Principles of Routine Exodontia

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INDICATIONS FOR REMOVAL OF TEETH

1.Caries : the most common and widely accepted reason to remove a tooth is that it is so severely carious that it cannot be restored

2.Pulpal Necrosis : the presence of pulpal necrosis or irreversible pulpitis that is not amenable to endodontic

3.Periodontal Disease : If severe adult periodontitis has existed, excessive bone loss and irre-versible tooth mobility will be found

4.Orthodontic Reasons : The most commonly extracted teeth are the maxillary and mandibu-lar premolars,but a mandibular incisor may occasionally need to be extracted for this same reason

5.Malposed Teeth : if they traumatize soft tissue and cannot be repositioned by orthodontic treatment, they should be extracted

6. Cracked Teeth : An uncommon indication for extraction of teeth is a tooth with a cracked crown or a fractured root

7. Impacted Teeth : If it is clear that a partially impacted tooth is unable to erupt into a functional oc-clusion interference from adjacent teeth,or some other reason, it should be considered for surgical removal.

8. Supernumerary Teeth

9. Teeth Associated with Pathologic Lesions : This is often seen with odontogenic cysts. In some situations, the tooth or teeth can be retained and endodontic therapy performed.

10. Radiation Therapy

11. Teeth Involved in Jaw Fractures : if the tooth is injured, infected, or severely luxated from the surrounding bony tissue or interferes with proper reduction and fixation of the fracture, its removal may be necessary.

12. Financial Issues

CONTRAINDICATIONS FOR REMOVALOF TEETH

Systemic Contraindications

Local Contraindications

RADIOGRAPHIC EXAMINATION OF THE TOOTH FOR REMOVAL

Figure 7-6 Maxillary molar teeth immediately adjacent to sinus present increased danger of sinus exposure

Figure 7-7 Mandibular molar teeth that are close to inferior alveolar canal. Third molar removal is a procedure most likely to result in in-jury to nerv

Figure 7-8 Before premolar extractions that require a surgical flap are performed, it is essential to know the relationship of the mental foramen to root apices. Note the radiolucent area at the apex of the second premolar, which represents the mental foramen.

1. Relationship to Vital Structures : Sinus / The inferior alveolar canal / mental foramen

2.Configuration of Roots

number of roots curvature of root Root caries

Hypercementosis Internal resorption previous endodontic therapy

Figure 7-2 Teeth with large carious lesions are likely to fracture during extraction, making extraction more difficult

Figure 7-3 Teeth with large amalgam restorations are likely to be fragile and to fracture when extraction forces are applied.

Figure 7-4 Mandibular first molar. If the molar is to be removed, the surgeon must take care not to fracture amalgam in the second premolar with elevators or forceps

3.Condition of the Crown

CHAIR POSITION FOR EXTRACTIONS

maxilla

The chair is tilted back so that the maxillary occlusal plane is at about 60-degree angle to the floor

The height of the chair should ensure that the levelof the patient’s mouth is slightly below the surgeon’s el-bow

Figure 7-19 : Extraction of teeth in the maxillary right quadrant. Note that the surgeon turns the patient’s head toward self.

Figure 7-20 : Extraction of anterior maxillary teeth. The patient looks straight ahead.

Figure 7-21 : Patient with head turned slightly toward surgeon for extraction of maxillary left pos-terior teeth

Figure 7-29 In the surgeon-seated position, the patient is positioned as low as possible so that the mouth is level with the surgeon’s elbow

Figure 7-30 For extraction of maxillary teeth, the patient is reclined back approximately 60 degrees. Hand and forceps positions are the same as for the standing position

mandible

For mandibular extractions, the patient is more up-right so that the mandibular occlusal plane of the opened mouth

is parallel to floor

The height of the chair is also lower to allow the op-erator’s arm to be straighter

the surgeon’s arm should be inclined downward to approximately a 100-degree angle at the elbow

Figure 7-23 Patient with head turned toward surgeon for removal of mandibular right teeth

Figure 7-24 For extraction of mandibular anterior teeth, the surgeon stands at the side of the patient, who looks straight ahead

Figure 7-26 For extraction of mandibular posterior teeth, the patient turns slightly toward the surgeon

Figure 7-31 For extraction of mandibular teeth, the operator holds the forceps in the underhanded position

Figure 7-32 For removal of mandibular posterior teeth, the surgeon’shand can hold the forceps from above

Figure 7-33 For removal of anterior teeth, the surgeon moves to a position behind the patient so that the pa-tient’s mandible and alveolar process can be supported by the surgeon’s other hand.

PRINCIPLES OF ELEVATOR AND FORCEPS USEthe lever : wedge

wheel-and-axle

Forceps can apply five major motions to luxate teeth and expand the bony socket :

1. apical pressure

Two goals:

1. bony expansion , tooth moves in an apical direction minimally

2. the center of rotation ofthe tooth is displaced apically

2. buccal force 3. lingual or palatal pressure 4. rotational pressure

PROCEDURE FOR CLOSED EXTRACTIONStep1:involves loosening of the soft tissue attachment from the cervical portion of the tooth

with a : scalpel blade the sharpend of the No. 9 periosteal elevator

The purpose: it allows the surgeon to ensure that profound anesthesia has been achieved

allow the elevator and tooth extraction forceps tobe positioned more apically, without interference from or impingementon the soft tissue of the gingiva

Step 2 : luxation of the tooth with a dental elevator

1.The straight elevator is inserted perpendicular to thetooth

2.the inferior portion of the blade rests on the alveolar bone and thesuperior, portion of the blade is turned toward the toothbeing extracted

3. Strong, slow, forceful turning of the handle moves the tooth in a posterior direction

The handle of elevator may be turned in the opposite direction to displace the tooth further from the socket.This can be accomplished only if no tooth is adjacentposteriorly.

Step 3 : adaptation of the forceps to the tooth

The beaks of the forceps should be shaped to adapt anatomically to the root surface

The lingual beak is usually seated first and then the buccal beak

Step 4 :

luxation of the tooth with forceps

The surgeon uses slow, steady force to displace the tooth buccally rather than a series of rapid, small movements that do little to expand bone

Step 5 :

removal of the tooth from the socket

SPECIFIC TECHNIQUES FOR THE REMOVAL OF EACH TOOTHMaxillary Teeth

Incisors :

canines

Figure 7-58A, Hand and forceps positions for removal of the maxillary canine are similar to those for removal of incisors. The forceps are seated as far apically as possible.B, The initial movement is in the buccal direction.C, Small amounts of lingual force are applied.D, The tooth is delivered in the labial–incisal direction with a slight rotational force.

First premolar :

Figure 7-59 A, Maxillary premolars are removed with the No. 150 forceps. The hand position is similar to that used for anterior teeth. B, Firm apicalpressure is applied first to the lower center of rotation as far as possible and to expand crestal bone. C, Buccal pressure is applied initially to expandthe buccocortical plate. The apices of roots are pushed lingually and are there-fore subject to fracture. D, Palatal pressure is applied, but less vigorously than buccal pressure. E, The tooth is delivered in the bucco-occlusal direction with a combination of buccal and tractional forces.

Second premolarFigure 7-60 A, When extracting the maxillary second premolar, the forceps are seated as far apically as possible.

B, Luxation is begun with buccal pressure.

C, Very slight lingual pressure is used.

D, The tooth is delivered in the bucco-occlusal direction

Molars :

Figure 7-61 A, Extraction of maxillary molars. Soft tissues of the lips and cheek are retracted, and the alveolar process is grasped with the oppositehand. 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, The tooth is delivered in the bucco-occlusal direction

Mandibular Teeth

Figure 7-63 To provide support for the mandible to prevent excessive temporomandibular joint pressures, a rub-ber bite block can be placed between the patient’s teeth on the contralateral side.Figure 7-62 Extraction of mandibular left posterior teeth. The surgeon’s left index finger is positioned in the buc-cal vestibule, retracting the cheek, and the second finger is positioned in the lingual vestibule, retracking the tongue. The thumb is positioned under the chin. The mandible is grasped between the fingers and the thumb to provide support during extraction

Anterior teeth

Figure 7-64 A, When extracting mandibular anterior teeth, the No. 151 forceps are used. The assistant retracts the pa-tient’s cheek and provides suction. B, The forceps are seated apically as far as possible. C, Moderate labial pressure is used to initiate the luxation proces. D, Lingual force is used to continue the expansion of bone. E, The tooth is delivered in the labial–incisal direction.

mandibular premolar :

Mandibular molars

Figure 7-67 A, Mandibular molars are extracted with the No. 17 or No. 23 forceps. The hand positions of the sur-geonand the assistant are the same for both forceps. B, The No.17 forceps are seated as far apically as possible. C, Luxationof the molar is begun with a strong buccal movement. D, Strong lingual pressure is used to continue the luxation.E, The tooth is delivered in the bucco-occlusal direction.

Figure 7-68 A, The No. 23 forceps are carefully positioned to engage the bifurcation area of the lower molar. B, The handles of the forceps are squeezed forcibly together, which causes the beaks of the forceps to be forced into the bifurcation and exerts tractional forces on tooth.C, Strong buccal forces are then used to expand the socket.D, Strong lingual forces are used to luxate the tooth further. E, The tooth is delivered in the bucco-occlusal direction with buccal and tractional forces.