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2. 1. Introduction
2. Definition
3. Indications
4. Contraindications
5. Presurgical assessment
6. Armamentarium
7. Mechanical principles of extraction
8. Methods of extraction
9. Extraction procedure.
10. Post extraction instructions
11. Sequence of extraction
12. Complications
13. Conclusion
Contents:
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3. Introduction:
Extraction of the teeth is a procedure that combines the principles of surgery
and principles of physics and mechanics. When these principles are applied
correctly, a tooth can be easily removed from a alveolar process without
untoward force or sequelae.
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5. 1.Carious teeth that is non restorable
2.Periodontally involved teeth
3.Teeth which can’t be restored endodontically
4.Prophylactic removal of teeth for radiation therapy
5.Teeth in the line of fracture
6.Fractured teeth which is non restorable
7.Teeth associated with pathologic lesions
8.Malposed teeth
9.Cracked teeth
10.Impacted teeth
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7. Most feared side effect of
radiotherapy is
osteoradionecrosis.
Should teeth be extracted ?
Extraction may spare the
patient, months or years of
suffering from
osteoradionecrosis
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8. Woman's head undergoing radiotherapy
treatment for basal cell carcinoma
Attempt is made to remove a good
portion of the alveolar process along
with the teeth & achieve a primary
soft tissue closure
Traditionally 7 to 14 days between
tooth extractions and radiotherapy
has been suggested
Radiotherapy should be delayed for 3
weeks if possible to ensure sufficient
soft tissue healing
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9. If tooth is grossly
displaced, severely mobile,
or grossly decayed –
remove
If tooth is non carious &
appears secure in alveolar
bone – retain
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11. Systemic contraindications
Absolute Relative
Severe uncontrolled metabolic diseases
( Brittle diabetes & End stage renal disease
with severe uremia)
Uncontrolled leukemia & lymphoma
Severe uncontrolled cardiac diseases
(severe MI, unstable angina pectoris,
malignant hypertension, recent MI,
CVA
Pregnancy
Severe bleeding disorders like
hemophilia or platelet disorder
Pt. taking certain medications like
corticosteroids, immunosuppressive
agents, cancer chemotherapeutic
agents
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12. Local contraindications
Absolute Relative
Teeth located in malignant tumor
Vascular lesions like A-V malformations
& Hemangioma in the vicinity of the tooth
H/O therapeutic radiation
(Osteoradionecrosis)
Severe Pericoronitis around
impacted molars
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13. Medical history
Dental history (history of
difficult extraction)
Patient’s emotional maturity
Clinical examination
Radiographic examination
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22. Armamentarium: Extractionforceps
Even though elevator can be used to luxate the tooth, it’s
extraction forceps that does most of the work.
Forceps have blades and handles joined by a hinge joint.
The larger the ratio between the length of the handle and
length of the blades, greater the leverage that can be
exerted upon the root.
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23. Ideally, the blade of the forceps should be sharp and also the
whole of the inner surface of the forceps blades should fit the root
surface. But because of variation in size & shape of tooth from
individual to individual, it is not practicable.
Hence a forceps is termed ideal if two point contact is achieved.
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24. Expansion of the body socket by use of wedge shaped
beaks of the forceps and the movement of the tooth itself.
Removal of the tooth from the socket
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26. How a forceps cause luxation of tooth and
expansion of bony socket
Apical pressure : Helps to wedge the forceps firmly in
PDL space but results in minimal movement of the
tooth
Care should be taken so that beaks are not placed too
apically and also not above the CEJ.
Buccal force : results in expansion of buccal cortical
plate.
lingual force : cause expansion of lingual cortical plate.
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27. Rotational force : cause rotation of tooth and this
results in internal expansion of the tooth socket.
This force in used in single, conical rooted tooth.
Tractional force : used to deliver the tooth from the
socket once adequate bone expansion is achieved.
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28. Dental elevators
Indications:
To reflect mucoperiosteum
To luxate & remove teeth which can’t be engaged by the beaks of forceps
To remove fractured or carious root
To loosen teeth prior to application of forceps
To remove intraradicular bone
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29. Rules when using elevators:
Never use adjacent tooth as fulcrum unless that tooth is to be extracted also.
Never use buccal plate at the gingival line as a fulcrum, except where
odontectomy is performed
Never use lingual plate at the gingival line as a fulcrum.
Always use finger guards to protect the patient in case the elevator slips.
Forces applied should be under control.
When cutting through interseptal bone, take care not to engage the root of
an adjacent tooth, thus inadvertently forcing it from its alveolus.
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30. Classification of elevators:
According to use:-
1. Elevators designed to remove the entire tooth( 1L- 1R).
E.g. Cross bar elevator
2. Elevators designed to remove roots broken off at the gingival line(30-4-5)
E.g. Apexo elevators
3. Elevators designed to remove roots broken off halfway to the apex (30-4-5, or
14L-14R, or 11L- 11R)
E.g. Apexo elevators, Cryer elevator, cross bar elevator
4. Elevators designed to remove apical third of the root
E.g. Apical fragment ejectors No. 1, 2 & 3
5. Elevators design to reflect mucoperiosteum
E.g. Periosteal elevator
According to Form:-
1. Straight: wedge type
2. Angular: Right & Left
3. Cross bar( handle at right angle to shank)
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41. Patient’s & operator’s position
Administration of L.A
Severing of gingival attachment from the tooth
Positioning of Elevators & Forceps for extraction
Role of other hand
Compression of socket
Pressure pack
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44. Forceps always held with palm of hand above the
handles of the forceps.
Patient is inclined 15-20o for extraction in the lower
left quadrant & 30 – 45o in the other 3 quadrants.
Dentist stands behind the patient for extraction in the
lower right quadrant & in front of the patient for all
other extractions.
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45. Forceps are usually held with the palm of
the hand below the handles of the forceps
The patient is usually inclined 30-45 degrees
for all extractions
The dentist normally stands behind the
patient in all extractions
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46. “You have to see well what you do in
order to do well what you see”
G.C Ingham
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48. Specific technique for removal of each tooth
Maxillaryteeth:
The left index finger of the surgeon should reflect the
lip and cheek tissue
Thumb should rest or palatal process.
Stabilize the patients head and support alveolar
process
In this position of extraction surgeon can frequently
feel the left palatal root of the molar becoming free in
alveolar process.
Right side index finger is positioned on the palate
and thumb on buccal aspect.
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54. Maxillary 2nd molar : anatomy is
similar to the first molar except the roots
are short and less diverged. Buccal roots are
more lowerly fused and same techniques
used as 1st molar.
Maxillary 3rd molar has conical root
extracted with no.210s forceps.
Universal forceps for both right and left
side. Erupted 3rd molar usually extracted
with elevators.
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55. Mandibular teeth:
Index finger of left hand in buccal vestibule and
second finger in lingual vestibule reflecting lip cheek
and tongue
The thumb of the left hand is placed below chin to
support the mandible and minimize
Temporomandibular joint pressure
Bite block on contra lateral side also useful in limiting
pressure on TMJ
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56. strong buccal and lingual motion used to expand the socket
and allow the teeth to be delivered in buccal-occlusal
direction.
Lingual bone is thinner in 2nd molar hence can more easily
be removed with stronger lingual than buccal pressure.
Erupted 3rd molar usually have fused conical roots. care
should be taken not to use large amount of forces.
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64. Alveolar purchase technique
Kruger recommended a unique closed method technique for removal
of anterior teeth or root.
A fractured tooth often can be grasped by root forceps, or anterior
forceps.
Alveolar purchase may be obtained by detaching labial gingival cuff.
Then labial beak of forceps is placed under the tissue on the labial
plate of the alveolar plate of the bone.
The pressure on a forceps grasp the root along with labial alveolar bone
By this technique the root can be delivered with labial alveolar bone
easily. www.indiandentalacademy.com
69. Debride only if necessary-
Periapical pathology
Debris
Compress the expanded buccal and lingual plate
Granulation tissue of gingiva should be curetted when
required
Bone margins should be smooth
Hemorrhage should be controlled
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70. Post extraction instructions
1. Patient should be advised to firmly bite on the gauze piece placed on the
extraction socket for a minimum of half an hour after extraction.
2. Patient should be advised not to rinse his mouth vigorously for the next 24 hours.
3. To avoid any hot food or beverages for the next 24 hours. Patient should take
cold food.
4. Advised to take soft diet on the day of extraction.
5. Not to suck from a straw on the day of extraction.
6. Warm saline rinses & gentle brushing should be advised from the next day.
7. Do not spit.
8. Take prescribed medication on time.
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72. Procedure involves reflection
of a mucoperiosteal flap,
cutting of the bone obstructing
the removal of the tooth & if
required sectioning of the roots
& then removal
Forceps extraction of these teeth
resulted in removal of bone & tooth
instead of just tooth
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73. Indications :
1. Attempts at forceps extraction have failed
2.Retained roots, especially those in close proximity to the maxillary
sinus
3.History of difficult or attempted extractions.
4. Heavily restored tooth
5. Hypercementosed & ankylosed teeth
6. Geminated & dilacerated teeth
7. Teeth shown radiographically to have
-Complicated root patterns or
-Roots with conflicting lines of withdrawal
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74. Heavy buccal plate suggests
difficult forceps extraction
Teeth exhibiting bruxism
may have denser bone &
stronger PDL attachment
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75. procedure:
Raising a flap
Removal of bone
Tooth division
Removal of tooth
Wound toilet
Primary closure
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78. Flap must be large enough to allow easy access
without stretching
Flap must be full thickness and include
periosteum when reflected
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79. Incisions that outline the flap must be made over intact bone
The flap should avoid injury to local vital structures
In the mandible vertical releasing incisions could
damage the lingual nerve & the mental nerve
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80. Releasing incisions should
be used only when necessary
When necessary, only single
vertical incision used
Healing time for a short flap
is comparatively less to that
for a long one
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85. Maxillary bone much more
porous than mandibular
Mallet should follow with a
sequence of taps
Advantage
• ease of autoclaving
• no irrigation required
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86. No: 8 rose head bur
Rose head burs cut more
efficiently & clog less than
flat fissure burs
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87. Rose head burs have 3
advantages over flat
fissure burs for removal
of bone
1. More easily cooled by water jet
2. Site of cutting more readily seen
3. Easier to control
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88. Chisel and Mallet
Quicker and cleaner removal
of bone when used correctly
No heat production
Do not require irrigation
No chances of bone
necrosis
Not pleasant for the patient
Bur
Slow removal of bone
comparatively
Heat production
Require constant irrigation
Chances of bone necrosis due
to heat
Comparatively pleasant
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90. Particularly useful in
cases where
Lines of withdrawal of
different roots conflict
Minimize need to remove
more bone
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91. Teeth sectioned using either osteotome or powered
hand piece
Before splitting the tooth, point of application to
elevator facilitate delivery of the roots must be
made
Separate the root mass of the lower molar from
below upwards
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92. Progress of healing & the amount of after-pain
greatly influenced by the care with which
postoperative socket cleaning is performed
Judicious bone removal will speed healing by
reducing the
• amount of bone to be resorbed & remodeled
• Volume of blood-clot which fills the socket
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93. Surgical defect must be sealed from the oral
environment by replacement of the flap
The flap acts as a primary dressing & contains the
osteogenic layer of periosteum which will help
promote bone regeneration
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94. 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
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95. Removal of root will cause excessive destruction of
surrounding tissue
Removal of root endangers vital structures
Attempts of recovering the root can displace it into
the maxillary sinus or tissue spaces
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97. COMPLICATIONS OF TOOTH EXTRACTION
ARE MANY & VARIED
Some are unavoidable (occurs even when utmost care
is exercised)
Some are avoidable (if proper planning & surgical
execution done)
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102. Dry socket
Causes:
Preexisting infection
Trauma to bone during extraction
Decreased bleeding due to hemostatic effect of epinephrine or
other vasoconstrictor injected with L.A
Infection entering into the socket after the tooth has been removed
Presence of dense bone
General dehabilitation
Loss of clot because of rinsing of the mouth or sucking the woundwww.indiandentalacademy.com
105. Before undertaking the extraction of a tooth, one
should thoroughly evaluate the problems involved
and select the right anesthesia , radiographs and
forceps. The right procedure is selected to yield the
best result.
Hurry always leads to worry
Conclusion:
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106. references
Contemporary oral & Maxillofacial Surgery, 5th Edition
James R. Hupp, Edward Ellis III, Myron R. Tucker
The extraction of teeth, 3rd Edition
Geoffrey Howe
Minor oral surgery Geoffrey Howe, 3rd Edition
Oral & Maxillofacial Surgery, Vol: 2
Daniel M. Laskin
Oral & Maxillofacial Surgery, Vol: 1
W. Harry archer, 5th Edition
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Extraction is the primary & original procedure of oral surgery so much that the dentistry for a layman implies extraction, while an apparently simple procedure, the process of extraction of teeth is like a serpentile path with many twist and turns.
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 & no postoperative prosthetic complication is created.
Malposed teeth causing soft tissue trauma or can’t be aligned by orthodontic treatment and prevents construction of opposing denture should be extracted.
Many absolute contraindications are relative contraindications if we have requisite training & equipments.
An absolute contraindication is a situation which makes a particular treatment or procedure absolutely inadvisable. In a baby, for example, aspirin is absolutely contraindicated because of the danger that aspirin will cause Reye syndrome.
A relative contraindication is a condition which makes a particular treatment or procedure somewhat inadvisable but does not rule it out. For example, X-rays in pregnancy are relatively contraindicated (because of concern for the developing fetus) unless the X-rays are absolutely necessary.
Reye syndrome is sudden (acute) brain damage (encephalopathy) and liver function problems of unknown cause.
The syndrome has occurred with the use of aspirin to treat chickenpox or the flu in children. However, it has become very uncommon since aspirin is no longer recommended for routine use in children.
There are a few absolute contraindications to the removal of teeth when it is necessary for the well-being of the patient . However there are a no. of instances where it may be judicious to delay extraction until local n systemic contraindications r corrected or modified.
Diabetes- 1.peripheral circulation is reduced as a result of deposition of cholestrol into peripheral vessels.
2. high% of sugar in the body fluids helps in bacterial growth by supplying the organisms with a rich source of food.
Recent MI- defer Rx for 6 months becoz 1. some pts. Are physiologically more stable after they have had a chance to recover from the infarction. 2. some of the more unstable postmyocardial infarction patients exclude themselves by having second infarction, the likelihood of which decreases with increasing time since initial infarct.
3. If symptomatic teeth can’t be palliated by use of antibiotics, then emergency Rx is indicated even in the relatively immediate postinfarction period. The operating room is the safest setting 4 these pts. Although suitably equipped & staffed ambulatory facility is satisfactory in most cases.
Hemophillia: mild- 10 to 50% factor, major surgeries cause excessive bleeding.
Moderate: 2 to 10% factor levels, mild trauma causes excessive bleeding.
Severe: <2% factor level, spontaneous hemarthroses. aPTT & CT increased, Manage- whole blood, FFP & cryoprecipitate not used nowadays, freeze dried factor 8 & 9 concentrate, desmopressin acetate(vasopressin analogue), EACA & tranexemic acid (antifibrinolytic) block conversion of plasminogen to plasmin.
Malignant tumor- spread of tumor & non healing wound in extn site.
First evaluate number
Then
Curvature
Shape
Size
length
No.2 for mesial application & no.3 distal.
Apexo elevators No.4(302), 301, no. 5(303) are particularly effective in the removal of roots #ed at gingival line.
Lever 1- scissor, elevators. Lever 2- Nut cracker, Lever 3- tweezer.
Apexo elevators are wedge elevators
2.Use of lever & fulcrum to force a tooth or root out of the socket along the path of least resistance.
3. Beaks of forceps act as wedge to expand alveolar bone & displace tooth in occlusal direction.
Five general steps in closed extraction- 1. loosening of soft tissue attachment from the cervical portion of the tooth.
2.Luxation of the tooth with a dental elevator. 3. adaptation of the forceps to the tooth. 4. luxation of the tooth with the forceps. 5. removal of the tooth from the socket.
Standing or sitting
In front or behind patient
Patient almost supine (back 10 to ground) for maxillary teeth
Patient almost supine or semi-sitting (back 20 - 30 to ground)
Be comfortable. Back straight. Head not bent forward blocking light.
• Comfortable for both the patient and surgeon
• Stand or sit during extraction
• Maxillary occlusal plane 60° to the floor
• Mandibular occlusal plane parallel to the floor
In standing posn., 3 inch /8cm below the operator’s shoulder for maxillary extraction & 6 inch /16 cm below operator’s elbow. Force should be applied from the trunk. When extracting any tooth except the right mand. cheek teeth, the operator stands on the right side of the patient. For the removal of right mandibular cheek teeth , the operator stands behind the patient.
Three fundamental requirement of good extraction- 1. adequate access & visualization of field of surgery
2. Unimpeded pathway for the removal of tooth 3. use of controlled force to luxate & remove the tooth.
-Mouth props: bite block, side action mouth prop
-Not usually required in awake patient
Elevator shd be grasped in fingers & forced down the PDL memb. At angle of 45 degree to the long axis of the root. Tip of index finger rests against the alveolar bone for control of instrument.
All maxillary anteriors & 2nd premolars are removed by upper universal forceps(150),
Initial movement slow steady firm in labial direction
Less vigorous palatal force used
Followed by firm rotational movement
Tooth delivered in labio-incisal direction with small amount of traction force.
Longest tooth in mouth
Root is oblong in cross section
Difficult in extraction because of long root
Often universal forceps used for extraction
Beaks should be placed more apically as possible
Initial movement is to buccal aspect with return pressure palataly
As the bone expands & tooth mobilized, reposition the forceps more apically
Small amount of rotational forces for expansion of socket
Delivered in labio incisal direction
Usually bifurcated palatal and labial root and furcated at middle of apical 3rd
Thin roots: more chances of fracture
Forceps used is upper universal (150A) forceps (upper premolar forceps)
Careful control of forceps - single root are thin and bifurcated
mild forces to luxate the tooth
more force toward buccal direction
rotation forces are avoided
buccally delivered with slight tractional forces
Single rooted teeth for entire root length
Thick root with blunt end
Forceps used is universal forceps no.150
Apical placement of beaks
Strong movement in buccal and palatal direction
With rotational and traction forces
large and strong roots
Buccal roots closes together ,palatal root diverges more palataly
Buccal cortical plate thin
Thick heavy palatal plate
Radiograph to evaluate size shape and curvature of tooth
Carefully evaluate the roots approximation to sinus
Close proximity to sinus: surgical extraction preferred.
No. 53R & 53L for all max. molars & some prefer No. 89 & No. 90, used preferrably for grossly decayed or large restorations. No. 210S forceps( universal forceps) for Max. 3rd molar.
No. 151 lower universal forceps for mand. ant. & PM. Alternative NO. 151A or English style of Ashe forceps. No. 17 for mand. molars, No. 23 cowhorn forceps for GD. Usually erupted mand. 3rd molar have fused root, No. 222 forceps- short beaked, right angled forceps are used to extract this tooth.
For extraction of primary teeth No. 150S & 151S forceps are used which are adaptation from upper & lower universal forceps respectively. Roots of primary teeth are long & delicate & subject to fracture.
Mandible stabilised soft tissue reflected, No. 151 forceps are positioned. Forceps are seated apically as far as possible to displace center of rotation & to begin expansion of crestal bone, moderate buccal force applied followed by slight lingual force, tooth delivered with rotational & tractional force.
No. 17 or 23 forceps, strong buccal then strong lingual force, tooth delivered in buccoocclusal direction with buccal & tractional forces.
Use of apexo elevator no. 302(4) & 303 (5) as wedges for removal of a lower bicuspid root fractured at gingival line. 302 mesial application on both side & 303 distal application on both side.
Technique for removal of apical 3rd root tip. B. slide the apical fragment ejector up the alveolus on the same side as the root flange. C. contact the flange & gently work the point B/W the flange & alveolus, moving flange away from tooth socket wall. D. rotate the tip of the instrument & work it b/w flange of the root tip & alveolus, gradually increasing the space b/w the root tip & the alveolus. E. slide the apical third root tip forceps up the side of the alveolus & grasp the flange. Rock the tip & withdraw.
Removal of bicuspid root or lingual molar root in proximity to antrum.
Root in situ. B & C. Williams apical pick inserted into the socket & intraradicular bone removed, if this bone is too dense to be removed round bur. D. williams apical pick reinserted, root engaged & removed with downward pressure.
E & F. if root cannot be engaged with hook, drill a pathway along the lingual surface of the root with a small round bur, insert a straight no. 1 apical fragment ejector into this space & with wedging action move the root into the center of the socket, where it can be grasped with the apical fragment forceps & removed.
To reflect the soft tissues
To protect other teeth
To stabilize patients head during extraction
While extraction of mandibular teeth, to support the jaw
To determine the alveolar bone expansion
Helps in stabilization of the clot in the socket. 2. cause dislodging of the clot from the socket.
Heat may cause vasodilatation & encourage bleeding from the socket. Also as the region may be numb, the pt. may not be able to sense the heat & it may produce burns. 4. hard food may traumatize the socket clot & cause bleeding.
Create a negative pressure in the mouth which may dislodge the clot & causes bleeding.
To maintain oral hygiene & to prevent infection. 7. repeated spitting can dislodge the clot.
Periosteal elevator: #9 molt
Full thickness
Pointy end: initiate flap, elevate papilla, severe crestal PDL, sub-periosteal dissection
Broad end: sub-periosteal dissection for much larger maxillofacial surgery flaps; not for exodontia
If flap is too narrow at d base ,blood supply may b inadequate which may lead to flap necrosis.
A- releasin incision is given with adequate bone width
B- releasin incision is given too close to bone removel-delayed healing results
Ash surgical burs( toller’s pattern) excellent can cut most dense mand. bone quickly & efficiently.
A row of small holes are made with a bur and then joined together with either bur or chisel cuts.
Maxillary tuberosity #- if attached to periosteum should take measures to ensure the survival of that bony fragment. If bony fragment can be dissected away from the tooth, & tooth removed in usual way. Tuberosity is then stabilised with mucosal sutures. If it can’t be dissected from tooth then- splint the tooth with adjacent teeth for 6 to 8 weeks. Teeth is then extracted with open technique.
Alveolar osteitis, fibrinolytic alveolitis. Diagnosis is confirmed by gently passing a probe into extraction socket, bare bone is encountered which is extremely sensitive. Suppuration –ve, foul odour +ve, severe throbbing and radiating pain, third to fifth day of extraction, if untreated last for 7 to 14 days.
Nitzin theory(1983)- bacterial enzymes cause dissolution of clot. It is possible that all these factors may play varying parts in the etiology. Bacteriologic examination- mixed infection(Alling) shows large no. of fusiform bacilli & vincent’s spirochetes.
Primarily directed towards relieve of pain- local therapy: irrigation of socket with warm sterile saline or dilute solution of H2O2 to remove necrotic material & other debris, followed by application of either obtundant(eugenol) or topical anesthetic(benzocaine) & analgesics are prescribed. Reexamine after 24 hrs. if pain stopped no need to change dressing, otherwise repeat the procedure. Curretage should never be employed. Routine use of antibiotics not recommended. Use systemic antibiotics if required not topical. Pom pom containing whitehead’s varnish can be left in situ for 2 to 3 weeks, & socket found to be granulating when removed.