reduction technique
Instructions to patient

Precautions

Take history
Exraoral support beneath the angle of
mandible

DISPLACEMENT OF ROOT INTO MAXILLARY SINUS

Causes
Abnormal root curvature
Carious root
Roots of premolars & molars involved by sinus
Excessive / incorrectly applied force
Inadequate grasping of tooth
Precautions
Take past dental history
Apply the forcep on sufficient tooth structure
Leave uninfected apical 1/3 rd of root
Never force the root towards sinus
Transalveolar method

OROANTRAL
COMMUNICATION
Causes

Maxillary posterior teeth


Involvement of sinus lining by Periapical pathology

Diagnosis
Increased intra nasal pressure air coming out from
mouth can be heard
Amount of blood will be doubled
Wisp of cotton wool will be deflected

Management
Mucoperiosteal flap rising
Decrease alveolar height
Interrupted horizontal suture
Protect the clot with acrylic, denture base, impression
material
Give incision in sinus membrane
Precautions
Mouth rinsing with antiseptic solution before closure of
oroantral communication
Passage of instruments from mouth to sinus should be
avoided.

Diagnosis
Air bubbles from socket
Cotton wool deflection
Fluid taken from oral cavity

nose

Management
Take radiograph .
Blow the air through nose
Under general anesthesia stop the general anesthesia
wait till regaining the cough reflex

Suction + irrigation
inch wide iodoform gauze
Sometimes incision in sinus membrane
Caldwell-Luc approach

DISPLACEMENT OF ROOT INTO INFRATEMPORAL FOSSA

Mostly maxillary third molars

Management
Extend the incision posteriorly
Blunt dissection
Grasp the tooth carefully
Or wait for several weeks until it becomes somewhat
encapsulated.

DISPLACEMENT OF ROOT INTO SUBMANDIBULAR SPACE

Reflect the soft tissue flap on lingual aspect of mandible as


forward to the premolars

gently dissect the mucoperiosteum

Detach the mylohyoid muscle.

DISPLACEMENT OF ROOT INTO


PHARYNGEAL SPACE

If the root is not appearing in the oral cavity/pressure pack

Ask the patient to cough & spit


Turn the patient towards the operator & position with
the mouth towards the floor.
Radiograph of alveolar socket/ sinus/ chest
Re-examine the patient after 3 days
Patient is asked to report immediately- fever, cough,
chest pain occurs.

EXCESSIVE HEMORRHAGE
Perioperative hemorrhage
Oozing of blood during operation
Management
Wipe
Sucker
Hot 50 degree celcius for 2 min.
Hemostate
Local anesthetic solution having vasoconstrictor
Gelatine sponge
oxidized cellulose
After tooth removal moist pressure pack for 10min.
horizontal mattress suture

Postoperative hemorrhage
Instructions to the patients
1. Pressure pack
2. Less talk for 2-3 hrs.
3. Tea bag
4. No smoking for 12 hours
5. No staneous exercise
.
.
.
.

Psychological approach
Determine site & amount of hemorrhage
Remove excess blood clot
Provide firm gauze pack with tannic acid

Horizontal mattress suture into mucoperiosteum


Wait for 5 minutes after placing gauze pressure on suture

Gelatin / fibrin foam


&
All post extraction instructions and avoid frequent aggressive
mouth rinsing

DAMAGE TO SOFT TISSUES


Gingiva
Lower lip mechanical & thermal injury
Tongue & floor of mouth

Injury to the inferior alveolar nerve


Causes
Compression with clot or bone debris
Partially or completely torn
Precautions
Preoperative radiograph
Elevator should not be forced below tooth
Resect 1 root before tooth elevation
Management
Reposition the ends at close
approximation
Decompression
Microsurgical reanastomosis
Nerve grafting

Injury to the mental nerve


Causes
Transalveolar extraction of premolars
Precautions
More Bone reduction mesial to 1st premolar & distal
to 2nd premolar
Retraction of nerve with mental retractor

Injury due to breakage of


instrument

Burs
Management drilling the groove around it .

Eccymosis

Submucosally & subcutaneously

Older patients increased capillary fragility


decreased tissue tone
weaker inter cellular attachments

Onset 2-4 days


Resolve within 7 10 days

WOUND DEHISCENCE
Cause
Suture without adequate bony foundation
Suturing the wound under tension
Mostly in the region of mandibular 2nd & 3rd molar
(internal oblique ridge)

Management
Leave the projection slough out within 2-4 weeks
Smooth it with bone file under local anesthesia.

POSTOPRATIVE PAIN
1.
.
.
.
.

2.
.

Due to traumatized hard tissue


Bruising from bone during intrumentation
Excessive heating from bur
Sharp bony edges
Avoidance of tissue toileting
Due to traumatized soft tissue
Incision only through mucous membrane
ragged flap - heals slowly

.
.

Too small flap much traumatic retraction


Injury from bur.

DRY SOCKET
Synonyms :
alveolar osteitis (AO),
localized osteitis,
postoperative alveolitis,
alveolalgia,
alveolitis sicca dolorosa,
septic socket,
necrotic socket,
localized osteomyelitis,
fibrinolytic alveolitis

Definition Postoperative pain in and around the extraction site, which


increases in
severity at any time between 1 and 3 days after the
extraction
accompanied by a partially or totally disintegrated blood
clot within
the alveolar socket with or without halitosis.
I. R. Blum: Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization,

etiopathogenesis and management: a critical review. Int. J. Oral Maxillofac. Surg. 2002; 31: 309317. 2002
International Association of Oral and Maxillofacial Surgeons

ONSET AND DURATION

Mostly 13 days after tooth extraction .

Within a week - In 95% and 100% of all cases.

Unlikely - before the first postoperative day.


because the blood clot contains anti-plasmin that
must be
consumed by plasmin before clot disintegration can
take place.

The duration of alveolar osteitis varies to some degree,


depending on the severity of the disease, but it usually
ranges from 510 days.

SIGN & SYMPTOMS


The denuded alveolar bare bone may be painful and tender.
Initially blood clot appears dirty gray
disintegrates

1.

grayish yellow bony socket bare of granulation


2.

tissue
Some patients may also complain of intense continuous
pain irradiating to the ipsilateral ear, temporal region or
the eye.

3.

Regional lymphadenopathy (occasionally).

4.

unpleasant taste (occasionally).

5.

Trismus is a rare occurrence in mandibular third molar


extractions
probably due to lengthy and traumatic surgery.

ETIOLOGY

1.
2.
3.
4.
5.
6.
7.
8.

Multifactorial origin
Following have been implicated most commonly as
etiological, aggravating and precipitating factors:
Oral micro-organisms - Treponema denticola
Difficulty and trauma during surgery
Roots or bone fragments remaining in the wound
Excessive irrigation or curettage of the alveolus after
extraction
Physical dislodgement of the clot
Local blood perfusion & anesthesia
Oral contraceptives - estrogens, like pyrogens will
activate the fibrinolytic system indirectly.
Smoking

RISK FACTORS
1.

Previous experience.

2.

Deeply impacted mandibular third molar (risk factor is directly


proportional to increasing severity of impaction) .

3.

Poor oral hygiene of patient .

4.

Active or recent history of acute ulcerative gingivitis or


pericoronitis .

5.

Associated with the tooth to be extracted .

6.

Smoking (especially >20 cigarettes per day) .

7.

8.

Use of oral contraceptives .


Immunocompromised individuals .

BIRN : (BIRN H. Etiology and pathogenesis of fibrinolytic alveolitis (dry


socket). Int J Oral Surg 1973: 2: 215263.)

CONTACT

This conversion is
accomplished in the presence of
tissue or
plasma pro-activators and
activators.

Plasminogen
Activators
Direc
t

Intrins
ic
1. Factor XII
dependent
activator
2. urokinase,

Indirec
t

1. streptokinas
e
2. staphylokin
ase

activato
r
comple
x

plasminoge
n

Extrinsi
c plasminogen activators
1. Tissue
2. Endothelial plasminogen
activators

Fibrinolytic system
Plasminogen
activator
(kallikrein, XIIa, leukocytes,
endothelium)

Plasmino
gen
C3

Plasm
in

C3a
Fibri
n

Fibrin
split
products

PROPHYLACTIC
MANAGEMENT
References in the literature correlating to
the prevention of alveolar osteitis can be
divided into
1.

Non-pharmacological and

2.

Pharmacological preventive measures.

Non-pharmacological measures
1.

Use of good quality current preoperative


radiographs

2.

Careful planning of the surgery

3.

Use of good surgical principles

4.

Extractions should be performed with minimum


amount of trauma and maximum amount of care

5.

Confirm presence of blood clot subsequent to


extraction
(if absent, scrape alveolar walls
gently)

6.

Wherever possible preoperative oral hygiene


measures to reduce plaque levels to a minimum
should be instituted

7.

Encourage the patient (again) to stop or limit smoking in


the immediate postoperative period .

8.

Advise patient to avoid vigorous mouth rinsing for the


first 24 h post extraction and to use gentle toothbrushing
in the immediate postoperative period .

9.

For patients taking oral contraceptives extractions should


ideally be performed during days 23 through 28 of the
menstrual cycle .

10.

Comprehensive pre- and postoperative verbal instructions


should be supplemented with written advice to ensure
maximum compliance .

PHARMACOLOGICAL
MEASURES 1. Antibacterial agents 2. Antiseptic agents and lavage Chlorhexidine
(CHX)

3. Antifibrinolytic agents - para-hydroxybenzoic


acid (PHBA),

4. Steroid anti-inflammatory agents - polylactic


acid (PLA)

5. Obtundent dressings
6. Clot supporting agents

NON-DRESSING INTERVENTIONS
TO MANAGE ALVEOLAR OSTEITIS
1.

Remove any sutures to allow adequate exposure of the extraction site. As


the socket may be exquisitely tender local anaesthesia may be required.

2.

Irrigate the socket gently with war sterile isotonic saline or local
anaesthetic solution, which is followed by careful suctioning of all excess
irrigation solution.

3.

Do not attempt to curette the socket, as this will increase the level of pain.

4.

Prescription of potent oral analgesics.

5.

The patient is given a plastic syringe with a curved tip for home irrigation
with chlorhexidine solution or saline and instructed to keep the socket
clean.

6.

Once the socket no longer collects any debris, home irrigation can be
discontinued.

SURGICAL MANAGEMENT OF

DRY SOCKET

S.C. Anand, V. Singh, M. Goel, A. Verma, B. Rai: Dry


Socket An Apriasal And Surgical Management. The
Internet Journal of Dental Science. 2006 Volume 4
Number 1. DOI: 10.5580/e31

Under block anesthesia


The clot devoided socket is thoroughly curetted, both
from the floor of the socket as well as from the bony
walls.
The sharp margins were trimmed, rounded.
Any foreign bodies if present were thouroghly
removed.
The detached gingival margins were also scraped.
The desired medications as well as precautions .
Patient was not only without pain, but was also
comfortable both physically as well as psychologically
from the very next day.

POSTOPERATIVE SWELLING
Normal oedema
After multiple teeth extraction
surgical tooth extraction

Management
Ice pack application
Heat application

Traumatic oedema
Blunt instrumentation
Excessive extraction of badly designed flap
Too tight suture

Subcutaneous emphysema
Air into connective tissue of intramuscular & fascial
spaces
Swelling is of sudden onset.
Crackles can be felt under finger
Resolves within 1-2 days
Due to infection of wound
Preoperative antibiotic
Prevention of entry of micro-organism into wound
Mild infection intraoral hot saline mouth wash

TRISMUS

It is defined as inability to open the mouth due to muscle


spasm.

Causes
Post operative oedema
Hematoma formation
Inflammation of soft tissue
After mandibular block
Traumatic arthritis of TMJ
Multiple injections

Management
Treat underlying cause
Intraoral heat application
Antibiotics & specialist treatment.

SYNCOPE

Transient loss of consciousness and postural tone


characterized by rapid onset, short duration, and spontaneous
recovery due to global cerebral hypoperfusion that most often
results from hypotension.

Sign & symptoms dizziness, weakness, nausea skin is cold,


pale & sweating.
Management
Position
Oxygen administration
Blood pressure & pulse measurement
250 mg aminophylline is given slowly.

RESPIRATORY ARREST

Skeletal muscle become flaccid


pupil dilate widely

management
Patient flat on the floor
Clean the airway
Pull the mandible forward
Extend the neck fully
Pulmonary resuscitation so that chest is seen to rise every
3-4 sec.
Brook airway can be inserted over tongue
Check carotid pulse & apex beats at regular intervals

CARDIAC ARREST
Sign & symptoms

Deathly pallor & grayness of skin


Cold sweat
Pulse & apex beat can be felt
Heart sounds can not be audible

Children Beginning of heartbeat if the sternum is tapped sharply

Adult
Patient flat on the floor
Cardiac compression at 1 second interval

ANESTHETIC EMERGENCIES

Syncope, respiratory arrest & cardiac arrest complicate the general


anesthesia.

Management
i.
Clear the airway
ii. Remove all the packs, debris & apparatus from mouth.
iii. Pull the mandible forward
iv. Extend the neck
v.
Head downward /forward in dental chair
- upward if lying on the floor
vi. Oxygen
vii. Larygotomy
viii. Tracheostomy

RESOURCES
Text books
1.

The extraction of teeth by GEOFFREY L HOWE

2.

Oral & maxillofacial surgery volume 2 , by DANIEL M. LASKIN

3.

Oral Surgery by - FRAGISKOS D. FRAGISKOS

4.

Contemporary Oral & maxillofacial surgery by- HUPP, ELLIS,


TUCKER

5.

Text book of Oral & maxillofacial surgery by S M BALAJI.

RESOURCES
1. Technological Advances in Extraction Techniques and Outpatient Oral Surgery Adam

Weiss, DDS*, Avichai Stern, DDS, Harry Dym, DDS Dent Clin N Am 55 (2011) 501513
doi:10.1016/j.cden.2011.02.008 dental.theclinics.com 0011-8532/11/$ see front matter 2011 Elsevier
Inc.
2. Powertome Assisted Atraumatic Tooth Extraction, The Journal of Implant & Advanced Clinical

Dentistry, Jason White, Dan Holtzclaw, Nicholas Toscano, September 2009 Volume 1, No. 6
3. Staged Removal of Horizontally Impacted Third Molars to Reduce Risk of Inferior Alveolar Nerve Injury

Luca Landi, DDS,* Paolo Francesco Manicone, DDS, Stefano Piccinelli, DDS, Alessandro Raia, DDS,
PhD, and Roberto Raia, DDS, J Oral Maxillofac Surg 68:442-446, 2010
4. Enhancing Extraction Socket Therapy Robert A. Horowitz, Michael D. Rohrer, Hari S. Prasad, Ziv Mazor,

The Journal of Implant & Advanced Clinical Dentistry, Jason White, Dan Holtzclaw, Nicholas
Toscano, September 2009 Volume 1, No. 6
5. Coronectomy oral surgerys answer to modern day conservative dentistry V. Patel, S. Moore and C.

Sproat, Refereed Paper Accepted 29 April 2010 DOI: 10.1038/sj.bdj.2010.673 British Dental Journal
2010; 209: 111114, BRITISH DENTAL JOURNAL VOLUME 209 NO. 3 AUG 14 2010

RESOURCES
6. Atraumatic Teeth Extraction in Bisphosphonate-Treated Patients Eran
Regev, DMD, MD,* Joshua Lustmann, DMD,and Rizan Nashef, DMD
2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac
Surg 66:1157-1161, 2008 0278-2391/08/6606-0011$34.00/0

doi:10.1016/j.joms.2008.01.059

THANK
YOU