Exodontia class

#EXODONTIA #OMFS #JOJI #PETER #SURGERY #PPT

1. DR JOJI PETER MDS,FIBCSOMS

2. Exodontia

3. “ Exodontia 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” ~ Geffory L. Howe

4. “7 Minimum Essentials” R adiograph A nesthetic F orceps & elevators F lap tray L ight E fficient assistance S uction apparatus Raffles founded modern Singapore Sir Thomas Stamford Raffles (1781 – 1826 )

5. Pre-Surgical Evaluation :-

6. Clinical Evaluation of teeth for removal assess difficulty of extraction . Access to tooth: if mouth opening of PT is compromised-surgical extraction. Mobility of tooth: teeth with less than normal mobility should be assessed for hypercementosis and ankylosis ----surgical removal 6

7. Condition of crown calculus present on tooth 7

8. If adjacent tooth has amalgam restoration or undergone endodontic therapy, care must be taken while using elevators. 8

9. Radiographic Examination of tooth for removal If it is a I° tooth, its relationship with a succedaneous tooth should be visible Configuration of roots- If excess curvature surgical extraction Length of roots Hypercementosis 9

10. Relationship of associated vital structures For Max. teeth relation with max. sinus. For Mand . Molars inferior alveolar canal For Mand premolars relation with mental foramen 10

11. Patient & surgeon Preparation All patients should be considered as having blood born disease . Surgeon should wear surgical gloves, mask, eyewear with side shield, long sleaving gowns. If surgeon has long hair it should be covered with surgical CAP. 11

12. Order of extraction Lower teeth are removed before the upper & posteriors are removed before anteriors to prevent bleeding from socket obscuring field of operation ( prof.J.Moore ) 12

13. I ndications :-

14. Over retained deciduous teeth Teeth involved in significant infection Patients inability to afford more optimal treatment because of limited finances or time. teeth in the line of #

15. Supernumerary teeth Preprosthetic extractions Teeth associated with pathologic lesions Esthetics Economics

16. Contraindications Local : H/o radiation therapy in the area Acute pericoronal infection Teeth involved with central hemangioma /vascular malformation Teeth associated with a tumor

17. C ontraindicatrions :- Systemic : - Uncontrolled metabolic diseases Malignant diseases Uncontrolled Cardiac conditions Pregnancy Sever blood dyscrasias

18. CHOICE OF ANESTHESIA

19. Pain and anxiety control Position of the patient Position of the operator Clear access to and vision of the surgical field Use of controlled force- elevators & forceps Unimpeded path of removal PRINCIPLES OF EXODONTIA

20. Wedge Principle Lever Principle Wheel and axle Principle

21. PRINCIPLES OF ELEVATION Lever principle: Fulcrum is between the load & the effort arm. For mechanical advantage the effort arm must be longer than the load or resistance arm.

22. Wedge principle: Elevator forced between the root & the bone along the long axis of the tooth

23. Wheel & axle principle:. Can be used with lever or wedge principle. Cross bars work in this principles.

24. Mechanical Principles:- Expansion of the bony socket Use of a lever and fulcrum Insertion of wedge(s) b/w root and bony socket wall

25. SOCKET EXPANSION WEDGE

26. POSITION OF THE OPERATOR

27. C hair and operator position :-

28. ROLE OF DENTIST’S LEFT HAND

29. Hand Support During Extraction of Maxillary Central Incisor

30. Hand Support During Extraction of Maxillary Premolar

31. Hand Support During Extraction of Maxillary Molar

32. Hand Support During Extraction of Mandibular Central Incisor

33. Hand Support During Extraction of Mandibular Premolar

34. Hand Support During Extraction of Mandibular Molar

35. FORCEP EXTRACTION OF DECIDUOUS TEETH Upper & lower anteriors & canines-Extracted similar to the permanent tooth Care should b taken with the extraction of the primary molars due to the developing permanent premolars underneath them Broken primary molar teeth can be elevated using the right angled Warwick James elevator.

36. INTRA ALVEOLAR EXTRACTION It means direct access is gained on the tooth to be extracted . It is carried out with the help of dental forceps and elevators .

37. Forceps Technique Indications Fairly mobile teeth, Extraction of single tooth, Extraction of multiple teeth which are scattered. Contraindications In complicated extractions, Deformed roots, Hard tissue pathology of roots like hyper- cementosis etc. Badly destroyed teeth.

38. Advantages – It causes the least amount of trauma. Promotes retention of a satisfactory blood clot. Favours rapid healing.

39. Various movement for extraction of individual tooth Upper central, lateral, canine, first pre-molar, second pre-molar First apical slight labial/buccal slight palatal rotation with traction Upper molars First apical buccal palatal deliver the tooth buccaly Lower central, lateral, canine, first pre-molar, second pre-molar First apical slight labial/buccal slight lingual rotation with traction Lower molars First apical buccal lingual deliver the tooth buccaly

40. Elevator technique Indications To luxate teeth which cannot be engaged by beaks of forceps eg : impacted, malposed or grossly destructed teeth. To remove roots

41. DISADV Fracture of maxilla or mandible. Fracture of the alveolar process. Injuring the soft tissue if proper care is not taken. Penetrating into the maxillary sinus, during extraction of maxillary posterior teeth. Forcing a maxillary root into the maxillary sinus or forcing the apical third of the root of the lower third molar into the mandibular canal or into submaxillary or pterygomandibular space depending upon the position of the impacted third molar .

42. Rules to be followed when using an Elevator – Never use an adjacent tooth as a fulcrum unless that tooth is also to be removed. Never use the buccal plate at the gingival line as fulcrum except in third molars. Always use finger guards to protect the patient in case the elevator slips. Use interseptal bone as fulcrum. Avoid using an elevator to luxate a tooth which has a tooth distal to it.

43. APPLICATION OF FORCEP BLADES

44. Maxillary forceps

45. Maxillary forceps

46. Mandibular forceps

47. Elevators

48. Elevators

49. Transalveolar method

50. OPEN METHOD/ TRANS-ALVEOLAR EXTRACTION Consists of dissecting the tooth or root from bony attachments by removal of some bone investing the tooth/roots, which are then delivered by use of elevators and/or forceps

51. I ndications :- Root # during forcep extraction Need for excessive force that may lead to # root, bone or both Dilacerated roots Ankylosed tooth Impacted/submerged tooth Endanger to anatomical structures

52. Advantages: Removal of teeth lying in difficult position without damaging the neuro -vascular bundle. Fracture of bone avoided. Less danger of creating an oro-antral fistula. Less chance of tearing of soft tissues & fracture of large pieces of alveolar bone.

53. Steps in Trans-alveolar extraction : Local anesthesia. Incision and reflection of mucoperiosteal flap. Removal of bone/ bone cutting. Sectioning of tooth, if required. Elevation of the tooth.

54. Smoothening of sharp edges of bone. Control of bleeding. Debridement of the socket. Suturing the flap. Suture removal & post-operative follow up.

55. I ncision:-

56. Firm, continuous stroke, deep to the bone Avoid vital adjacent structures Base should be wider than the apex of the flap Flap should either include or exclude a papila Relieving incisions should cross the mucogingival junction so that flap can be reflected well healing takes place across and not on the incision line (so length does not affect the healing time)

57. Bone removal: Either with a dental bur or by the use of a chisel. (hand or mallet pressure). Using Chisel & mallet is usually used for removal of bone in maxilla because the bone is soft. Adv: - post operative edema will be less - less time consuming. Disadv : - in conscious patient, the sensation produced by chisel & mallet is objectionable. - problem to TMJ. - chances of slippage of instrument. - chances of fracture of jaw. Contraindications: -if the bone surrounding the tooth is very hard & sclerotic - if the mandible is thin. - if the root is brittle.

58. Using bur: Bone may be removed with bur either by simply cutting it using a No.8 or 10 round bur or flat fissure pattern or by using the ‘ postage stamp method.’ The bur must never be allowed to over-heat during bone removal. Constant irrigation should be done with sterile normal saline. Postage stamp method In this technique, rows of small holes is made with a small round bur & then they are joined together with either bur or chisel cuts. This simple procedure will minimize the risk of damage to the surrounding tissues & limits the cutting. Disadv : - post operative pain & edema - delayed wound healing

59. Chisel vs Bur technique Criteria Chisel & mallet Bur Technique Difficult Easy Patient acceptance Not tolerated Well tolerated Chance of # bone High Less Healing of bone Good Delayed Post op edema Less More Dry socket Less More Post op infection Less More

60. Bone removal :- Bone belongs to patient and the tooth to the surgeon.

61. Tooth Sectioning :-

62. Stobie technique – extraction of multiple mandibular anteriors by using elevators b/w teeth

63. Policy for leaving root fragments 3 conditions must exist for a tooth to be left in the alveolar process Root fragment must be small Root deeply embedded in bone Root must not be infected

64. POST OPERATIVE CARE Care of the empty socket Post operative instructions Prescription of antibiotics and analgesics

65. REFEREENCES THE EXTRAACTION OF TEETH, SECOND EDITION -GEOFFREY L. HOWE PRINCIPLES OF ORAL SURGERY, FOURTH EDITION -J.R. MOORE ORAL & MAXILLOFACIAL SURGERY, VOL-2 -DANIEL M. LASKIN TEXTBOOK OF ORALMAXILLOFACIAL SURGERY -NEELIMA MALIK TEXTBOOK OF ORAL SURGERY - F. D. Fragiskos

66. Thank You…