Principles of Exodontia

Principles of Exodontia *This lecture will help you selecting properly patients to do extraction for.. First of all and before extraction you have to deal with: # Pain management and anxiety control, by giving the proper type of LA (you should decide for example to give LA with vasoconstrictor or without for patients with hypertension).. Basically anesthesia for extraction is different from that needed for cons or endo procedures. Endo and cons need only buccal or labial anesthesia, because our interest is anesthetizing the pulp, while extraction needs full anesthesia of surrounding tissues and supporting structures.. -In lower jaw we give ID + lingual nerve + long buccal nerve block, to anesthetize both buccally and lingually. -Sometimes for lower premolars we do mental block+ lingual infiltration. -For lower anteriors you can do infiltration but you should give both right and left because in that area there is decussation. And if he still feels pain we give him ID block. -In the upper jaw it s always infiltration for different branches of maxillary nerve labially & buccaly ( anterior superior alveolar, middle superior alveolar, posterior superior alveolar), and infiltration palatally for greater palatine basically, or nasopalatine depending on the concerned area. #Contraindications for Extractions: A- Systemic Factors: -Severe uncontrolled metabolic disease (it s an absolute contraindicated, ex: uncontrolled diabetic patient. **if it was controlled you can do extraction for him in the normal scenario). -End stage renal disease. -Uncontrolled leukemia and lymphoma (he will probably end up with complications that may reach to death). -Uncontrolled cardiac disease (ex: ischemic cardiac disease). ** you should refer them to oral surgery or to a hospital center because they need hospitalization and special care of their physician. -Bleeding problems, ex: hemophilia, Von Willebrand disease. (the Dr told us a story of a patient with hemophilia that died after tooth extraction because of uncontrolled bleeding, in this case he should be referred to the hospital, and should receive replacement for hemophilic factors to a specific level, after that extraction can be done, and after extraction there are some measures that should be done too. **dealing with such type of patients we will talk about later on.) (another story for a female patient that had extracted her tooth in a clinic without controlling her diabetes, after that she had sepsis, and after 2-3 years she attended dr.sukaina s clinic gasping, 6 of 1Page

She was immediately referred to the emergency operations, she had sepsis and facial spaces swelling, they did incision drainage and there was a huge amount of pus. She entered the ICU, and she had a problem in the heart (ischemic heart disease) with uncontrolled diabetes, after 2 days she died). -medications (ex: warfarine v.common, heparin, INR normally=1, in these patients it s 2, 3 or even 4 specially in patients that have prosthetic heart valve. ***INR (International Normalised Ratio) is the ratio between the coagulation time of a sample of blood and the normal coagulation time, when coagulation takes place in certain standardised conditions (INR=pt/ptt). also Steroids medications, ex: cortisone) you should give these patients prophylactic dose of steroids before extraction or they will end up having crisis; sudden drop of blood pressure. -Immunosuppressive agents, ex: patients receiving chemotherapy. B-Local factors: -History of radiation to cancer especially for head and neck area (radiation decreases the blood supply, so healing will be compromised). Cancer patient should be referred to dental clinic for extraction before radiation, or after stopping radiation with long time, otherwise he may get what is called Osteoradionecrosis for that area, which is a type of osteomyelitis that means he might lose his jaw bone. -Teeth in the area of tumor, if you extract a tooth in tumor area, you may cause dissemination of tumor s cells. -Pericoronitis around an impacted mandibular molar (inflammation of the operculum on partially erupted wisdom 3 rd molar) if you extract for such patient the tooth in contact with this inflammation, you may cause dissemination of infection to deep facial spaces. In this case the proper handling of it may be irrigation and cutting of the operculum (surgical excession), along with antibiotics until reaching normal healthy status, then extraction can be performed. #Clinical evaluation of teeth for removal: 1- Access to tooth (mouth opening). 2- Mobility of tooth (periodontal disease bone loss easier for extraction (try to start with these cases).) 3- Condition of the crown (large caries, large amalgam restorations refer them to 5 th year students). 4- Scaling (periotherapy) before extraction (to minimize the load of bacteria, so healing becomes better). 5- Radiographic evaluation of teeth, it s a must to take a radiograph for the tooth that needs extraction, to check the root and its configuration, and to check if there is lesion, ankylosis and condition of surrounding bone). 6 of 2Page

This is a radiograph for a very mobile tooth due to severe periodontal disease with bone loss and wide periodontal ligament space, easy to extract (straight forward). A radiograph for retained mandibular second deciduous molar E with an absent succedaneous tooth. The molar is partially submerged, and the likelihood for ankylosed roots is high. Usually seen in a 20 s patient, and usually it s hard to be extracted. (But if the retained tooth was C not E, usually it s easy to be extracted because there will be pressure on its root that causes resorption of the root, making extraction easier) A radiograph for a big crown with very large caries, this crown is susceptible to fracture once we use forceps and apply force. (Large caries (pic on the left), large amalgam restorations (pic on the right), try to avoid them at this stage). **There was a radiograph for periapical lesion, you should do percussion test for the tooth, if the pain resulted was acute don t apply extraction, give antibiotics and wait. If the lesion was chronic and there was no pain or it was a dull pain, you can go for extraction. **for wisdoms, it s better to refer them to oral surgery; they may have ankylosed roots that make them harder for extraction. A radiograph for upper 1 st premolar with root caries, it will most probably break when applying force (for you students try to bring patients that need extraction of upper 5 instead of 4, because 5 has mostly single conical root, while 4 has mostly 2 cylinder thin roots). 6 of 3Page

**After extraction you have to inspect the socket, if there is remaining root or granulation tissue you should excavate it, don t leave anything. A radiograph for upper central with dilacerated root, if you don t take a radiograph for it, you will not expect the curvature of the root, so you may break it while extraction. **Sometimes if the remaining root was a very small tip, we can leave it and give antibiotics. But if we leave a big tip without removing it, it will become a focus of infection and make other complications. (You can extract it using apexo(elevator specially designed for the apex), or using a large endo file, or surgically (ex: opening buccal window or a flap ). **There was a radiograph for an isolated tooth, and there is a great ankylosis in the root, so when trying to extract it you may fracture the bone of the jaw or the tuborosity and the tooth, and the patient may end up having many complications, it should be referred for oral surgery (isolated teeth (one tooth in a jaw) are often harder to extract, try to avoid them). For every tooth has been extracted the maxillary sinus becomes bigger and bigger, this is called pneumatization of the sinus. The sinus may reach the roots of molars and premolars, so when applying the force of extraction, you will extract the tooth with the wall of the sinus, so oroantral communication happens which is a bad problem. Or the tooth may break and root remains, so when using elevator you may push the root (that can be infected) inside the sinus and cause bad complications. (there are many cases referred to our hospital surgery in which a remaining root or an implant or even a tooth is pushed to the sinus) A radiograph showing teeth having hypercementosis with bone resorption, if you don t take a radiograph you may think that this is an easy case because of resorption, which is not easy because of hypercementosis. **it s very important not to work blindly, you always have to dry the socket very well in order to see what you are doing, and to see if there are any remaining broken tooth structures. ** you always have to respect all the vital structures around the tooth, as the dr said before, we apply support while doing extraction for many reasons; to make our work much better, to protect the soft tissue around the tooth and the palate from being injured accidentally by the elevator. Also be careful about maxillary sinus, ID nerve and canal. ** After this lecture you are supposed to be able to decide if the extraction will be closed (by using forceps) or needs surgical extraction. 6 of 4Page

A radiograph for a tooth with internal resorption, this tooth is susceptible to fracture at the resorption area which makes closed extraction almost impossible. A radiograph for endo treated teeth, these teeth are brittle and susceptible to fracture during extraction. the teeth structures would be in adherent to bone so extraction would be so hard, so most of these cases should be referred to surgery. # Chair position for forceps extraction: (very important) Dentists usually stand during extraction, and their elbow position is at the level of the patient s shoulder. Chair position: In maxillary extraction: - maxillary occlusal plane is about 60 degrees to the floor (so you adjust the chair until the angle between maxilla and the floor is about 60 degrees). Mandibular extraction: - more upright position, occlusal plane is parallel to the floor. **The support in the lower jaw is three fingers support, and your position is always anterior to the patient except for lower right posterior teeth extraction you stand posterior to the patient (for right handed, but for left handed it s for lower left extraction). The surgeon is prepared for surgery by wearing protective eyeglasses, mask, and gloves. Surgeons should have short or pinnedback hair, and should wear long-sleeved smocks that are changed daily,or sooner if they become soiled. # Mechanical priciples of extraction: -Levers principle elevators straight or curved elevators-. - Wedge principle 1- peaks of the forceps (when applied on CEJ cause bone expansion) 2- elevator during luxation.( the elevator first cause detachment of the soft tissues,then cause luxation by wedging action) -Wheel and axle principle مبدأ العتلة triangular elevator (cryer). 6 of 5Page

Notice the finger support on the elevator well supported -, the mesiobuccal* point is the best point usually to put your elevator on, the force should be resilible(?), and resistance of tooth for extraction should be as low as possible. Triangular elevator (cryer) in the role of a wheel-and-axle machine used to retrieve the root from the socket. The forceps grip is below the CEJ, all the forces distribute along the long access of the tooth. We apply dilatation for the bony socket to release the root using gentle forces. # Forceps use (steps of tooth extraction): 1. Apical pressure (center of the tooth rotation is displaced apically). 2. Buccal force (move the tooth buccally). 3. Lingual force or pressure. 4. Rotational movement, this is best applied when the tooth root is conical like the central incisors and the lower teeth. 5. Tractional force (tooth delivery). Steps of extraction:- detachment of soft tissue using elevator luxation by wedging action of elevator on mesiobuccal angle forceps grip is below CEJ buccally-lingually pressure (dilatation of bone socket) rotational movement tractional(tooth delivery). **We always move more buccally in all the teeth except in lower posterior teeth, we move more lingually because buccaly there is the buccal shelf of bone. **always give the bone time to expand when using the forceps, and avoid jerky and uncontrolled movements. The End Best Wishes 6 of 6Page