Extraction of Teeth .PPT, POWER POINT SLIDE: Indications and Complications

Extraction of Teeth: Indications and Complications

Oral and Maxillofacial Surgery Department

Historical Background

Extraction of teeth has been regarded as a formidable procedure due to the terrifying experiences associated with it historically. Even today, many patients view tooth extraction as a dreadful process, often leading to what is termed "extractionphobia." The speed of extraction is crucial to minimize patient discomfort.

Introduction

Exodontia, or tooth extraction, involves the careful consideration of several factors, including:

• Analgesia
• Asepsis
• Instrumentation
• Lighting
• Surgical assistance
• Hemostasis

Geoffrey L. Howe defined tooth extraction as:

“The painless removal of the whole tooth, or root, with minimal trauma to the investing tissues, so that the wound heals uneventfully and no post-operative prosthetic problem is created.”

Analgesia

Purpose of Analgesia

Profound local analgesia is crucial for pain control during oral surgery. Intravenous sedatives do not provide local analgesia.

Methods of Analgesia

• Most patients can be treated with local anesthetics.
• General anesthesia may be necessary for some patients.

 

Purpose of Analgesia
Total and profound local analgesia is critical in oral surgery procedures. It's important to note that intravenous sedatives do not provide local analgesia.

Methods of Analgesia
Each patient should be evaluated individually, and the method of pain control should be carefully selected. Most patients can be adequately treated with local anesthetics, whereas some may require general anesthesia.

Indications for Extraction of Teeth

1. Caries
2. Periodontal diseases
3. Tooth with necrosed pulp and periapical lesion not responding to endodontic treatment
4. Retained deciduous tooth (radiographic assessment recommended)
5. Orthodontic purposes
6. Prosthetic purposes
7. Unrestorable tooth
8. Impacted tooth
9. Supernumerary teeth
10. Grossly decayed first/second molar (to create space for third molar)
11. Tooth in the fracture line
12. Teeth directly involved by cysts or tumors
13. Teeth in the area of therapeutic irradiation
14. Teeth acting as foci of infection (e.g., bacterial endocarditis, rheumatic fever)
15. Cracked tooth
16. Financial reasons
17. Patient's choice

Contraindications to Extraction of Teeth

1. Delay may be wise until specific local or systemic conditions are corrected.
2. Acute infections of odontogenic origin are not absolute contraindications for immediate extraction, especially in the era of antibiotics.

Systemic Contraindications:

1. Acute blood dyscrasias (e.g., acute leukemia, agranulocytosis)
2. Untreated coagulopathies (both congenital and acquired)
3. Adrenal insufficiencies
4. Recent myocardial infarction (within 6 months)

Absolute Contraindications:

• Central hemangioma (may cause uncontrolled bleeding)
• A-V malformations

Relative Contraindications:

Local conditions such as:

• Acute cellulitis
• Acute necrotizing ulcerative gingivostomatitis Systemic conditions such as:
• Uncontrolled diabetes
• Hypertension
• Bleeding disorders
• Cardiovascular diseases
• Liver disorders
• Patients on long-term steroid therapy
• Teeth subjected to radiation (within 6 months to 1 year)

Preoperative Assessment

A thorough assessment should include:

1. History of general diseases
2. Nervousness and previous difficulties with extraction
3. Oral hygiene status, including any needed oral prophylaxis
4. Clinical examination of the oral cavity and any prostheses

Clinical Evaluation of Teeth for Removal

1. Access to the tooth
2. Mobility of the tooth
3. Condition of the crown
4. Presence of pain
5. Radiographic examination of the tooth for removal
6. Relationship to vital structures
7. Configuration of roots
8. Condition of surrounding bone

Technique for Extraction of Tooth

There are two main techniques used for tooth extraction:

1. Intraalveolar Technique: This technique relies on gaining sufficient grip on the tooth root by forcing the blades of the instrument into the periodontal space. Known as 'Forceps Technique' or 'Closed Method of Extraction,' it includes:

   • Forceps technique
   • Elevator technique

2. Transalveolar Technique: This technique is utilized when the roots of the tooth cannot be engaged using the forceps technique, entailing bone removal around the roots. It is also called 'Surgical Technique' or 'Open Method of Extraction.'

Rubber Band Extraction

This technique is utilized for patients with bleeding disorders.

Principles of Exodontia

To remove teeth from the alveolar process, certain mechanical principles and simple machines are employed:

• The lever
• Wedge
• Wheel and axle

Application of Principles

• Elevators primarily serve as levers, translating modest forces into movements against significant resistance.
• Wedge principle: Useful in various contexts including the expansion of the bone and forcing the tooth out of the socket.
• Wheel and axle principle: Used with triangular elevators, facilitating the elevation of tooth roots.

Movements During Extraction

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

1. Apical force
2. Buccal force
3. Lingual force
4. Rotational force
5. Tractional force

The objective of forceps usage is to achieve:

1. Expansion of the bony socket
2. Removal of the tooth from the socket.

General Rules of Forceps Use

1. Correct forceps selection for specific teeth.
2. Grasp forceps with the palm as far from the beak as possible.
3. Keep the long axis of the forceps beak parallel to the tooth.
4. Ensure minimal injury to adjacent teeth and structures.
5. Position the forceps as apically as feasible.

Elevators

Classification by Use:

1. Designed to remove entire teeth
2. Designed for roots broken off at the gingival line
3. Designed for roots broken halfway to baseline
4. Designed for roots at the apical third
5. Designed to reflect the mucoperiosteum

Classification by Form:

1. Straight elevators
2. Angular elevators
3. Cross-bar elevators (handle at right angle to the shank)

Indications for Use of Elevators

1. Luxate and remove teeth not reachable by forceps
2. Reflect mucoperiosteal membranes
3. Extract fractured or carious roots
4. Loosen teeth before forceps usage
5. Remove intraradicular bone

Precautions

• Avoid using adjacent teeth as fulcrum.
• Employ a finger guard to protect the patient.
• Apply controlled force to prevent fractures.

General Arrangement

1. Position of the Operator: Maintain an erect stance with evenly distributed weight.
2. Position of the Patient: Ensure comfort on the dental chair.
3. Height of Dental Chair:
   • Maxillary teeth: 8 cm below operator’s shoulder level
   • Mandibular teeth: 16 cm below operator’s elbow
4. Angulation of Chair:
   • Maxillary teeth: 45-60 degrees
   • Mandibular teeth: parallel or 10 degrees
5. Lighting: Ensure adequate illumination.

Role of Opposite Hand

1. Reflection of soft tissue
2. Protection of other teeth
3. Stabilization of the patient's head
4. Support of the mandible
5. Tactile information

Order of Extraction of Teeth

When multiple extractions occur, follow these rules:

• Extract maxillary teeth before mandibular.
• Extract posterior teeth before anterior.
• First molars and canines should be extracted after adjacent teeth to preserve bony stability.

Sequence of Extraction

1. Third molar
2. Second molar
3. Second premolar
4. First molar
5. First premolar
6. Lateral incisor
7. Canine
8. Central incisor

Procedure for Closed Extraction

Forceps Technique

1. Beaks should be seated as far apically as possible.
2. Maintain axial alignment of beaks to the long axis of the tooth.
3. Avoid excess force.

Displacement of Tooth from Socket

1. Apply pressure by moving the trunk from the hip, not the elbow.
2. Movements include:
   • Buccopalatal
   • Linguobuccal and buccolingual
   • Rotational force
3. Considerations for maxillary and mandibular bones differ.

Post-extraction Tooth Socket Care

1. Inspect and irrigate the socket.
2. Remove debris/tooth fragments.
3. Squeeze the socket.
4. Suture if needed.
5. Trim any sharp edges on the alveolar bone.
6. Clean the patient's lips and face.
7. Provide medication and post-extraction instructions, both verbal and written.

Postoperative Instructions

1. Bite on gauze for 10-15 minutes post-extraction.
2. Avoid mouthwash for at least 24 hours.
3. Steer clear of hot food or drink for the day.
4. Maintain a diet of cold fluids or soft food.
5. Rest and avoid strenuous activities.

Trans-Alveolar Extraction (Open Method)

Indications

1. When intra-alveolar attempts fail.
2. Retained roots in close proximity to the maxillary sinus.
3. History of difficult extractions.
4. Heavily restored tooth.
5. Geminated/dilacerated tooth.

Components

1. Design of mucoperiosteal flap.
2. Method for tooth/root extraction.
3. Bone removal technique.

Technological Advancements in Extraction Techniques

1. Powered periotome
2. Piezosurgery
3. Lasers
4. Coronectomy
5. Orthodontic extraction
6. Physics forceps

Powered Periotome

• Ensures precise tooth extraction while preserving bone and gingival architecture.

Piezosurgery

• Innovative technique that uses ultrasonic frequency, facilitating clean and precise cuts. It allows for surgical control without damaging nearby soft tissues.

Lasers for Extraction of Impacted Teeth

• The covering bone is first ablated layer by layer, creating minimal bone loss and improving outcomes, such as decreased postoperative pain and limited scarring.

Orthodontic Extraction

• Involves orthodontic traction over time but risks soft tissue damage due to impingement.

Physics Forceps

• Utilize first-class lever mechanics to achieve atraumatic tooth extraction.

Complications of Exodontia

Operative Complications

1. Tooth fracture
2. Injury to adjacent teeth
3. Wrong tooth extraction
4. Fracture of bony structures
5. Perforation of the maxillary antrum
6. Soft tissue laceration
7. Injury to nerve bundles
8. Hemorrhage
9. Subcutaneous emphysema
10. Thermal injury to tissues

Post-operative Complications

1. Hemorrhage
2. Pain
3. Ecchymosis and hematoma
4. Edema and swelling
5. Alveolar osteitis
6. Post-operative infections

Management of Unerupted and Impacted Teeth

The most commonly impacted teeth include:

• Third molars
• Maxillary canines
• Premolars

Management Steps

1. Conduct thorough clinical and radiological assessments to localize the tooth.
2. For maxillary canines:
   • Manage buccal impactions with a buccal flap.
   • Palatal impactions with a palatal flap.
3. Ensure proper flap design and bone removal technique.

Maxillary and Mandibular Canines and Premolars

• Follow specific access methods based on the orientation of the tooth and its surrounding anatomy.

Supernumerary Teeth

• These teeth may require approaches similar to the primary tooth they obstruct.

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