EXODONTIA.pptx

exodontia

1. EXODONTIA Presented by Mala. M 1 st year Post graduate student Dept. of oral and maxillofacial surgery Guided by Dr. Santosh Nandimath

2. CONTENTS INTRODUCTION DEFINITION TYPES HISTORY INDICATIONS CONTRAINDICATIONS PRE OPERATIVE ASSESSMENT ARMAMENTARIUM GENERAL CONSIDERATIONS EXTRACTION PROCEDURE INTRALVEOLAR EXTRACTION TRASALVEOLAR EXTRACTION POST OPERATIVE CARE COMPLICATIONS AND ITS MANAGEMENT NEWER ADVANCES

3. INTRODUCTION EXODONTIA- The term exodontia means extraction/removal of teeth. Extraction of tooth does not require large amount of force, but a fine and controlled force, so that the tooth is gently lifted from alveolar process and not pulled out.

4. DEFINITION 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 post operative prosthetic problem is created. - Geoffrey L Howe Types Intra-alveolar extraction Trans-alveolar extraction

5. HISTORY The first Dentist was an Egyptian _Hesi re(3100-2181bc) The History of Dental Extraction forceps was very old and goes back to the time of Aristotle (384-322bc). Aristotle described the mechanics of oral surgery forceps and later Archimedes studied and discussed principles of lever.

6. Dentistry was not a separate profession at that time and mainly the barbers were extracting the tooth popularly known as ‘barber surgeons’. They used to hang rows of rotten teeth outside their shops to advertise their services as tooth pullers. The operator used to hold the patient’s head between his knees, the soft tissue was cut with a sharp scalpel, and the tooth was pulled out in single direction. Often the wound was cauterized with a red hot iron.

7. Evolution of dental forceps

8. INDICATIONS SEVERE CARIES PULP AND PERIAPICAL PATHOLOGY SEVERE PERIODONTAL DISEASE ORTHODONTIC CONSIDERARTION

9. Impacted teeth Fractured teeth Prosthodontic considerations

10. Over retained deciduous teeth Cracked teeth Pre radiation Fractured tooth

11. Teeth associated with pathological lesions Supernumerary teeth Teeth in fracture line Aesthetic considerations Economics

12. CONTRAINDICATIONS RELATIVE CONTRAINDICATIONS LOCAL CONTAINDICATIONS Acute infection Acute pericoronitis Acute oral infections

13. SYSTEMIC CONTRAINDICATIONS Uncontrolled diabetes mellitus Pulmonary disorders Bronchial Asthma COPD Pulmonary Effusion CVS Disorders Hypertension Ischemic Heart Disease Angina Pectoris Myocardial infraction Congestive Cardiac failure Valvular heart disorders

14. Hepatic disorders Acute liver infections Liver disorders Rental Disorders Glomerulonephritis Uremia Chronic renal failure Neurological disorders Stroke Epilepsy Endocrine disorders Hyperthyroidism Hypothyroidism Adernal insufficiency

15. Blood dyscrasias Severe anaemia Leukopenia Thrombocytopenia Pancytopenia Leukaemia Agranulocytosis Bleeding and clotting disorders Immunocompromised patients

16. ABSOLUTE CONTRAINDICATIONS Within 6 months of myocardial infraction Teeth associated with vascular lesions Teeth in the irradiated jaw Teeth associated with malignant tumor

17. PHYSIOLOGICAL CONTRAINDICATIONS Pregnancy (1 st and 3 rd trimester) Menstruation period Extreme old age

18. PREOPERATIVE ASSESSMENT Medical assessment Clinical evaluation of tooth Radiographic evaluation of tooth Treatment planning

19. MEDICAL ASSESSMENT When evaluating a patient preoperatively, it is critical that the surgeon examine the patient's medical status. Patients can have a variety of maladies that require treatment modification or medical management before the surgery can be performed safely. Special measures may be needed to control bleeding, lessen the chance of infection, and prevent worsening of the patient's preexisting disease state.

20. CLINICAL EVALUATION OF TEETH FOR REMOVAL Access to tooth Mobility of tooth Condition of crown Condition of adjacent tooth and opposing tooth

21. RADIOLOGICAL EVALUATION OF TOOTH FOR REMOVAL Configuration of roots Relationship of associated vital structures Condition of surrounding bone

22. Indications for preoperative radiographs : ■ History of difficult or attempted, failed extraction ■ A tooth which is abnormally resistant to elevation or forceps extraction (hypercementosis, ankylosis, dilacerated roots, extra long roots, curved roots) ■ Any teeth or roots in close relationship to either the maxillary sinus or inferior dental canal or mental nerve ■ Any teeth with history of trauma (fractured crown or roots or alveolar bone) ■ Any partially erupted, unerupted tooth, missing tooth, supernumerary tooth, retained root, lingually placed tooth, impacted tooth ■ Heavily restored tooth or pulpless tooth—brittle, possible presence of periapical pathology ■ Any condition, which predisposes to dental or alveolar abnormalities, like: osteitis deformans (hypercementosis of the roots), osteoradionecrosis, osteopetrosis, etc.

23. Configuration of roots: ■ Number of roots ■ Width—greater below cementoenamel junction (CEJ) than at the CEJ ■ Size of roots ■ Curvature of roots, divergence of roots ■ Length—thin, tapered roots ■ Resorption of roots ■ Shape of the individual root ■ Hypercementosis, ankylosis, root caries/root resorption ■ Previous endodontic therapy. .

24. Relationship with associated vital structures : ■ Maxillary sinus ■ Inferior alveolar canal ■ Mental nerve ■ Adjacent teeth roots. Condition of surrounding bone: ■ Density of bone surrounding the tooth ■ Dense bone—condensing osteitis, sclerosis will increase the difficulty.

25. As the proverb says ‘Failing to plan is planning to fail’. It is of paramount importance to device a proper treatment plan before carrying out an extraction procedure. The degree of difficulty must be anticipated during the pre-extraction period. A large amount of force during simple exodontia must be avoided as it may injure local soft tissue and damage surrounding bone and teeth. There are also chances of crown fracture which makes the procedure more difficult. Also, the application of excessive force aggravates the intraoperative and postoperative discomfort of the patient Treatment Planning

26. ARMAMENTARIUM Instruments used for the extraction of teeth : Elevators Forceps

27. Extraction forceps Primary instrument used to remove a tooth from the alveolar process is known as extraction forceps. COMPONENTS OF FORCEPS 1. Handle 2. Hinge 3. Beaks

28. The forceps are of two types : 1. English Pattern : These forceps have a hinge that is directed vertically to the handles of the forceps . 2. American Pattern : These forceps have a hinge that is directed in a horizontal direction with the handles of the forceps .

29. MAXILLARY FORCEPS MAXILLARY ANTERIOR FORCEPS(NO. 01) Identical beaks, approximated with each other. Use : Extraction of maxillary incisors and canines.

30. 2. Maxillary premolar forceps(no. 07 ) Identical beaks, Beaks do not approximate use : Extraction of maxillary premolars

31. 3. Maxillary molar forceps(no.17 and no. 18) These are paired forceps having unidentical and broader beaks. Beak is pointed on one side(known as prong) which engages the buccal bifurcation of roots and blunt on the other side engaging palatal root. Use : extraction of maxillary molars.

32. 4. Maxillary cowhorn / splitbeak forceps (no.89 and no. 90) These are also paired forceps, pointed on one side engaging buccal bifurcation and notched/split on the other engaging palatal root. Use: Extraction of maxillary molars with extensive loss of coronal structure.

33. 5. Maxillary third molar forceps(no.67) Beaks are curved, identical and angulated, offset to engage the crown of third molars. Handle is long for accessing the posterior region. Use : Extraction of maxillary third molars

34. 6. Bayonet forceps (no. 65) Beaks of the forceps are narrow, Identical and approximating, angulated to provide access to posterior areas as well. Use: To remove maxillary broken roots .

35. MANDIBULAR FORCEPS Mandibular anterior forceps(no.75) Beaks are perpendicular to handle, identical and approximating each other. use: Extraction of mandibular incisors and canines

36. 2. Mandibular premolar forceps(no.75) Beaks do not approximate. Identical beaks, Handle is similar to the of the anterior forceps . Use : Extraction of mandibular premolars

37. 3. Mandibular molar forceps(no.22) Beaks are broader with triangular projections(prongs) to engage the buccal and lingual furcations use: Extraction of mandibular molars

38. 4. Mandibular cowhorn forceps.(no.86) Beaks are pointed and conical resembling the horns of cow. Beaks engage the furcation. Use: Extraction of mandibular molars with extensive loss of coronal structure

39. 5. Mandibular root forceps Have identical, slender beaks that are closed Longer than premolar forceps which enables to get a firm grip on the root stump.

40. 5. American pattern mandibular molar forceps. Beaks are similar to that of mandibular molar forceps except that they are facing forward toward each other at right angles use : Extraction of mandibular molars.

41. Principles of forceps use Selection of appropriate forceps Grasp Application Movements/forces

42. Maxillary forceps must be held in a ‘palm up’ position (b) mandibular forceps must be held in a ‘palm down’ position. Grasp

43. Application Forceps must be placed as apically as possible. 2 Point contact Parallel to the long axis of tooth lingual beak is inserted first and then the buccal beak The handles are grasped at the end to gain the maximum mechanical advantage. Center of rotation of tooth gets displaced apically when the forceps is inserted beyond cementoenamel junction

44. The forceps can apply five major motions to luxate the teeth and expand the bony socket: 1.Apical pressure 2.Buccal pressure. 3.Lingual pressure. 4.Rotational pressure. 5.Tractional forces

45. ELEVATORS 1.Elevators are the instruments used for luxating (loosening) the teeth before application of forceps making extraction easier, subsequently avoiding complications like fracture of crowns, roots, and bone. 2. Elevators are single bladed instruments designed for specific purposes delivering maximum mechanical advantage with minimum efforts.

46. Elevators have three components • Handle : It is of generous size for proper grip and delivering adequate but controlled force. Handle can be a continuation of the shank or at a right angle to the shank. • Shank : It connects the handle with the working end or blade of the elevator. It is strong enough to transmit the force from the handle to the blade. • Blade : It is the working end of the instrument and transmits the force to the tooth, bone, or both to achieve the desired action

47. Classification According to the working tip shape Straight- Miller’s, Pott Triangular- Cryer Pick type- Crane, Root tip According to the use designed To remove the entire tooth- Straight, Coupland To remove the roots broken at the gingival margin- Apexo , Coupland To remove the roots halfway to the apex- Cryer, Winter’s To remove the apical third of the root- Crane, Root pick To reflect the mucoperiosteum- periosteal elevators 3. According to the form- Straight- wedge type (straight, apexo ) Angular- right and left Cryer Cross bar- (handle at right angle to shank)winter’s

48. 7. Crane pick elevator Used as a lever to elevate a broken root from the tooth socket A hole of 3 mm is drilled into the root at the bone crest and the tip of the pick is inserted into the hole and with the buccal plate as the fulcrum, the root is elevated .

49. 8. Apex/ root tip elevators Delicate instrument used to tease the small root tip from the socket 9. Potts elevator

50. 10. Hockey stick/ London Hospital elevator Working blade is at an angulation to the shank but blade is straight. It has a flat and convex surface where the flat surface is the working surface and has transverse serrations for better contact

51. OTHER INSTRUMENTS USED 1. No 9 MOLT’S PERIOSTEAL ELEVATOR It has 2 ends- a sharp pointed end and a broad, rounded end. The pointed end is used to release the interdental papillae, separation of periosteal attachment from bone The broad end is used for elevation of the periosteum from the bone and can be used to retract the soft tissues. The types of motions used- Prying- the pointed end used in pryring motion to elevate the soft tissues, e.g. reflecting the interdental papillae. Push- broad end to reflect the periosteum

52. 2. MOON’S PROBE It is a thin, flat instrument with a narrow and sharp tip at right angles to the handle It is used to elevate the attached gingiva around the tooth prior to the extraction

53. Principles of Exodontia Biological principles Hold the elevator with palm grip. Never use the adjacent tooth as the fulcrum, unless that the adjacent tooth is also to be extracted. Never use the buccal or lingual plate as the fulcrum. Always use finger guards to protect the soft tissues if the elevator slips. Support the shank of the elevator with the index finger to control the forces applied to the elevator. Always elevate from the mesial side of the tooth. The concave or flat surface of the elevator faces the tooth/root to be elevated, following the root curvature.

54. HOLDING THE ELEVATOR IN PALM GRASP

55. MECHANICAL PRINCIPLES LEVER PRINCIPLE WEDGE PRINCIPLE WHEEL AND AXIAL PRINCIPLE

56. Lever Principle : Most commonly used principle The elevator is the lever of first class. To gain mechanical advantage in frst -class lever, the effort arm must be longer (3/4th of the total length) than the resistance arm. Mechanical advantage : 3 Example: Coupland elevator.

57. 2.Wedge Principle: Introduction of the blade of an elevator between the bone and tooth, parallel to the long axis of the tooth is wedging. A wedge is basically a movable inclined plane which overcomes a larger resistance at right angle to the applied effort. The resistance has its effect on the slant side when the effort is applied at the base of the plane. Mechanical advantage: 2.5 Example: straight elevator, apexo elevator

58. 3. Wheel and Axle Principle : In this principle, the effort is applied to the circumference of a wheel, which turns the axle generating the force to raise a weight. Greater the diameter of the wheel, more is the mechanical advantage. Mechanical advantage: 4.6 Example: Cryer's elevator, crossbar

59. GENERAL CONSIDERATIONS ADMINSTRATION OF LOCAL ANESTHESIA SURGEON AND PATIENT PREPARATION PATIENT AND CHAIR POSITION OPERATOR POSITION ROLE OF OPPOSITE HAND

60. ADMINSTRATION OF LOCAL ANESTHESIA Extraction of the tooth can be effectively carried out under local anesthesia. Hence, administration of local anesthesia must be carried out with proper technique and appropriate agent. Once the nerve block and/or local infiltration is administered, surgeon must wait for it to act and confirm the same by subjective and objective tests

61. Surgeon and patient preparation The principles of universal precautions must be followed. To avoid transmission of diseases, a surgeon and the assistant must wear surgical gloves, surgical mask, eye-wear with shields, surgical cap, and a long-sleeved surgical gown. Before the patient is subjected to the extraction procedure, a sterile drape should be put over to the patient to decrease the risk of contamination. It is advisable to reduce the bacterial contamination in the patient’s mouth by making him/ her rinse the mouth vigorously using an antiseptic rinse like chlorhexidine prior to the procedure .

62. PATIENT AND CHAIR POSITION

63. OPERATOR POSITION

64. Maxillary teeth extraction, (a) Right posterior, (b) Anterior, and (c) Left posterior Mandibular teeth extraction (a) Right posterior,(b) Anterior and (c) Left posterior

65. Role of opposite hand 1 .For reflecting soft tissues, cheeks, lips, tongue 2. Supporting and stabilizing the jaw. 3. Provides the tactile information to the operator concerning the expansion of alveolar process during luxation. 4. Stabilizes TMJ during mandibular teeth extraction.

66. INTRA ALVEOLAR EXTRACTION ALSO CALLED AS CLOSED EXTRACTION/FORCEPS EXTRACTION CONSISTS OF REMOVING THE TOOTH/TOOTH ROOT BY THE USE OF FORCEPS OR ELEVATOR OR BOTH.

67. Step 1: Loosening of soft tissue attachments around the tooth. Step 2: Luxation of the tooth with a dental elevator. Step 3: Adaptation of the forceps to the tooth. Step 4: Luxation of the tooth with the forceps Step 5: Removal of the tooth from the socket. PROCEDURE OF INTRA ALVEOLAR EXTRACTION

68. Step 1: Loosening the soft tissue attachments around the tooth. It is carried out using periosteal elevator or moons probe. It also helps to asses the depth of anesthesia. It allows the forceps to be placed more apically without impingement on gingiva. The pointed end of the instrument is used in prying motion to elevate dental papilla and attached gingiva.

69. 2. Step 2: Luxation of the 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 resting on alveolar bone and superior 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

70. 3 . Step 3: Adaptation of the forceps to the tooth. Forceps must be placed as apically as possible. 2 Point contact Parallel to the long axis of tooth Palatal/lingual beak is inserted first and then the buccal beak The handles are grasped at the end to gain the maximum mechanical advantage. The surgeon should be prepared to apply force with the shoulder and upper arm without any wrist pressure.

71. 4. Step 4: Luxation of the tooth with the forceps various motions are carried out to luxate the tooth Once the tooth is luxated, apical force is applied again to shift the center of rotation further apically. This is again followed by buccal and lingual movements of tooth. The forces applied in buccal and lingual direction must be slow deliberate pressures with no jerky movements

72. 5. Step 5: Removal of the tooth from the socket. Once the alveolar bone has expanded sufficiently and the tooth has been luxated, a slight tractional force, usually directed buccally, can be used. Tractional forces should be minimized, because this is the last motion that is used once the alveolar process is sufficiently expanded and the periodontal ligament completely severed

73. Specific techniques for removal of each tooth 1. Incisors Left hand grasps alveolar process. Forceps are seated as far apically as possible. Luxation is begun with labial force. Slight lingual force is used. E. Tooth is delivered with rotational, tractional Movement Maxillary teeth

74. 2.Canine A, Hand and forceps position for removal of maxillary canine is similar to that for incisors. Forceps are seated as far apically as possible. B, Initial movement is buccally. C, Small amounts of lingual force are applied. D, Tooth is delivered in labial-incisal direction with slight rotational force.

75. 3.1st Premolars A, Hand position is similar to that used for anterior teeth. B, Firm apical pressure is applied first to lower center of rotation as far as possible and to expand crestal bone. C, Buccal pressure is applied initially to expand Bucco cortical plate. D, Palatal pressure is applied but less vigorously than buccal pressure. E, Tooth is delivered in Bucco occlusal direction with combination of buccal and tractional forces.

76. 4. 2 nd Premolars A, When extracting maxillary second premolar, forceps are seated as far apically as possible. B, Luxation is begun with buccal pressure. C, Very slight lingual pressure is used. D, Tooth is delivered in Bucco occlusal direction.

77. 4. Molars A, Extraction of maxillary molars. Soft tissue of lips and cheek is reflected, and alveolar process is grasped with opposite hand. B, Forceps beaks are seated apically as far as possible. C, Luxation is begun with strong buccal force. D, Lingual pressures are used only moderately. E, Tooth is delivered in Bucco occlusal direction.

78. A MANDIBULAR TEETH Anterior teeth A, left hand supports the mandible and the alveolar process B, Forceps are seated apically as far as possible. C, Moderate labial pressure is used to initiate luxation process. D, Lingual force is used to continue expansion of bone. E, Tooth is delivered in labial-incisal direction.

79. A B C D E 2. premolar . A. Mandible is stabilized, soft tissue is reflected, left hand supports the mandible and alveolar process , B, Forceps are seated apically as far as possible to displace center of rotation and to begin expansion of crestal bone. C, Buccal forceps are applied to begin luxation process. D, Slight lingual pressure is used. E, Tooth is delivered with rotational, tractional force.

80. 3. Molars A, Hand positions of surgeon is similar to that used for premolar teeth. B, forceps are seated as far apically as possible. C, Luxation of molar is begun with strong buccal movement. D, lingual pressure is used to continue luxation. E, Tooth is delivered in Bucco occlusal direction.

81. EXTRACTION SEQUENCING Maxillary teeth are extracted first as the anesthesia acts early in maxilla. Followed by mandibular teeth. Posterior teeth are removed first followed by anterior teeth. First molar and canine are extracted after their adjacent teeth are removed. Order of extraction – 3 rd molar, 2 nd molar, 2 nd pre molar, 1 st molar, 1 st premolar, lateral incisor, canine, central incisor.

82. TRANSALVEOLAR EXTRACTION Commonly called the ‘surgical extraction’ This method involves removal of the bone investing the roots, which are then delivered by the use of elevators and/ or forceps.

83. INDICATIONS Any tooth, which offers a lot of resistance for elevation technique. Retained roots, which cannot be grasped by the forceps or delivered with an elevation technique Previous history of difficult or attempted and failed extraction technique Any large restoration with root canal therapy— brittle teeth Hypercementosis/ankylosis of a tooth Geminated/dilacerated tooth

84. Radiographic evidence of complicated/difficult root pattern or roots with unfavorable or conflicting lines of withdrawal Sclerosis of the bone Teeth associated with pathology—periapical granuloma, cyst, tumor, etc. Impacted teeth, embedded teeth. Roots close to maxillary sinus. Fractured teeth

85. 1. FLAP DESIGN The term flap Indicates a section of soft tissue that (1) is outlined by a surgical incision, (2) carries its own blood supply, (3) allows surgical access to underlying tissues, (4) can be replaced in the original position, and (5) can be maintained with sutures and is expected to heal.

86. PRINCIPLES OF FLAP DESIGN When the flap is outlined, the base of the flap must usually be broader than the free margin . The flap must be of adequate size Sufficient soft tissue reflection is required to provide necessary visualization of the area. Adequate access also must exist for the insertion of instruments required to perform the surgery. the flap must be held out of the operative field by a retractor that must rest on intact bone. a long, straight incision with adequate flap reflection heals more rapidly than a short, torn incision, which heals slowly by secondary intention. If a relaxing incision is to be made, the incision should extend one tooth anterior and one tooth posterior to the area of surgery Flaps for tooth removal should be full-thickness mucoperiosteal flaps.

87. A, Flap must have base that is broader than free gingival margin. B, If flap is too narrow at its base, the blood supply may be inadequate, which can lead to flap necrosis. A, To have sufficient access to root of second premolar, envelope flap should extend anteriorly, mesial to canine, and posteriorly, distal to first molar. B, If releasing incision (i.e. , three-cornered flap) is used, flap extends mesial to first premolar.

88. A, When designing flap, it is necessary to anticipate how much bone will be removed so that after surgery is complete, the incision rests over sound bone. In this situation, the vertical release was one tooth anterior to bone removal and left an adequate margin of sound bone. B, When releasing incision is made too close to bone removal, delayed healing results.

89. A, Correct position for end of verticalreleasing incision is at line angle ( mesiobuccal angle in this figure) of tooth. Likewise, incision does not cross .canine eminence. Crossing such bony prominences results in increased chance for wound dehiscence. B, These two incisions are made incorrectly: (1) incision crosses prominence over canine tooth, which increases risk of delayed healing; incision through papilla results in unnecessary damage; (2) incision crosses attached gingiva directly over facial aspect of tooth, which is B likely to result in soft tissue defect and periodontal and aesthetic deformities.

90. TYPES OF FLAPS ENVELOP FLAP 3 CORNERED FLAP 4 CORNERD FLAP SEMILUNAR FLAP

91. Developing a Mucoperiosteal Flap Scalpel handle is held in pen grasp for maximal control and tactile sensitivity . No. 15 blade is used to incise gingival sulcus.

92. A, Knife is angled slightly away from tooth and incises soft tissue, including periosteum, at crestal bone. B, Incision is started posteriorly and is carried anteriorly, with care taken to incise completely through interdental papilla. Reflection of flap is begun by using sharp end of periosteal elevator to pry away interdental papilla.

93. When three-cornered flap is used, only anterior papilla is reflected with sharp end of elevator. Broad end is then used with push stroke to elevate posterio superiorly. Periosteal elevator is used to reflect mucoperiosteal flap. Elevator placed perpendicular to bone and held in place by pushing firmly against bone, not by pushing it apically against soft tissue .

94. Removal of bone Bone should be excised to provide a point of application for an elevator or forceps. It is removed by using dental bur or chisel and mallet Round head burs cut more efficiently. No 8, No 10, or flat fissured burs are used. The bur must not be allowed to over heat and constant saline irrigation should be provided which removes the debris and prevents the bur from clogging The width of buccal bone that is removed is essentially the same width as the tooth in a mesiodistal direction . In a vertical dimension, bone should be removed approximately one half to two thirds the length of the tooth root. Postage stamp method can be employed.

95. When removing bone from buccal surface of tooth or tooth root to facilitate removal of that root, mesiodistal width of bone removal should be approximately same as mesiodistal dimension of tooth root itself. This allows unimpeded path for removal of root in buccal direction . Bone is removed with bone-cutting bur after reflection of standard envelope flap. Bone should be removed approximately one half to two thirds the length of tooth root.

96. ODONTECTOMY/TOOTH DIVISION Tooth sectioning is usually accomplished with a straight handpiece with a straight bur, such as the no. 8 round bur, or with a fissure bur, such as the no. 557 or no. 703 bur. The tooth may be divided with a bur to convert a multirooted tooth into two or three single-rooted teeth, when the path of withdrawal of multirooted teeth is different. Once the tooth is sectioned, the small straight elevator is used to luxate and mobilize the sectioned roots

97. If lower molar is difficult to extract, it can be sectioned into single-rooted teeth. A, Envelope incision is reflected, and small amount of crestal bone is removed to expose bifurcation. Drill is then used to section the tooth into mesial and distal halves. B, Lower universal forceps are used to remove two crown and root portions separately.

98. A, This primary second molar cannot be removed by closed technique because of tipping of adjacent teeth into occlusal path of withdrawal and of high likelihood of ankylosis. B, Envelope incision is made, extending two teeth anteriorly and one tooth posteriorly .

99. C, Small amount of crestal bone is removed, and tooth is sectioned into two portions with bur D, Small straight elevator is used to luxate and deliver mesial portion of crown and mesial root.

100. E, Distal portion is luxated with small straight elevator. F, forceps are used to deliver remaining portion of tooth

101. SOCKET TOILET Unwanted bony prominences should be removed with rongeur, chisel or burs Infected granulation tissue has to be removed using a curette. Sharp edge should be smoothened with bone files Wound should be irrigated with normal saline so that the debris is removed from the socket.

102. SUTURING OF THE FLAP When an envelope flap is repositioned into its correct location, it is held in place with sutures that are placed through the papillae only. If a three-cornered flap is used, the vertical end of the incision must be closed separately. Two sutures usually are required to close the vertical end properly

103. A, To make the suturing of three-cornered flap easier, periosteal elevator is used to elevate small amount of fixed tissue so that suture can be passed through entire thickness of mucoperiosteum. B, When three-cornered flap is repositioned, first suture is placed at occlusal end of vertical-releasing incision (1). Papillae are then sutured sequentially ( 2 , 3 ) , and finally, if necessary, superior aspect of releasing incision is sutured (4).

104. Removal of root fragments If fracture of the apical one third (3 to 4 mm) of the root occurs during a closed extraction, an orderly procedure should be used to remove the root tip from the socket Retrieval can be done by two methods: closed method open method The closed technique for root tip retrieval is defined as any technique that does not require reflection of soft tissue flaps and removal of bone. If sufficient luxation occurred before the fracture, the root tip often is mobile and can be removed with the closed technique. Irrigation-suction technique Tease the root apex from the socket with a root tip pick

105. A, When small (2 to 4 mm) portion of root apex is fractured from tooth, root tip pick can be used to retrieve it. B, Root tip pick is teased into periodontal ligament space and used to luxate root tip gently from its socket.

106. A, When larger portion of tooth root is left behind after extraction of tooth, small straight elevator can sometimes be used as wedge to displace tooth in occlusal direction. One must remember that pressure applied in such fashion should be in gentle wiggling motions; excessive pressure should not be applied. B, Excessive pressure in apical direction results in displacement of tooth root into undesirable places, such as maxillary sinus.

107. If the closed technique is unsuccessful, the surgeon should switch—without delay—to the open technique A, If root cannot be retrieved by closed techniques, soft tissue flap is reflected and bone overlying root is removed with bur. B, Small straight elevator is then used to luxate root buccally by wedging straight elevator into palatal periodontal ligament space.

108. A, Open-window approach for retrieving root is indicated when Bucco crestal bone must be maintained. Three-cornered flap is reflected to expose area overlying apex of root fragment being recovered. B, Bur is used to uncover apex of root and allow sufficient access for insertion of straight elevator. C, Small straight elevator is then used to displace tooth out of tooth socket.

109. POST EXTRACTION CARE Inspection of the socket: debris, tooth fragments, bone fragments should be removed. Curettage of granulation tissue, smoothening of sharp bony edges. The expanded buccolingual plates should be compressed back to their original configuration. Finger pressure should be applied to the buccolingual cortical plate to compress the plates gently but firmly to their original position(Bidigital alveoloplasty) Initial control of hemorrhage is achieved by use of a moistened 2 x 2-inch gauze placed over the extraction socket. A larger gauze sponge (4 x 4 inches) may be required if multiple teeth have been extracted or if the opposing arch is edentulous.

110. Gauze pad (2 x 2-inch pad) is folded in half twice and placed into space. When patient bites on gauze, pressure is transmitted to gingiva and socket. If large gauze is used, pressure goes on teeth, not on gingiva or socket.

111. Instructions to the patient Maintenance of pressure pack for 30 – 60 minutes (Initial clot is soft and friable. Clot retraction takes 30-45 minutes) Swallow the saliva and not to spit or rinse till 24 hours post extraction Soft and cold diet for 24 hours so as not to disturb the clot and for vasoconstriction Warm saline rinses after 24 hours to enhance healing of socket Avoid smoking as it may dislodge the clot and lead to bleeding Avoid violent exercise, stimulants, very hot food or drinks to minimize the risk of post extraction hemorrhage A ntibiotics and analgesics are prescribed.

112. COMPLICATIONS OF EXODONTIA INTRAOPERATIVE COMPLICATIONS 1. Failure to secure anesthesia 2. Fracture of- crown root alveolar bone maxillary tuberosity adjacent or opposing tooth mandible 3. Dislocation of – Adjacent tooth TMJ 4. Displacement of the root- into soft tissues into the maxillary antrum

113. Hemorrhage- during tooth removal On completion of the extraction Damage to- gums Lips Inferior dental nerve or its branches Lingual nerve tongue and floor of mouth 7. Extraction of wrong tooth 8.Aspiration of tooth

114. Postoperative (delayed complications): Haemorrhage: Reactionary, secondary Pain Dry socket: Alveolar osteitis Postoperative oedema/swelling Hematoma/ecchymosis Infection Trismus Creation of Oro antral communication

115. Late complications : ■ Chronic osteomyelitis/osteoradionecrosis ■ Nerve damage: Anaesthesia/paresthesia ■ Chronic pain

116. Failure to secure anesthesia Due to faulty technique or insufficient dosage of the anesthetic agent After administration of anesthesia, a blunt probe is pushed firmly into buccal and lingual gingival crevice to check for anesthetic effect Fracture of crown Caused by improper application of forceps One point contact of forceps. weakened tooth structure due to severe caries, large restorations Hurry is usually the underlying cause of these errors. Exhibition of excessive force to overcome resistance.

117. Fracture of roots Same factors that cause the fracture of crown cause fracture of the root as well Although all the root fragments are advised to be retrieved in all the circumstances, some have to be left behind in certain situations Root fragments lesser than the apical third, or 5 mm, with a vital pulp in a healthy patient can be left alone; while those greater than 5 mm, with necrotic pulps and with periapical radiolucent areas should be removed.

118. . 4. Fracture of alveolar bone Caused due to accidental inclusion of alveolar bone in the forceps or due to pathological conditions of the bone Canine extractions can cause the fracture of labial plate when the premolar and lateral incisor are not extracted first Advised to remove all the alveolar fragments which has lost its periosteal attachment and sutures placed.

119. Fracture of the maxillary tuberosity Caused by the invasion of the tuberosity by the antrum commonly seen in the case of isolated maxillary molars

120. 6. Fracture of adjacent or opposing tooth Careful examination will reveal whether the adjacent or the opposing tooth is carious, heavily restored or in the line of withdrawal. If the tooth to be extracted is an abutment tooth, bridge should be divided with burs prior to extraction Care should be taken not to use the adjacent tooth as the fulcrum Opposing tooth may get chipped or fractured if the tooth being extracted yields suddenly to uncontrolled force and the forceps strikes them. Therefore, controlled forces have to be used.

121. Fracture of the mandible Caused by excessive and incorrectly applied force, weakened bone due to pathological changes. Controlled forces have to be applied If a fracture occurs, then treatment of the fracture has to be done by reduction and stabilization of the fracture

122. Dislocation of the adjacent tooth Can occur during elevation One finger should be placed upon the adjacent tooth to support the tooth Subluxation: Tooth is stabilized with wire or acrylic splint Avulsion: Reimplanted immediately and stabilized with splints Endodontic therapy is planned

123. Dislocation of the TMJ Complication of mandibular extraction Application of excessive force, failure to support the mandible, more likely to occur under GA, when masticatory muscles are relaxed

124. 10. Displacement of the tooth/root into tissue space Tooth can get displaced into the in the lingual pouch, in pterygopalatine fossa, through the lingual cortex of bone in submandibular space. Causes are thin cortical plate, uncontrolled force, and fenestration in cortical plates Use controlled force, and support the alveolus during extraction and support of one finger over lingual cortical plate. Radiographs may be required. Attempt should be made for its retrieval. Manipulation or pushing the root piece back into its socket should be tried.

125. Displacement of the tooth/root into the maxillary sinus Commonly involved root: Palatal root of maxillary first molar Large antral cavity close to the apices of posterior teeth Use of controlled force with support to the alveolus Leave the apical third of maxillary molar palatal roots; unless there is an indication for their removal

126. 12. Soft tissue injury Improper surgical technique: (Inadequate size of flap) Improper handling of instruments: (careless retraction) Use of excessive and uncontrolled forces Common areas: Upper—posterior palate Lower—tongue and floor of the mouth Managed by : Proper surgical technique (Proper designing of flap) Proper handling of instruments Use of controlled force Closure of tear after completion of surgical procedure

127. 13. Extraction of a wrong tooth Caused due to carelessness Improper communication (Referred patients, particularly by orthodontists) Careful extraction Replace tooth as soon as possible; and stabilize with wire or splint/arch bar Plan for endodontic treatment

128. 14. Haemorrhage Primary hemorrhage: Hemorrhage at the time of surgery Reactionary hemorrhage: Hemorrhage within few hours after surgery, when vasoconstriction of damaged blood vessels has ceased Secondary hemorrhage: Hemorrhage up to 14 days postoperatively, as a result of infection causes Local: Bleeding from arteriole or vessel Granulation tissue Crush injury General: (a) Natural: i . Haemophilia A ii. Haemophilia B (b) Acquired: Anaemia (Severe) Hypertension (uncontrolled) Vitamin K deficiency Vitamin C deficiency Anticoagulation therapy Liver diseases, Hemorrhagicdisorders Idiopathic thrombocytopenia

129. Control the hemorrhage from soft tissues: Mechanical pressure in the form of finger/thumb pressure Electric cauterization Injection of local anesthetic containing a vasoconstrictor (adrenaline), for relief of pain as well as for vasoconstriction Suturing; particularly, figure-of-eight type, across the margins of the socket Clamping of bleeding vessel and ligation with 3/0 or 4/0 ligature, or coagulation with diathermy

130. Application of hemostatic substances: absorbable sponges: gelatin foam ( gelfoam ), surgicel , liquid preparation of topical thrombin, collagen Smearing of bone wax into relevant spaces in bone marrow with the help of an instruments such as burnisher or Mitchell’s trimmer A block of impression compound is moulded over the area to offer compression

131. 15. Dry socket/ Fibrinolytic alveolitis/ alveolar osteitis/ localized osteitis alveolalgia / alveolar osteomyelitis/ Alveolitis sicca dolorosa/ Post operative osteitis It involves part or whole of the walls of socket; or the lamina dura. Geoffrey Howe, defined it as well recognized, but ill understood complication of extraction of teeth. Characteristics: The condition is characterized by acute pain, bony walls of the socket are denuded of blood clot. The bare bone is extremely sensitive to the touch of probe. Etiology: Not clear/obscure.

132. Birn’s hypothesis, 1973 – trauma and infection cause inflammation of the marrow spaces which releases fibrinolytic agents. This fibrinolytic activity results in lysis of the blood clot. Liberation of tissue activators which convert plasminogen in blood clot to plasmin. This dissolves blood clot and releases kinins from kininogen; which is present in blood clot causing pain. The final result is of dissolution of blood clot and severe pain Predisposing factors: Infection of socket occurring either before, during or after the extraction Trauma Vasoconstrictor Existence of systemic etiologic Bacteriological origin

133. Management Aim: ( i ) Relief of pain, and (ii) Speed of resolution Irrigation of debris and debridement with warm saline and dilution of hydrogen peroxide Medicated dressing/Iodoform gauze or composed of zinc oxide eugenol on cotton wool could be packed. Broad-spectrum antibiotics if suppuration exists. Analgesics, and hot saline mouth baths

134. 16. Infection/suppuration at the site Lack of aseptic technique, inadequate preparation of the site, inadequate sterilization of instruments Use of antibiotics, and may be incision and drainage 17. Odema / hematoma Use of blunt instruments, excessive retraction of soft tissues, badly designed flaps, tightly approximated sutures Usually both the conditions regress if the patient uses hot saline mouth baths for 2-3 days

135. 18. Creation of oro -antral communication Maxillary posterior teeth are in close proximity with floor of maxillary sinus With advancing age, there is increase in pneumatization Solitary molar tooth in atrophic maxillary alveolus Molar roots with large splayed roots close to antral floor

136. Management Inspection of extraction socket Nose-blowing test, fog test Instruments, such as, suction tips and probes through the socket into the antrum in an attempt to confirm the defect. Retrieval of the tooth/root Defect less than 2 mm: Blood clot gets organized Defect >2 and < 6 mm: Hemostatic agents are inserted in the socket and the socket is sutured. Decongestant nasal spray. Defects > 7 mm : Surgical closure by flaps Patients should be advised to avoid blowing the nose, sneezing violently, sucking on straws, and smoking.

137. NEWER ADVANCES 1. Powered periotomes

138. 2 . Using implant drills for extractions prior to immediate implant placement

139. 3. Physics forceps

140. 4. Peizosurgery

141. 5. Use of LASER low-vibration bone cutting to allow precise bone ablation without any visible, negative, thermal side effects Er:YAG laser can be used for surgical extractions to ablate the covering bone layer by layer exposing the portion of the root. Once the tooth/root is uncovered, they can be conventionally removed tend to be time consuming sound and smell of the laser surgical procedure lack of a feedback system for depth control

142. REFERENCES THE EXTRACTION OF TEETH- GEOFFREY L HOWE ORAL AND MAXILLOFACIAL SURGERY, VOLUME ONE, 5 TH EDITION - W. HARRY ARCHER TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY, 6 TH EDITION- GUSTAV O. KRUGER CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY, 7 TH EDITION- JAMES R HUPP, EDWARD ELLIS III, MYRON R TUCKER ORAL AND MAXILLOFACIAL SURGERY, VOLUME TWO- DANIEL M LASKIN