Exodontia

Exodontia? Its the removal of the tooth from the alveolus of the jaw bone/ mandible. Commonly known as tooth extraction.

1. EXODONTIA

2. PRESENTED BY- ABHIJIT SARKAR FINAL YEAR BDS HALDIA INSTITUTE OF DENTAL SCIENCES & RESEARCH

3. What is Exodontia? Exodontia in dentistry deals with the extraction of teeth. The ideal extraction is the painless removal of the whole tooth-root with minimum trauma to the investing tissues, so that the wound heals uneventfully and no post operative prosthetic problem is created.

4. INDICATIONS Severe caries Pulp necrosis Odontalgia Severe Periodontal disease Orthodontics Cracked/ fractured teeth Impacted teeth Pre prosthetic extraction

5. Supernumerary tooth Pathological lesions Malopposed teeth Teeth associated with jaw fracture Esthetics Retained deciduous Economics

6. CONTRAINDICATIONS Systemic contraindications: - Severe uncontrolled metabolic diseases. Eg - uncontrolled diabetes, hyperthyroidism, osteoporosis, renal diseases. - Malignant diseases such as leukaemia & lymphoma. - Cardiac diseases that are uncontrolled (unstable angina) or events such as myocardial infraction or stroke in past 6 months. - Severe uncontrolled hypertension - Pregnancy

7. - Bleeding disorders. Eg - Haemophilia, Christmas disease - Whether the patient is on medications like corticosteroids, immuosuppressives cancer chemotherapeutic agents, anticoagulant therapy. Local Contraindiactions - Teeth located in area of tumour - Severe pericoronitis - Increased calcification in elderly - Therapeutic radiation for cancer

8. TECHNIQUES OF TOOTH EXTRACTION Forceps extraction: Consists of removing the tooth or root by the use of forceps or elevators or both. The blades of these instruments are forced down the periodontal membrane between tooth-root and the bony socket wall, none of which is removed electively. This method is better described as intra alveolar extraction. Trans-alveolar extraction: Method is to dissect the tooth or root from its bony attachments. This separation is achieved by removal of some of the bone investing the roots, which are then delivered by the use of elevators or/and forceps.This technique is commonly called the surgical method.

9. POSITIONS OF PATIENT AND OPERATOR: Position of Patient : The best possible position is the one that is comfortable for both the patient and the surgeon. Position of patient’s head, neck and trunk : Chair is adjusted in a way that the head, neck and trunk are in one line. Angulation of chair : When operating on mandibular teeth, the occlusal surface should angulated parallel or 10º to the floor. When operating on maxillary teeth, the occlusal plane is angulated between 45º and 60º to the floor . Height of chair : When maxillary tooth is being extracted , the chair should be adjusted so that the site of operation is 3” below the shoulder level of the operator. During extraction of mandibular tooth the chair height should be adjusted so that the tooth to be extracted is about 6” below the level of operator’s elbow.

10. Height adjusted for: A. Maxillary tooth extraction B. Mandibular teeth extraction

11. Position of the Operator during extraction : The surgeon should position himself in such a way that he can apply the forces necessary for extraction without stress to his shoulders. For extraction of maxillary teeth : The surgeon should stand on the right side and in front should apply the forceps on to the tooth while the other hand holds the alveolus with the finger and the thumb on the either side of the involved tooth. For the extraction of mandibular teeth : The surgeon stand on the right side of both the quadrants. For the extraction of left lower side the operator should stand in front of the patient and for the right lower side, the operator should stand behind the patient. Apart from supporting the alveolus on each side by the thumb and forefinger, the left hand should also support the mandible.

12. Position of the operator for various extraction procedures

13. Mechanical Work Principles: Lever Principle : Elevators are primarly used as levers. Thus elevators includes a effort arm which is the handle, fulcrum which is the crest of the alveolar bone & resistance arm which exerts the pressure on the tooth which is the resitance here. Maximum mechanical advantage is gained by keeping the e ffort arm longer than the resistance arm.

14. Wedge Principle : It consists of two moveable inclined planes, which meet and form a sharp angle. The wedge is a movable inclined plane which overcomes a large resistance at right angles to the applied effort. The effort is applied to the base of the plane and the resistance has its effect on the slant.It is usually used in conjunction with the lever principle. It is an established physics principle that a wedge can be used to split, expand or displace the portion of a substance that receives force. Sharper the angle, the less effort is required to overcome the resistance. Mechanical effort is required to overcome the resistance.

15. Wheel and Axle Principle: Resembles the wheel of a vehicle attached to a axle around which the wheel moves . Cryers & Cross bar elevators works on these principle. The handle serves as the wheel and blade engages the tooth . When the handle is rotated the force created on the blade of the elevator is multiplied creating a greater mechanical advantage to elevate tooth out of its socket .

16. ARMAME N TARIUM

17. Elevators Elevators are used on the lever and fulcrum principle to force the tooth or root along the line of withdrawal. The fulcrum used for the extraction of teeth should always be a bony one. Use of adjacent tooth as a fulcrum is only permissible when the tooth is to extracted at the same visit. Elevators may be forced down the periodontal membrane either mesially , buccally or distally to the tooth being extracted.The elevators are held in fingers and forced down the periodontal membrane at an angle of 45 º to the long axis of the root. The elevator has three components: - Handle: To facilitate a good grip on the instrument - Shank: Connects handle to the blade - Blade: Working tip of the elevator

18. Guiding Principles: Avoidance of excessive force No injury can occur to patient even if the instruments slips Force being applied should be in a direction that it moves away from major structures Should never be used blind in a socket Neighbouring tooth to never be used as fulcrum unless it is to be extracted Elevators must be sharp and in their correct shape Effective and logical point of application of force by elevator to the tooth should be predetermined: - Mesial - Distal - Buccal

19. When should elevators be used? To provide a point of application for beaks of forceps To loosen teeth prior to using forceps To dislodge whole tooth from socket For typical tooth ‘stump’ Fractured lower molar root Other types of apices: - Sliver - Apical 2/3 - Apical 1/3

20. When should elevators not be used? When applying force to a root which one cannot see When root is in close proximity to the antrum When root is in close proximity to the mandibular canal When operating in lower third molar region where the lingual alveolar plate may offer little or no resistance to the displacement of into submandibular space When elevating in the region of the angle of mandible in the aged edentulous patient When extraction is being attempted without radiographic assessment

21. COMMONLY USED ELEVATORS: Periosteal Elevators : Periosteal elevators are used particularly for the reflection of the mucoperiosteum from the underlying bone before extracting the teeth.

22. Apexo Elevators : No. 301 straight apexo elevators are used for removal of fractured roots of maxillary central and lateral incisors, bicuspids and cuspids . No. 73 and 74 elevators are used for removing the impacted maxillary third molars. No. 302 and 303 elevators are used when the mandibular root has fractured below the gingival line.

23. Crossbars: Winter Cryer’s Elevator : Applications are similar to the cryer’s elevator. Works on wheel and axle principle.

24. Cryer’s elevator: Based on the lever and wedge principle. Uses: For extraction of root stump of mandibular molars when one root is removed and the other is to be removed. For extraction of mandibular molar root stumps when both the roots are present but one is fractured at a lower level than the other or when bifurcation is intact

25. FORCEPS Forceps are the main instruments used in the extraction of teeth. It helps in dilatation of the alveolar socket, luxation of the tooth and its removal. Parts of forceps: - Pair of handles - Pair of beaks - A hinge Forceps design styles: - American pattern- Hinge is horizontally with the handle of the forceps. - English pattern- Hinge is directed vertically to the handles of the forceps.

26. Forceps are picked up in the operator’s right hand, which is used to grip and control them. The position of the thumb just below the joint of forceps and the position of the forceps handles in the palm of the hand, give the operator a firm grip on and fine control over the instrument. The little finger is placed inside the handle and used to control the opening of forceps blades during their application to root. When the tooth is gripped the little finger is placed outside the handle. The fingers of the left hand grip and support the alveolus around the tooth being extracted and transmit information to the operator during the procedure .

27. Common errors in forceps extraction Failure to grip the tooth firmly in forceps blade Attempts to move the root within its socket when there is no movement in response to application of moderate force Griping the crown in forceps blade instead of root or root mass Incorrect alignment of forceps “ TIME TAKEN IN CAREFUL APPLICATION OF FORCEPS BLADES TO THE RADICULAR PORTION OF THE TOOTH IS NEVER WASTED”

28. Maxillary Extraction Forceps Crown Forceps

29. Maxillary Root Forceps

30. Maxillary Cowhorn Forceps Maxillary 3 rd Molar Forceps

31. Mandibular Extraction Forceps Mandibular Crown Forceps Mandibular Root Forceps

32. Mandibular Cowhorn Forceps Mandibular 3 rd molar Forceps

33. STEPS TO CARRY OUT SIMPLE EXTRACTION: STEP 1: Loosening the soft tissue attachment around the tooth Separating the tooth from the alveolar bone along the crestal and principal periodontal fibers and gingival papilla is carried out by using moon’s probe or periosteal elevator. Its also helps to access the depth of local anaesthesia. It also allows the extraction forceps to be placed more apically without impingement on the gingiva. The pointed end of the instrument is used in a prying motion to elevate dental papillae between the teeth or attached gingiva around the tooth.

34. STEP 2: Luxation of tooth with a dental elevator Usually straight elevator is used, which is inserted perpendicular to the tooth into the interdental space after reflection of interdental papilla. Slow strong, forceful turning of the elevator is carried out with inferior portion of the blade is turned towards the tooth to be extracted. This will result in some amount of alveolar expansion and tearing of the periodontal ligament and tooth will move in the posterior direction.

35. STEP 3: Adaptation of the forceps to the tooth Expansion of bony socket : Bone is relatively elastic, so it is possible to expand the bony socket by inserting the beaks of the forceps below the CEJ over the root. The beaks act as wedges to dilate the crestal bone on the buccal and lingual side. Rules to be followed : Proper selection of a dental forceps is a must. After placing the left hand in position, the clear view of the tooth is obtained. Tips of the forceps are inserted parallel to the long axis. Lingual beak is inserted first and then buccal beak. Forceps beaks must be placed on the root surface as far apically as possible and not on the crown. The root is grasped at the ends to gain maximum advantage. A controlled force is applied with the wrist locked and arm held against the body, the operator is ready to apply force with the shoulder and upper arm without any wrist pressure.

36. STEP 4: Major movments of forceps for luxation of a tooth Apical force during introduction of dental forceps: This is the first force generated, by giving a firm vertical pressure up and down the long axis of the tooth. The beaks of the forceps are forced into periodontal ligament space, the center of rotation is moved apically, which results in greater movement of forces at the crest of the ridge and less force is directed towards the apex. This decreases the chances of apical root fracture. Labial/buccal pressure: It produces expansion of the buccal cortical plate at the crest and offers simultaneous lingual apical pressure. Lingual/palatal pressure: It expands the lingual cortical plate and offers buccal apical pressure with expansion. Rotational pressure: Internal expansion of socket achieved by rotational force

37. NOTE: The major portion of the force is directed towards the thinnest bone. Thus in maxilla all teeth in the mandible, except lower molars, the major movements is labial/buccal. First the pressure is always applied on less accessible side of the tooth, in case of cervical caries, first movement is directed towards carious portion. The next movement is then towards the opposite direction with slow, deliberate, strong pressure. Buccal and lingual pressure will continue to expand the alveolar socket. Considerable force is used in upper jaw, while in lower jaw, this must be limited to that of the operator can counteract by supporting the mandible with left hand.

38. STEP 5: Removal of a tooth from the socket Tractional force is used for final delivery of the tooth out of socket, so it should be as gentle as possible. When the tooth is luxated enough, the major portion of the force should be directed towards the thinnest cortex and tooth is lifted up gently from alveolar socket. Tractional force is the last movement after the sufficient expansion. STEP 6: Compression of the socket is carried out .

39. TRANSALVEOLAR EXTRACTIONS This method of extraction comprises the dissection of the tooth or root from its bony attachments. This technique is often called the open or surgical method . Indications: - Any tooth which resists attempts at intra-alveolar extraction when moderate force is applied. - Retained root stumps. - History of difficult or attempted extractions - Heavily restored tooth, root filled - Hypercemented and ankylosed tooth - Germinated and dilacerated tooth - Complicated root patterns - Immediate dentures

40. Mucoperiosteal flaps: They are used to render the operative site clearly visible and accessible and their design should ensure that they provide adequate visual and mechanical access. The base of the flap should be broader than its free end and must contain an unimpaired blood supply. Healing by first intention is promoted when flap has a good blood supply, does not fall into the bony defects created during the operation and the suture lines lie upon a firm bony base and not over blood clot.

41. Bone Removal: The alveolus which invests the tooth or roots to be extracted is exposed when the mucoperiosteal flap is raised and in most cases it will be necessary to remove some of this bone. Alveolar bone must not be sacrificed unnecessarily and removal of it must be limited to what is required to achieve certain objectives. Bone is usually removed either with a dental bur or by the use of a chisel or gouge with hand or mallet pressure. Bone removal by chisel is quicker and cleaner than removal by bur, however its more suitable for removal of dense mandibular bone under local anaesthesia. Bone may be removed with burs either by simply cutting it away, using a size no. 8 or 10 round or flat fissure pattern or by the use of postage stamp method.

42. Tooth division: It is obvious that the lines of withdrawal of different roots of some multi-rooted tooth will conflict and in these cases either forceps removal or a buccal application of an elevator will deliver the tooth if the bone is sufficiently elastic and yielding and the roots not too widely splayed. If these measures do not succeed, the root-mass must be divided and separated roots removed along their individual paths of withdrawal. The root mass should be divided with dental burs. This technique allows the cut to be positioned very accurately and creates a space between the separated roots which aids their removal. If a lower molar is to be divided, bifurcation should be exposed and roots separated from below upwards with a bur. The separated roots are then delivered with small elevators using the point of application dictated by their individual lines of withdrawal.

43. Socket Toilet: Unwanted bony prominences should be removed with either rongeur forceps, chisel, burs and sharp edges smoothed with either smoothed with bone files. Bone files are toothed to cut only in one direction and are not so useful in dental surgery as the ‘vulcanite’ burs which cut quickly and cleanly. When any necessary bone removal is complete and the bone edges are smooth, the wound should be irrigated with warm normal saline and all bone debris removed. Mucoperiosteal flap should then be replaced and a decision made as to whether sutures are needed.

44. Suturing: During the operation a suture maybe inserted to retract a mucoperiosteal flap from the field of operation. At the end of an oral surgical operation sutures are inserted either to hold the cut edges of the soft tissues together to promote healing by first intention, to appose loosely the soft tissues to minimize wound contamination with food debris or to arrest haemorrhage. The needle is usually passed through the more mobile flap first. Toothed dissecting tweezers grip the flap and steady it and the needle should be inserted close to the tips of the beaks and at least half an inch from any edge. The suture should be placed closer to the free end of flap than its base. Sutures should always be tied loosely to allow for any slight swelling of the soft tissues and knots should lie to one side of the incision line.

45. COMPLICATIONS OF TOOTH EXTRACTION: Failure to: - Secure anaesthesia - Remove the tooth with either forceps or elevators Fracture of: - Crown of the tooth being extracted - Roots of tooth being extracted - Alveolus - Maxillary tuberosity - Adjacent or opposing tooth - Mandible Dislocation of: - Adjacent tooth - Temporo -mandibular joint Displacement of root: - Into the soft tissues - Into the maxillary antrum

46. Excessive haemorrhage: - During tooth removal - On completion of the extraction - Post-operatively Damage to: - Gums - Lips - Inferior dental nerve or its branches - Lingual nerve - Tongue and floor of the mouth Post-operative pain due to: - Damage to hard and soft tissues - ‘Dry socket’ - Acute osteomyelitis of mandible - Traumatic arthritis of the temporo -mandibular joint Post-operative swelling due to: - Oedema - Haematoma formation - Infection Trismus Creation of oro -antral fistula Collapse in dental chair

47. POST EXTRACTION CARE Inspect the socket: Remove the debris/bone/tooth fragments Irrigate the site with saline Compress the alveolar bone with firm finger pressure Smoothen any sharp edges from alveolar margin with bone file Ensure haemostasis Suture, if required Medications: Antibiotics/analgesics

48. INSTRUCTIONS TO PATIENT Moist pressure pack to be held with gentle pressure for atleast 30 minutes No spitting/gargling/smoking Avoid hot food/alcohol for atleast 24 hours Liquid/semisolid/soft diet

49. THANK YOU