Exodontia

EXODONTIA CAN BE DEFINED AS THE PAINLESS REMOVAL OF THE WHOLE TOOTH OR A TOOTH ROOT WITHOUT TRAUMA TO THE INVESTING TISSUES, SO THAT THE WOUND HEALS UNEVENTFULLY AND NO POST OPERATIVE PROSTHETIC PROBLEM IS CREATED.

1. EXODONTIA DEFINITION INDICATION CONTRAINDICATION PRINCIPLES By- Dr. Prathamesh Fulsundar

2. EXODONTIA CAN BE DEFINED AS THE PAINLESS REMOVAL OF THE WHOLE TOOTH OR A TOOTH ROOT WITHOUT TRAUMA TO THE INVESTING TISSUES, SO THAT THE WOUND HEALS UNEVENTFULLY AND NO POST OPERATIVE PROSTHETIC PROBLEM IS CREATED. DEFINITION

3. INDICATIONS AND CONTRAINDICATIONS

4. PERIODONTAL DISTURBANCES Most common cause of extraction in India. If loss of periodontal support is more than 40%, it warrants an extraction. DENTAL CARIES When the tooth is extensively damaged by dental caries, even if the patient and doctor desire to save the tooth , it is indicated for extraction if all conservative procedures fail. INDICATIONS

5. Multiple carious teeth may lead to deteriorating oral hygiene. In such cases, removal of teeth will improve the oral hygiene. 3. PULP PATHOLOGY If endodontic therapy is not possible or if the tooth is having pulpal pathology such as pulp necrosis or irreversible pulpitis , extraction is indicated. 4. APICAL PATHOLOGY If the teeth fail to respond to all conservative measures to resolve apical pathology, either because of technical reasons or systemic factors, such teeth are indicated for extraction.

6. 5. ORTHODONTIC REASONS During orthodontic treatment, few teeth may require extraction either due to therapeutic reasons or because of malposition . Serial extraction: During mixed dentition period, the dental surgeon may have to extract a few decidious teeth in a chronological order to prevent malocclusion as the child grows. 6. PROSTHETIC CONSIDERATIONS Extraction of teeth is indicated for providing efficient dental prosthesis.

7. 7. IMPACTIONS Retention of unerupted teeth beyond the chronological eruption may sometimes be responsible for facial pain, periodontal disturbances of adjoining teeth, TMJ problems, bony pathology like cysts and pathological fractures of the jaws. 8. SUPERNUMERARY TEETH Unless retention of supernumerary teeth are advantageous to the patients, they are indicated for extraction.

8. 9. TEETH PRIOR TO IRRADIATION Irradiation is one of the modalities of treating oral carcinomas . All patients before irradiation must be carefully examined so that a decision is taken regarding the extraction of teeth. Only teeth which which cannot be maintained in a sound oral condition require removal. 10. ECONOMIC CONSIDERATIONS Sometimes the dental surgeon and patient are faced with economic constraints even though technically conservation of teeth may be feasible.

9. 11. FOCAL SEPSIS Sometimes teeth may appear apparently sound. But radiologic evaluation is a guiding factor to decide whether any teeth are to be considered as foci of infection. In such circumstances, weightage is in favor of the underlying systemic disorders like dermatological lesions, facial pain, uncontrollable opthalmic problems etc. In such conditions, doubtful teeth are extracted instead of resorting to any conservative methods of management. 12. ASSOCIATED PATHOLOGY They are involved in cyst formation, neoplasm or osteomyelitis , extraction is indicated. However, carefully evaluation is required before extracting teeth involved in cyst formations.

10. 13. ESTHETICS Due to certain compelling reasons like marriage and job opportunities, some teeth may require attention for esthetic considerations. But due to time factor, it may not be possible to improve esthetics by any conservative orthodontic or surgical means. If so, such teeth are indicated for extraction, provided it is followed by immediate prosthetic restoration in a shorter duration.

11. 14. TOOTH IN LINE OF FRACTURE This has been controversial over the course of years. The present concept is to extract the tooth in the line of fracture if (a) it is a source of infection at the site fracture (b) the tooth itself is fractured ©the retention may interfere with fracture reduction or with healing of the fracture. Formerly, all the teeth in the line of fracture were routinely removed. But now, a conservative approach is advocated and hence extraction of such teeth requires guarded approach.

12. RELATIVE If the contraindication is provided with additional care one can overcome the complication. In other words, given the situation, the patient is made fit to undergo extraction once the underlying condition is treated. ABSOLUTE There are few conditions which are absolute contraindications. These factors will be impediment for extraction even if care is taken. If extraction is carried out in presence of such absolute contra indications, the outcome may be fatal. CONTRA INDICATIONS

13. LOCAL IRRADIATED TISSUE Extractions performed in an area of radiation may result osteoradionecrosis. ADJACENT NEOPLASM Teeth that are located within an area of tumor, especially a malignant tumor, should not be extracted. The surgical procedure of extraction could disseminate malignant cells and thereby seed metastasis.

14. PERICORONITIS Patients who have severe pericoronitis around an impacted mandibular third molar should not have the tooth extracted until the pericoronitis has been treated. Non surgical treatment should include irrigations, antibiotics and removal of maxillary third molar.

15. 2. SYSTEMIC DIABETES AND HYPERTENSION One should investigate the state of these disorders in every patient and extraction should be carried out only after confirming that they are under control. 2. PATIENTS ON STEROID THERAPY If patient gives history of cortisone therapy, the, dental surgeon has to take certain precautions. A physician’s opinion must be taken.

16. 3. PREGNANCY The clinician should bear in mind the existence of the possibility of obstetric complications during the first and last trimester. Hence if possible, extraction can be carried out after obtaining the obstetrician’s expert opinion. 4. BLEEDING DISORDERS The patients who give a definite history of bleeding episodes need careful evaluation Patients with anticoagulant therapy can undergo extraction after obtaining prior advice from the patient’s physician/cardiologist.

17. 5. ACTIVE INFECTIONS These are relative contra indications. For example: Extraction in the presence of active and uncontrolled infection will lead to the regional or systemic spread. Hence, it is preferable to control the infection and extraction can be safely carried out under the umbrella of antibiotic therapy. 6. EXTRACTION OF TEETH IN RECENTLY IRRADIATED PATIENTS These cases deserve special mention. Irradiation of jaws reduces blood supply due to fibrosis.

18. CLINICAL EVALUATION RADIOGRAPHIC EVALUATION PATIENT AND SURGEON PREPARATION PATIENT POSITION OPERATOR POSITION PRINCIPLES OF EXTRACTION PRINCIPLES OF ELEVATORS POST OPERATIVE INSTRUCTIONS GENERAL PRINCIPLES INVOLVED IN EXODONTIA

19. Access: The first factor to see is the adequacy of mouth opening. The cause of limited mouth opening must be ruled out. Status of supporting structures: The status of surrounding structure should be evaluated. Presence of any infection periodontal problems should be ruled out. Status of tooth and crown: The presence of large carious lesion, root canal filled tooth and large restoration should be checked. One must check for presence of mobility of teeth. CLINICAL EVALUATION

20. As bone density increases, the amount of socket expansion obtained during forceps extraction becomes less and tooth removal thus requires more force. Bone density can be interpreted radiographically by relative amount of trabeculation . This possible by standardising radiographic procedure in the office. INTERPRETATION OF A PRE OPERATIVE RADIOGRAPH

21. The concept of universal principles states that all patients must be viewed as having blood borne diseases that can be transmitted to the surgical team. Before extraction the patient must vigorously rinse their mouths with an antiseptic mouth rinse such as chlorhexidine . To prevent teeth or fragments of teeth from falling into the mouth and potentially being swallowed or aspirated into the lungs, it is preferable to place a 4*4 inch gauze loosely into the back of the mouth. However it should make the patient gag. PATIENT AND SURGEON PREPARARTION

22. The chair should be tipped backwards so that the maxillary plane is at 45 degrees to the floor. Height of the chair should be such that the mouth is at or slightly below the operator’s elbow level. CHAIR POSITION FOR MAXILLARY TEETH

23. For the left and anterior teeth, the left and index finger of the surgeon should reflect the lip and cheek tissue, the thumb should rest on palate. For right, the index finger is on the palate and thumb on the buccal aspect. POSITION OF OPPOSITE HAND

24. Patient should be positioned in a more upright position so that the occlusal plane is parallel to the floor when the mouth is opened. The chair should be lower than for extraction of maxillary teeth, and the surgeon’s arm is inclined downward approximately a 120 degree angle at the elbow. CHAIR POSITION FOR MANDIBULAR TEETH

25. For the left posterior and anterior teeth, the index finger of the hand reflects the cheek and lips as it is placed in the buccal vestibule. The middle finger reflects th tongue as it is placed in the lingual vestibule. The thumb is placed below the chin so that the jaw is held between the fingers and thumb. POSITION OF OPPOSITE HAND

26. Reflecting soft tissues to provide adequate visualization of the area of surgery. Protection of other teeth from the forceps. Stabilization of the patient’s head during extraction. Most importantly it supports the alveolar process and provides tactile information to the operator concerning the expansion of the alveolar process during luxation . Compress the socket after removal of the tooth. ROLE OF OPPOSITE HAND

27. WHEEL AND AXLE PRINCIPLE: It is a modified form of a lever. The effort is applied to the circumference of the wheel which turns the axle so as to raise a weight. It can be used a sole work principle in removing teeth. PRINCIPLE OF ELEVATORS

28. Expansion of bony socket i.e. the forcep creates micro fracture in the alveolar process by use of wedge shaped beaks and movement of the tooth itself with the forceps. Lever principle – this works same as that for elevator Wedge principle – the tip of the forceps beak is narrower anteriorly and broaden posteriorly . When the tip is forced between the mucoperiosteum and tooth it causes expansion of the bony socket so that the tooth displaced out of socket. PRINCIPLES OF EXTRACTION

29. DOS Bite firmly on the gauze for atleast 20 minutes . Take soft, cold food. Take the painkiller prescribed by your dentist. Maintain oral hygiene. DONTS Constantly spitting/rinsing out saliva. Taking hot food/drinks. Use straw to drink. Smoking/drinking alcohol. Meddling extraction site. Exert yourself. POST OPERATIVE INSTRUCTIONS

30. THANK YOU REFERENCES: 1.Oral and maxillofacial surgery, Edward Ellis, James Hupp , Myron Tucker 2.Exodontia practice, Abhay Datarkar