MINISTRY OF HEALTH OF UKRAINE Higher medical educational institution of Ukraine "Ukrainian medical stomatological academy"

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1 MINISTRY OF HEALTH OF UKRAINE Higher medical educational institution of Ukraine "Ukrainian medical stomatological academy" Approved On the meeting chair Of Pediatric Surgical Stomatology and Propaedeutics Surgical Stomatology The Head of the Department prof. Ткаchеnко P.I. 20 Educational discipline Module 1 Content module 2 Theme lesson GUIDELINES Individual work of students During preparation for Practical classes Course 3 Faculty Stomatological Surgical stomatology Propaedeutics Surgical Stomatology Tools and techniques removal of teeth and root Tool for the extraction of teeth and roots on the upper jaw. Method of typical extraction of teeth and roots on the upper jaw. Poltava 2016

2 1. Actuality of the topic: This theme presents the principles of surgery and mechanics for uncomplicated tooth extraction on the upper jaw. In addition to a discussion of the fundamental underlying principles, there is also a detailed description of techniques for removal of specific teeth with specific instruments. 2. The objectives of the studies: To know features of a structure top upper jaw and teeth, to acquire indications and contraindications to operation of an uncompleted exodontia. To be able to establish indications to operation of exodontia and contraindication to its carrying out. To be able to carry out inspection, preparation of the patient, processing of a surgery field and processing of arms of the surgeon. Correctly to carry out all stages of operation of an exodontia. 3. Basic knowledge, skills, skills necessary for study topics (interdisciplinary integration). Name of previous courses These skills Human anatomy, histology, physiology The pharmacology The propedeutics of internal illnesses General surgery The therapeutic odontology, children's surgical odontology, orthopedic odontology Surgical odontology. Precisely to be guided in a structure upper jaw. Truly to choose preparations for various kinds of a local anesthesia To carry out injections To find out indications to operation of an exodontia To establish indications to operation of an exodontia 4. Tasks for independent work in preparation for the classes A list of key terms, parameters, characteristics that must learn the student in preparation for the lesson: Term Nib S-shape Zygomatic-alveolar crest Bayonet-shaped forceps protrusion on the cheeks forceps sigmate curve handle forceps bone formation of the upper jaw special curve forceps handles Definition 4.2. Theoretical questions to lesson: 1. Signs of forceps to extraction of maxillary tooth. 2. Signs of elevators to extraction of maxillary tooth. 3. Singularity of extraction Maxillary incisor teeth. 4. Singularity of extraction Maxillary canine. 5. Singularity of extraction Maxillary first premolar. 6. Singularity of extraction Maxillary second premolar. 7. Singularity of extraction Maxillary molar. 8. Singularity of extraction Maxillary third molar Practical works (tasks) are performed in class: To lead clinical inspection. To determine the preliminary diagnosis. To determine a necessary anesthesia for carrying out of extraction upper tooth.

3 To be able to choose instruments for extraction upper tooth. To be able to choose anesthesia for extraction upper tooth. To be able to remove a tooth on the phantom. 5. Theme contents: Maxillary Forceps The removal of maxillary teeth requires the use of instruments designed for single-rooted teeth and for teeth with three roots. The maxillary incisors, canine teeth, and premolar teeth are all considered to be single-rooted teeth. The maxillary first premolar frequently has a bifurcated root, but because this occurs in the apical one third, it has no influence on the design of the forceps. The maxillary molars are usually trifurcated and therefore require extraction forceps, which will adapt to that configuration. The single-rooted maxillary teeth are usually removed with maxillary universal forceps, usually (Fig. 1). The maxillary universal forceps are slightly curved when viewed from the side and are essentially straight when viewed from above. The beaks of the forceps curve to meet only at the tip. The slight curve of the maxillary universal forceps allows the operator to reach not only the incisors, but also the bicuspids in a comfortable fashion. The beak of the maxillary universal forceps has been modified slightly to form the S-shaped forceps (Fig. 2). The S-shaped forceps is useful for the maxillary premolar teeth and should not be used for the incisors, because their adaptation to the roots of the incisors is poor. Fig. 1. Maxillary universal forceps Fig. 2. S-shaped forceps In addition to the, straight forceps are also available. The straight forceps (Fig. 3), which can be used for maxillary incisors and canines, are slightly easier to use than the maxillary universal forceps for incisors. The maxillary molar teeth are three-rooted teeth with a single palatal root and a buccal bifurcation. Therefore forceps that are adapted to fit the maxillary molars must have a smooth, concave surface for the palatal root and a beak with a pointed design that will fit into the buccal

4 bifurcation on the buccal beak. This requires that the molar forceps come in pairs: a left and a right. Additionally, the molar forceps should be offset so that the operator can reach the posterior aspect of the mouth and remain in the correct position. The most commonly used S-shaped forceps right and left (Fig. 4) or molar forceps (bayonet-shaped forceps) are the right and left (Fig. 5,6). These forceps are designed to fit anatomically around the palatal beak, and the pointed buccal beak fits into the buccal bifurcation. The beak is offset to allow for good positioning. Fig. 3. The straight forceps Fig. 4. S-shaped forceps right and left Fig. 5. Bayonet-shaped forceps right and left Fig. 6. Bayonet-shaped forceps right and left A design variation is the right and left forceps, which have a longer, more accentuated, pointed beak formation. These forceps are known as upper cowhorn forceps. They are particularly useful for maxillary molars whose crowns are severely decayed. The sharply pointed beaks may reach deeper into the trifurcation to sound dentin. The major disadvantage is that they crush alveolar bone, and when used on intact teeth without due caution, fracture of large amounts of buccal alveolar bone may occur. On occasion, maxillary second molars and erupted third molars have a single conically shaped root. In this situation, forceps with broad, smooth beaks that are offset from the handie can be useful. The bayonet-shaped forceps exemplify this design (Fig. 7). Another design variation is shown in the offset molar forceps with very narrow beaks. These are used primarily to remove broken maxillary molar roots but can be used for removal of narrow premolars and for lower incisors. These forceps, are also known as bayonet-shaped root tip forceps (Fig. 8).

5 A smaller version of the forceps, is useful for removing primary teeth. These adapt well to all maxillary primary teeth and can be used as universal primary tooth forceps. Fig. 7. Crown bayonet-shaped forceps Fig. 8. Root bayonet-shaped forceps In the correct position for extraction of maxillary left or anterior teeth, the left index finger of the surgeon should reflect the lip and cheek tissue; the thumb should rest on the palatal alveolar process. In this way the left hand is able to reflect the soft tissue of the cheek, stabilize the patient's head, support the alveolar process, and provide tactile information to the surgeon regarding the progress of the extraction. When such a position is used during the extraction of a maxillary molar, the surgeon can frequently feel with the left hand the palatal root of the molar becoming free in the alveolar process before realizing it with the forceps or extracting hand. For the right side, the index finger is positioned on the palate and the thumb on the buccal aspect. Maxillary incisor teeth. The maxillary incisor teeth are extracted with the direct forceps with divergent beaks (or upper universal forceps), although other forceps can be used. The maxillary incisors generally have conic roots, with the lateral ones being slightly longer and more slender. The lateral incisor is more likely also to have a distal curvature on the apical one third of the root, so this must be checked radio-graphically before the tooth is extracted. The alveolar bone is thin on the labial side and heavier on the palatal side, which indicates that the major expansion of the alveolar process will be in the buccal direction. The initial movement is slow, steady, and firm in the labial direction, which expands the crestal buccal bone. A less vigorous palatal force is then used, followed by a slow, firm, rotational force. Rotational movement should be minimized for the lateral incisor, especially if a curvature exists on the tooth. The tooth is delivered in the labial-incisal direction with a small amount of tractional force. Anaesthesia: a buccal injection and a palatal injection is usually not enough. In addition, few drops of the anaesthetic solution should be injected on the buccal side of die opposite central incisor, or infraorbital, incisival and terminal from opposite central incisor. Maxillary canine. The maxillary canine is usually the longest tooth in the mouth. The root is oblong in cross section and usually produces a bulge called the canine eminence on the anterior surface of the maxilla. The result is that the bone over the labial aspect of the maxillary canine is usually quite thin. In spite of the thin labial bone, this tooth can be difficult to extract simply because of its long root. Additionally, it is not uncommon for a segment of labial alveolar bone to fracture from the labial plate and be removed with the tooth. The direct forceps with divergent beaks (or upper universal forceps) is the preferred instrument for removing the maxillary canine. As with all extractions, the initial placement of the beaks of the forceps on the canine tooth should be as far apically as possible. The initial movement is to the buccal aspect, with return pressure to the palatal. As the bone is expanded and the tooth mobilized, the forceps should be repositioned apically. A small amount of rotational force may be useful in expanding the tooth socket, especially if the adjacent teeth are missing or have just been extracted. After the tooth has been well luxated, it is delivered from the socket in a labial-incisal direction with labial tractional forces. If, during the luxation process with the forceps, the surgeon feels a portion of the labial

6 bone fracture, a decision must be made concerning the next step. If the palpating finger indicates that a relatively small amount of bone has fractured free and is attached to the canine tooth, the extraction should continue in the usual manner, with caution taken not to tear the soft tissue. However, if the palpating finger indicates that a relatively large portion of labial alveolar plate has fractured, the surgeon should stop the surgical procedure. Usually the fractured portion of bone is attached to periosteum and therefore is viable. The surgeon should use a thin periosteal elevator to raise a small amount of mucosa from around the tooth, down to the level of the fractured bone. The canine tooth should then be stabilized with the extraction forceps, and the surgeon should attempt to free the fractured bone from the tooth, with the periosteal elevator as a lever to separate the bone from the tooth root. If this can be accomplished, the tooth can be removed and the bone left in place attached to the periosteum. Normal healing should occur. If the bone becomes detached from the periosteum during these attempts, it should be removed, because it is probably nonvital and may actually prolong wound healing. This procedure can be used whenever alveolar bone is fractured during extraction. Prevention of fractured labial plate is important. If during the luxation process with the forceps a normal amount of pressure has not resulted in any movement of the tooth, the surgeon should seriously consider doing an open extraction. By reflecting a soft tissue flap and removing a small amount of bone, the surgeon may be able to remove the stubborn canine tooth without fracturing a larger amount of labial bone. By using the open technique, there will be an overall reduction in bone loss and in postoperative healing time. Anaesthesia: a buccal injection and a palatal injection plus incisival, or infraorbital, incisival and palatal. Maxillary first premolar. The maxillary first premolar is a single-rooted tooth in its first two thirds, with a bifurcation into a buccolingual root usually occurring in the apical one third to one half. These roots may be extremely thin and are subject to fracture, especially in older patients in whom bone density is great and bone elasticity is small. Perhaps the most common root fracture when extracting teeth in adults occurs with this tooth. As with other maxillary teeth, the buccal bone is relatively thin compared with the palatal bone. The s-shaped forceps with divergent beaks (or upper universal forceps) is the instrument of choice. Because of the high likelihood of root fracture, the tooth should be luxated as much as possible with the straight elevator. If root fracture does occur, a mobile root tip can be removed more easily than one that has hot been well luxated. Because of the bifurcation of the tooth into two relatively thin root tips, extraction forces should be carefully controlled during removal of the maxillary first premolar. Initial movements should be buccal. Palatal movements are made with relatively small amounts of force to prevent fracture of the palatal root tip, which is harder to retrieve. When the tooth is luxated buccally, the most likely tooth root to break is the labial. When the tooth is luxated in the palatal direction, the most likely root to break is the palatal root. Of the two root tips, the labial is easier to retrieve because of the thin, overlying bone. Therefore buccal pressures should be greater than palatal pressures. Any rotational force should be avoided. Final delivery of the tooth from the tooth socket is with fractional force in the occlusal direction and slightly buccal. Anaesthesia: A buccal injection and a palatal injection here will be enough, or infraorbital and palatal. Maxillary second premolar. The maxillary second premolar is a single-rooted tooth for the root's entire length. The root is thick and has a blunt end. Consequently, the root of the second premolar fractures only rarely. The overlying alveolar bone is similar to that of other maxillary teeth in that it is relatively thin toward the bucca, with a heavy palatal alveolar palate. The recommended forceps is the s-shaped forceps with divergent beaks (or upper universal forceps). The forceps is forced as far apically as possible so as to gain maximal mechanical advantage in removing this tooth. Because the tooth root is relatively strong and

7 blunt, the extraction requires relatively strong movements to the bucca, back to the palate, and then in the buccoocclusal direction with a rotational, tractional force. Anaesthesia: Same as the Maxillary first premolar, sometimes plus tuberal. Maxillary molar. The maxillary first molar has three large and relatively strong roots. The buccal roots are usually relatively close together, and the palatal root diverges widely toward the palate. If the two buccal roots are also widely divergent, it becomes difficult to remove this tooth by closed, or forceps, extraction. Once again the overlying alveolar bone is similar to that of other teeth in the maxilla; the buccal plate is thin and the palatal cortical plate is thick and heavy. When evaluating this tooth radio-graphically, the dentist should note the size, curvature, and apparent divergence of the three roots. Additionally the dentist should look carefully at the relationship of the tooth roots to the maxillary sinus. If the sinus is in close proximity to the roots and the roots are widely divergent, sinus perforation caused by removal of a portion of the sinus floor during tooth removal is increasingly likely. If this appears to be likely after preoperative evaluation, the surgeon should strongly consider a surgical extraction. The paired forceps S-shaped forceps right and left or bayonet-shaped forceps right and left are usually used for extraction of the maxillary molars. These two forceps have tip projections on the buccal beaks to fit into the buccal bifurcation. Some surgeons prefer to use the forceps, which are sometimes called the upper cowhorn forceps. These two forceps are especially useful if the crown of the molar tooth has large caries or large restorations. The upper molar forceps is adapted to the tooth and apically seated as far as possible in the usual fashion. The basic extraction movement is to use strong buccal and palatal pressures, with stronger forces toward the buccal than toward the palate. Rotational forces are not useful for extraction of this tooth because of its three roots. As mentioned in the discussion of the extraction of the maxillary first premolar, it is preferable to fracture a buccal root than a palatal root (because it is easier to retrieve the buccal roots). Therefore if the tooth has widely divergent roots and the dentist suspects that one root may be fractured, the tooth should be luxated in such a way as to prevent fracturing the palatal root. The dentist must minimize palatal force, because this is the force that fractures the palatal root. Strong, slow, steady, buccal pressure expands the buccocortical plate and tears the periodontal ligament fibers that hold the palatal root in its position. Palatal forces should be used but kept to a minimum. Anaesthesia: A buccal injection in a point between the two buccal roots and a palatal injection gives satisfactory anaesthesia. Sometimes with the first molar, especially when the two buccal roots are widely divergent, one buccal injection at the point between the two roots may not be enough because of the different nerve supply to each of them. In this condition it is advised to give two buccal injections one at point opposite the mesiobuccal root and the other at a point opposite the disto-buccal root; tuberal plus palatal. The maxillary second molar's anatomy is similar to that of the maxillary first molar except that the roots tend to be shorter and less divergent, with the buccal roots more commonly fused into a single root. This means that the tooth is more easily extracted by the same technique described for the first molar. The erupted maxillary third molar frequently has conic roots and is usually extracted with the crown bayonet-shaped forceps, which is universal forceps used for both the left and right sides. The tooth is usually easily removed, because the buccal bone is thin and the roots are usually fused and conical. The erupted third molar is also frequently extracted by the use of elevators alone. It is important to clearly visualize the maxillary third molar on the preoperative radiograph, because the root anatomy of this tooth is quite variable and often small, dilacerated, hooked roots exist in this area. Retrieval of fractured roots in this area can be very difficult. Anaesthesia: Same as the Maxillary first molar. Maxillary third molar: The buccal injection should be at a point opposite the mesiobuccal root rather than the distobuccal root or between the two roots. This is done to avoid slipping of the needle on the posterior wall of the maxillary tuberosity with subsequent traumatic injury to the pterygoid plexus of veins (this leads to profuse bleeding and the development of hematoma)

8 or injection of the anaesthetic solution in a vein from the same plexus which causes toxicity. The palatal injection should be at a point opposite the palatal root of the maxillary second molar and midway between the cervical margin of this tooth and the middle palatal line. This is done to avoid anaesthesia of the lesser palatine nerves which are supplying the soft palate with its subsequent feeling of nausea and vomiting to die patient. Using of elevators The straight or gouge type elevator is the most commonly used elevator to luxate teeth. The blade of the straight elevator has a concave surface on one side so that it can be used in the same fashion as a shoehorn. The small straight elevator is frequently used for beginning the luxation of an erupted tooth, before application of the forceps. The larger straight elevator is used to displace roots from their sockets and is also used to luxate teeth that are more widely spaced. The shape of the blade of the straight elevator can be angled from the shank, allowing this instrument to be used in the more posterior aspects of the mouth. 6. Materials for self control: А. Assignments for self control (tables, charts, drawings, graphs). B. Self-control tests: 1. Choose forceps for extraction Maxillary incisor teeth: A. Maxillary universal forceps. B. S-shaped forceps. C. Direct forceps. D. Bayonet-shaped root tip forceps. E. S-shaped forceps right and left. 2. Choose forceps for extraction Maxillary canine: A. Maxillary universal forceps. B. S-shaped forceps. C. Direct forceps. D. Bayonet-shaped root tip forceps. E. S-shaped forceps right and left. 3. Choose forceps for extraction Maxillary first and second premolar: A. Maxillary universal forceps. B. Direct forceps. C. S-shaped forceps. D. S-shaped forceps right and left. E. Bayonet-shaped root tip forceps. 4. Choose forceps for extraction third Maxillary molar: A. Maxillary universal forceps. B. Bayonet-shaped forceps. C. S-shaped forceps. D. S-shaped forceps right and left, maxillary universal forceps. E. Bayonet-shaped root tip forceps. 5. The straight elevator using for: A. Extraction of upper roots. B. Extraction of third Maxillary molar C. Extraction of third mandibulary molar D. All answers are right. C. Tasks for self-control: THE TASK 1. In a surgical study of a stomatologic polyclinic the patient concerning partial defect of a crown 17 teeth, the acute pains intensifyed at bit has addressed. After survey of the patient the doctor ascertained necessity of extraction of a 17 teeth.

9 Questions 1. Amount of roots in 17, 27 teeth and features of their anatomic structure. 2. Features of an anatomic structure of an alveolar process of a maxilla in the field of 17, 27. THE TASK 2. Patient А., 28 years, has addressed concerning periodic whining pains in the field of 16 teeth. From an anamnesis it became known, that 16 tooth repeatedly was sick, but the patient to the doctor did not address. Objectively: the crown 16 teeth decayed completely. The mucosa of an alveolar process in the field of 16 teeth is not changed. The next teeth intact. The diagnosis: a chronic periodontitis 16 teeth. Extraction of a tooth 16 teeth is shown. Question. 1. What instrument necessary use for extraction of 16 teeth? 2. Technique of extraction of 16 teeth. 3. What instrument necessary use for extraction roots of 16 teeth? 7. Bibliography: Basic: 1. Contemporary Oral and Maxillofacial Surgery//Larry J. Peterson, Edvard Ellis III, James R.Hupp, Myron Tucker/ 2003, MOSBY, 776 p. 2. V.I. Mytchenok, A.I.Pan kevych Propedeutics of surgical stomatology / Vinnycya New book, Additional Sources: S.S.Mihajlov. "Human anatomy". Moscow., Berman SA: Basic principles of dentoalveolar surgery. In Peterson LJ, editor: Principles of oral and maxillofacial surgery Philadelphia, 1992, JB Lippincott. Byrd DL: Exodontia: modern concepts, Dent Clin North Am 15:273, Methodical Instruction is composed by docent Pan kevych A.I.