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EXODONTIA

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 wound heals uneventfully and no post operative prosthetic
problem is created.

INDICATIONS
When conservative treatment is failed :
Dental caries
Pulpal necrosis
Periapical infection
Severe Periodontal disease
Erosion
Attrition
Abrasion
Hypoplasia

INDICATIONS
Trauma to tooth or jaw

Fracture of root or crown


dislocated from socket
Tooth in the line of jaw fracture

Orthodontic treatment
Prosthetic treatment plan

Indications
Impacted teeth
Supernumerary teeth
Teeth associated with pathologic lesions
Pre radiation therapy
Esthetics
Economics

Contraindications
Two groups
1. Systemic
2. Local

Contraindications
Systemic contraindications
Endocrine disorders
Uncontrolled diabetes mellitus
Adrenal insufficiency
Hypothyroidism
Hyperthyroidism

Contraindications
Cardiac diseases
Ischemic heart disease
Angina pectoris
myocardial infarction
coronary artery bypass grafting
coronary angioplasty
Cerebrovascular accident (stroke)
Dysrhythmias
Heart abnormalities predisposed toward infective endocarditis
Congestive heart failure

Contraindications
Patients on anticoagulant therapy
Patients on corticosteroids
Patient on chemotherapy or Immuno suppressives

Contraindications
Pregnancy
Bleeding and clotting disorders
Severe renal or liver disease

Contraindications
Local contraindications
Acute infection
Teeth in the region of Irradiated jaw
Teeth with in the region of malignant tumour

Fundamental requirement for good extraction

Adequate access & visualization of the field of


surgery

Unimpeded pathway for removal of the tooth

Use of controlled force to luxate & remove the


tooth

METHODS OF EXTRACTION

Methods of extraction
1. Forceps extraction or
Intra alveolar extraction
2. Surgical method or
Trans alveolar extraction
Fundamental requirement for good extraction
Adequate access & visualization of the field of surgery
Unimpeded pathway for removal of the tooth
Use of controlled force to luxate & remove the tooth

Forceps extraction
Five general steps make up the Closed technique -

1.

Loosening of soft tissue attachment from the tooth

2.

Luxation of tooth with a dental elevator

3.

Adaptation of forceps to the tooth

4.

Luxation of the tooth with the forceps

5.

Removal of the tooth from the socket

Surgical extraction

Preoperative Assessment

Evaluation of level of anxiety

Determination of health status

Previous difficulty with extractions and Methods used for


removal of tooth

Clinical presentation of the tooth to be removed


Radiographic evaluation

Clinical evaluation of teeth for removal


Access to tooth

Mobility of tooth

Condition of crown

Clinical evaluation of teeth for removal


Access to tooth
1.mouth opening
Causes for Trismus infection , TMJ dysfunction & muscle
function
2. Location and position of the tooth to be extracted within a
dental arch should be examined.
Alignment of tooth- malposed or crowded teeth
Normal access to positioning of forceps or elevator

Clinical evaluation of teeth for removal


Mobility of tooth
Mobile tooth periodontally involved tooth
uncomplicated extraction

Less than normal mobility ankylosis or hypercementosis


surgical removal of tooth

Clinical evaluation of teeth for removal


Condition of crown

Grossly decayed or large restorations in the crown

Large accumulation of calculus interferes with placement of


forceps and fractured part in the socket delays healing

condition of adjacent tooth chances of # of restoration or


crown

Preoperative Assessment
Indications for pre operative radiograph
H/o attempted or difficult extraction

Tooth which is abnormally resistance to forceps


extraction

Wisdom tooth

Radiographic examination of tooth


Relationship with vital structures
Maxillary molars maxillary sinus
Mandibular 3rd molar inferior alveolar nerve
Mandibuar premolar - mental nerve

Radiographic examination of tooth


Configuration of roots
Number of roots
Curvature of roots and degree of divergence
Shape of individual roots

Long roots with severe and abrupt curves

hooks at apical 1/3rd

Long bulbous root

Clinical evaluation of teeth for removal


Configuration of root - no of roots

Clinical evaluation of teeth for removal


Configuration of root - no of roots

Clinical evaluation of teeth for removal


Configuration of root - hypercementosis

Radiographic examination of tooth


Root caries
Endodontically treated tooth
Root resorption internal or external

Clinical evaluation of teeth for removal


Pulpless tooth with unfavourable root pattern

Radiographic examination of tooth


Periapical radiolucencies periapical granuloma/cyst
socket curettage

Radiographic examination of tooth


Relationship with vital structures
Maxillary molars maxillary sinus
Mandibular 3rd molar inferior alveolar nerve
Mandibuar premolar - mental nerve

Clinical evaluation of teeth for removal


Relationship with vital structures Max sinus

Clinical evaluation of teeth for removal


Relationship with vital structures Max sinus

Clinical evaluation of teeth for removal


Relationship with vital structures I nf alv nerve

Clinical evaluation of teeth for removal


Heavily restored tooth

Clinical evaluation of teeth for removal


Undisplaced mandibular fracture

Clinical evaluation of teeth for removal


Root fracture

Clinical evaluation of teeth for removal


Gemination between unerupted 3rd molar and 2nd molar

Clinical evaluation of teeth for removal


Gemination

Clinical evaluation of teeth for removal


Impacted 3rd molar

Clinical evaluation of teeth for removal


Hypercementosis

Clinical evaluation of teeth for removal


Hypercementosis

Clinical evaluation of teeth for removal


Periapical lesion

Clinical evaluation of teeth for removal


Condition of surrounding bone
Increased density ( condensing osteomyelitis or sclerosis like
processes )

Mechanical principles of extraction

1.Expansion of the socket


2.The use of lever and fulcrum
3.The insertion of a wedge

Chair Position
Maxillary extraction
Mandibular extraction

Height of chain

operators position

Surgical removal of tooth


Indications

Any tooth which resists attempts at intra alveolar extraction when


moderate force is applied

Retained roots which can not be either grasped with forceps or delivered
with an elevator , especially those in relationship to the maxillary antrum

A history of difficult or attempted extraction

Surgical removal of tooth


Indications

Any heavily restored tooth, especially when root filled or pulpless

Hypercementosed and ankylosed teeth

Geminated and dilacerated teeth

Teeth shown radiographically to have complicated root patterns,


or roots with unfavourable or conflicting lines of withdrawal

Surgical removal of tooth


Diagnosis and treatment planning
Careful history taking and clinical examination supplemented by
special methods of examination when indicated enable

potential difficulties

possible complications

correct choice of extraction technique

Surgical removal of tooth


Steps of trans alveolar flaps

Muco periosteal flaps:


Bone removal
Tooth division
Socket toilet

Surgical removal of tooth


Steps of trans alveolar flaps
Muco periosteal flaps:
Flaps are raised to render the operative site clearly visible and
accessible and their design should ensure that they provide adequate
visual and mechanical access.
Incision firm pressure through both the mucous and periosteal layer
Reflection periosteal elevation

Bone removal
Use of dental bur or
Chisel and mallet

Tooth division
Line of withdrawl in multirooted tooth

Socket toilet