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  2. 2. EXODONTIAPrinciples, techniques & complications
  3. 3. INTRODUCTIONScience the earliest period of history of the extraction of thetooth has been considered a very formidable procedure by thelayman, & it is because of the horrifying experiencesassociated with the tooth extraction in the past that eventoday the removal of a tooth is dreaded by a patient almostmore than any other surgical procedure.Many patients suffer from extractionfobia & are often difficult tocare for, despite modern methods of anesthesia.Many dentists still believe that speed is essential whenextracting the teeth.
  4. 4. DEFINITION• The ideal tooth extraction is –The painless removal of the whole tooth, orroot, with minimal trauma to the investing tissues, so thatthe wound heals uneventfully & no post-operativeprosthetic problem is created.(Geoffray L Howe)
  5. 5.  The 1st dentist was an EGYPTIAN– HESI RE (3100-2181BC)The history of dental extraction forceps is very old andgoes back to the time of Aristotle (384 to 322 BC)where Aristotle described the mechanics of oral surgeryforceps .This was over 100 years beforeArchimedesstudied and discussed the principles of the lever.
  6. 6. Dental history arabic dentist cauterizingdental pulpThe Martyrdom of St. Apollonia, shows thetorturous extraction of teethCuring aToothache with FireThefumes from henbane seedsGermanTraveling Dentist
  7. 7. Traveling Dentist in a DutchVillageThe Italian "Oral Surgeon"That EffortlesslyRemoves Jawbones
  8. 8.  until the 16th century, dedicated dentists did not exist anddentistry was practiced by general physicians and barbers. A number of tools were invented for performing this procedure.Dental Pelican, which was invented in the 14th century by Guy deChauliac and used until the late 18th century.
  9. 9. The instrument is a combination of theattributes of the an extracting forceps and atoothkey 1843 to 1863In the 20th century, the key was replaced bythe forceps, which are still in use today
  10. 10. 1. Allen 1994 – caries in 48.8% cases – abscess2. Periodontal diseases – in 40.7% cases – to prevent alveolar ridgeresorption3. Tooth with necrosed pulp & periapical lesion – not responding toendodontic treatment4. Over retained deciduous tooth – but take radiograph first5. Orthodontic purpose6. Prosthetic purpose7. Unrestorable tooth8. Impacted tooth9. Supernumerary tooth10. Grossly decayed 1M / 2M – make room for 3rd molarHOTZ & SMITH11. Tooth in fracture line12. Teeth directly involved by cyst & tumor
  11. 11. 13. Teeth in the area of therapeutic irradiation14. Teeth acting as foci of infection –ex. – bacterial endocarditis- rheumatic feverRICHARDS (1932) – bacteremia after infected tooth extractionOKELL & ELLIOTT (1935) – STREPTOCOCCUS VIRIDANS inblood stream (75% of 40 patient)Use of local anesthetic solution (vasoconstrictor) - rate of spread ofinfection
  12. 12.  It may be judicious to delay the extraction until certainlocal or systemic condition corrected or modified. In the era of antibiotics acute infection of odontogenicorigin are not considered as absolute contraindication ofimmediate extraction. NUG / HERPETIC GINGIVOSTOMATITIS – spread ofinfection & greater degree of systemic reaction. Previously irradiated area (within 1 year) – less trauma +pre & post-op antibiotic prophylaxis
  13. 13. Other relative systemic contraindications – Acute blood dyscrasias – acute leukemia , agranulocytosis, Untreated coagulopathies – congenital or acquired Adrenal insufficiencies Within 6 months of myocardial infarction
  14. 14. A. Absolute : Central Haemangioma. May cause uncontrolled bleeding.A-V malformation.B. Relative :When some precautions have to be taken.1. Local Acute cellulitis.ANUG.2. Systemic Uncontrolled Diabetes Mellitus,Hypertension.Bleeding disorders.Cardiovascular diseases.Liver disorders.Patients on long-term steroid therapy.Teeth that have undergone radiation [6 months – 1 yr ].
  15. 15. Expansion of bony socketspecially for forcep extractionsufficient tooth structureelastic bone (children)multiple small fractures of buccal cortical bone1. Use of a lever & fulcrumremove the tooth/root along the path of least resistancebasic factor governing the use of elevators
  16. 16. 2. The insertion of wedge orwedges between tooth-root& bony socket wall
  17. 17. 3. Wheel & axle principle
  18. 18.  Take history of –1. general disease2. nervousness3. resistance to inhalational anesthesia4. previous difficulty with extraction Oral hygiene status of the patientoral prophylaxisantiseptic mouth rinse Clinical examination of the tooth Clinical examination of the oral cavity- any prosthesis
  19. 19.  PREOPERATIVE RADIOGRAPHS –Indicationsi. H/O difficult & attempted extractionsii. Resistance to forcep extractioniii. Planning to remove the tooth by dissectioniv. Close approximation with important anatomical structuresv. Abnormal root pattern – third molars, in standing premolars, misplaced caninevi. Tooth having periodontal problem & some sclerosis – hypercementosisvii. Trauma to tooth – fracture of tooth, roots & alveolar boneviii. Isolated & Unopposed maxillary molarsix. Partially erupted, unerupted tooth & retained rootsx. Delayed erupting or having abnormal crownxi. Condition indicating dental or dentoalveolar deformities –osteitis deformans - hypercementosiscleido-cranial dysosteosis - hooked roottherapeutic irradiationosteopetrosis
  20. 20. GENERAL ANESTHESIA• 5-10 min.• uncooperative patients• 30-45 min.• No pre-op preparation• Respiratory tract disease• Cardiovascular diseasesLOCAL ANESTHESIAGeneral factors
  21. 21. Local factors Acute infection at the site of injection Hemangioma
  22. 22.  Is defined as –removal of all micro-organisms from a given object. Hands of operator Instruments Operation area Engines, lights & chairs are inevitably sources of cross-infection. Use the sterile gauze /cloth – to change the position of light.
  23. 23. 1. Position of the operator –- Stand erect , equal distribution of weight on both feet- Force delivery – with arm & shoulder not with hand- application of force without stress to shoulders & back- generally on right hand side- for Right posteriors – back side- operating box
  24. 24. 2. Position of the patient –make the patient comfortable on dental chair3. Height Of Dental Chair –maxillary teeth – 8 cm / 3 inch below the shoulder levelof operatormandibular teeth – 16 cm / 6 inch below the elbow ofoperator
  25. 25. 4. Angulation of the chair –maxillary teeth – 45-60 degreemandibular teeth – parallel or 10 degree5. Light –good illumination
  26. 26. 6. Role of opposite hand Reflection of soft tissue Protection of other teeth Stablization of patient’s head Supporting & stablizing the mandible Supports alveolar bone Tactile information Compress socket Deliver the whole tooth, root, dislodged filling
  27. 27. 7. Role of assistant Helps the surgeon to gain access & visualize the field Suction Protect the teeth of opposite arch Support the head Support the mandible Psychological & emotional support Avoid casual , offhand comments– increase patient’s anxiety- decrease patient’s cooperation
  28. 28.  Clear access to & vision of the surgical field. Use of controlled force Unimpeded path of removal
  29. 29.  Separation of tooth from alveolar bone withcrestal & principal periodontal fibers. Alveolar expansion Bleeding is arrested by pressure pack.
  30. 30.  Severing SoftTissue AttachmentThe straight and curved desmotomes
  31. 31. Chompret elevators;a straight, and b curved
  32. 32. A. Intra-alveolar extraction (closedtechnique)B. Transalveolar extraction (openmethod)
  33. 33. 1. forcep Technique2. elevator Technique
  34. 34.  Commonly used Not used in – hypercementosis- root deformities- grossly decayed crown- grossly decayed root- brittle root Advantages - least trauma- gingival fibers reduces the size of extraction orificeso promotes healing
  35. 35. 1. Beaks should seated as far apically as possible2. Beaks should be parallel to the long axis of tooth3. Excess force should be avoided.HOWTO HOLDTHE FORCEPThumb – just below the jointHandle in palmLittle finger – inside the handle
  36. 36.  Buccally & lingual parallel to long axis of tooth. Forced through periodontal membrane, towards apex. Firm pressure. 1st apply on less accessible side of tooth under direct vision 2ndly on other side Cervical caries - 1st movement towards carious part
  37. 37. Time spent in careful application of forcepblades to the radicular portion of tooth isnever wasted.
  38. 38.  Pressure applied by the operator by moving his trunkfrom hips not from elbow. Movements – linguobuccal & buccolingual- firm, smooth & controlledrotatory / figure of 8looseremoval
  39. 39.  Maxillary buccal bone is thinner – buccally removal of teeth Mandibular buccal bone till molar is thinner - buccally removal ofteeth Mandibular buccal bone in molar region is thicker - linguallyremoval of teeth Socket compression Avoid soft tissue laceration
  40. 40.  In multiple extraction cases canine should be extractedprior to extraction of incisors, as prior extraction ofincisors weakens the labial cortex.
  41. 41.  Heavy bladed forceps areused.
  42. 42. Factors –1. Permanent successors2. Limited accessSo use fine bladesWarwick jameselevators can be usedExtraction of deciduous molar with forceps.Forceps are positioned mesially or distallyon the crown and not the center of the tooth
  43. 43.  Works on lever & fulcrum principle It forces the tooth / root along the line of withdrawal R/G Fulcrum – bone or adjacent tooth Elevator grasping
  44. 44.  Application –in periodontal space450 to long axis of toothPlacement of gauze between finger andlingual side, for protection from injury incase the elevator slips
  45. 45. Application of elevator –BuccallyMesiallydistally
  46. 46. Movement –rotate the elevator along its long axis
  47. 47. a During luxation of a tooth, thealveolar ridge is used as a fulcrum, notthe adjacent tooth.b Incorrectplacement of the instrument.c Photoelastic modelshowing extraction of the thirdmandibular molar using astraight elevator. Using the adjacenttooth (second molar) asa fulcrum creates great tension aroundthe tooth, with a riskof injury to tissues surrounding the root
  48. 48. Positioning of straight elevator on the distal surface of theroot, either perpendicular to, or at an angle to the root
  49. 49. Removal of the root of mandibular premolar with thespecial instrument (endodontic file-based action) for rootextraction
  50. 50. Separation of roots of the mandibularfirst molar with fissure bur
  51. 51. Roots of mandibular first molar.Extraction is accomplished by sectioningroots using a straight elevator
  52. 52. Positioning of the elevator and the fingers of the left hand for separation of molar roots
  53. 53. Using an elevator withT-shaped handles to remove intraradicular bone
  54. 54. Diagrammatic illustrations showing luxation of the root tip of themandibular second premolar, usingdouble-angled elevators
  55. 55. Technique for removing the tip of a mesialroot of a mandibular molar. Removal of intraradicular boneand luxation of the root tip using a double-angled elevator
  56. 56. Removal of the tip of the distal root of a maxillary molar
  57. 57. Removal of the root tip using an endodonticfile. After the endodontic file enters the root canal, the roottip is drawn upwards by hand (a), or with a needle holder (b)
  58. 58.  Irrigation of the socket Squeezing of the socket Mouth rinsing with warm bland water for once Suturing if require Moist gauze pack Medication Post extraction instructions – verbal & written
  59. 59. 1. Intra-alveolar attempt is failed2. Retained roots in proximity with maxillary sinus & not accessibleto forcep3. History of difficult or attempted extraction4. Heavily restored tooth5. Geminated / dilacerated tooth
  60. 60. Dens in dente of maxillary left canineFusion of teeth
  61. 61. Deciduous mandibular molar, whose rootsembrace the crown of the succedaneouspremolar. Risk of concurrent luxation withthe simple extraction technique.
  62. 62. Main components of transalveolar extraction –1. Design of mucoperiosteal flap2. Method to be used to deliver the tooth / root from socket3. Bone removal used to facilitate tooth / root removal
  63. 63. Raise to render the operative site clearlyvisible & accessibleSuture should not be placed over blood clotObliteration of buccal sulcus should be avoidedBase – broad
  64. 64.  Sharp scalpel Firm pressure Mucousa + periosteum Avoid Button hole formation in case of sinus Incision of sufficient length at once
  65. 65. Minnesota retractors forretraction of the cheek and tongueAustin’s retractor
  66. 66.  To expose root/tooth Facilitated by large flaps Provides point of application After tooth/root removal – remove all sharp edges & boneprominences Instruments used -
  67. 67.  Round / rose head provides – less clogging, better control. It doesnt cut the tooth that easily Should not contact soft tissue Avoid overheating Postage stemp method then join with chisel
  68. 68.  Different line of removal for different roots Divide the root from furcation area Make space for application of forcep / elevator Osteotome / burs
  69. 69.  Engage the elevator in a notch on side of root If notch is not present then create it with round bur directed at 450angle to the long axis of root.
  70. 70.  Irrigation of the socket Suturing Moist gauze pack Medication Post extraction instructions – verbal & written Recall after 48 hours Normally 7 days Within 2 days – if it was for control of hemorrhage OAC repair – 10 days
  71. 71. Steps in the surgical extraction of an intactmaxillary first molar. Reflection of the envelope flap,sectioning of two buccal roots from the crown (a), removalof the crown together with the palatal root, and then finallyremoval of the mesial and distal roots (b)
  72. 72. An L-shaped incision is made and the flap is reflected.The buccal plate covering the surface of the root isremoved, and the tooth is extracted using forceps
  73. 73. a, b. Surgical extraction of a mandibularmolarwith hypercementosis at the distal root tip.The envelopeflap is reflected, part of the buccal plate isremoved, and thetooth is sectioned buccolingually at the crownas far as theintraradicular bone
  74. 74. Extraction of the mesial portion of the tooth,which includes the crown and rootWidening of the alveolus with a round bur, sothat removal of the root is possible withoutfracturing the bulbous root tip
  75. 75. The surgical technique is indicated for its removal
  76. 76. Radiograph of roots of the mandibular first molar.The surgicaltechnique is indicated for their removal
  77. 77. INDICATIONS –1. Patient Under Coverage of BISPHOSPHONATE2. Hemophilic patientsPROCEDURE –Dentin bulge (arrows)preventing elastics from slidingapically.Root canal treated and split mandibular molar duringexfoliation process. Note extrusion of mesial root.
  78. 78. Atraumatic Teeth Extraction inBisphosphonate-Treated PatientsEran Regev, DMD, MD,* Joshua Lustmann, DMD,†and Rizan Nashef, DMD‡© 2008 American Association of Oral and Maxillofacial SurgeonsJOral Maxillofac Surg 66:1157-1161, 20080278-2391/08/6606-0011$34.00/0doi:10.1016/j.joms.2008.01.059
  79. 79. Sockets immediately after exfoliation of both teeth.
  80. 80.  Take careful history Take care of – airway, support of mandible & position ofpatient’s headThe dental surgeon should never act as bothoperator & anesthetist.
  81. 81. 1. Accompanying person2. No driving3. 6 hrs of NPO4. Emptying the bladder5. Loose the tight clothing6. Patient Comfortable in dental chair7. Head slightly extended8. Mandible should be parallel to floor9. Arm & leg position of patient10. Waterproof apron11. Hearing of patient’s each breath
  82. 82. 1. Identify the tooth2. All prosthesis are removed3. All instruments should be keep ready4. Larger the anesthesia – increase risk of anoxia &aspiration5. Ideal time – 5-10 min.
  83. 83. 1. Dental prop2. Mouth gauge3. Mouth pack4. Efficient suction apparatus5. Tracheostomy kit
  84. 84. 1. Tooth priorities2. Avoid excess force to mandible3. Soft tissue injury should be avoided4. Postpone – remove pulp if it is exposed5. Fractured root v/s resorbed root
  85. 85. 1. Hemorrhage & clot formation – 1-2 days2. Organization of clot by granulation tissue – 3-7 days3. Replacement of granulation tissue by connectivetissue & epithilialization of wound – 4-35 days4. Replacement of connective tissue by coarse fibrillarbone – 6-8 weeks5. Reconstruction of alveolar process & replacement ofimmature bone by mature bone tissue
  86. 86. 1. Infection2. Size of wound3. Blood supply4. Resting of part5. Foreign bodies6. General condition of the patient
  87. 87. Technological Advances in ExtractionTechniques and OutpatientOral SurgeryAdamWeiss, DDS*, Avichai Stern, DDS, Harry Dym, DDSDepartment of Dentistry and Oral and Maxillofacial Surgery, The BrooklynHospital Center,121 Dekalb Avenue, Brooklyn, NY 11201, USA* Corresponding author.E-mail address: aweissdds@gmail.comKEYWORDSPowered periotome Polyurethane foam PiezosurgeryImmediate implants Orthodontic extrusion Bone graftingPhysics forcepsDent Clin N Am 55 (2011) 501–513doi:10.1016/j.cden.2011.02.008 dental.theclinics.com0011-8532/11/$ – see front matter 2011 Elsevier Inc. All rights reserved.
  88. 88.
  89. 89. Powertome® AssistedAtraumaticTooth ExtractionThe Journal of Implant & AdvancedClinical DentistryJason White, Dan Holtzclaw, NicholasToscanoSeptember 2009Volume 1, No. 6
  90. 90.  Precise extraction of tooth Preserves bone & gingival architecture Option for immediate implant placement Mechanism of “WEDGINNG” & “SEVERING” Severs the periodontal ligament Multirooted teeth requires sectioning.
  91. 91. Presurgical radiograph of Case 1.Powertome® blade advanced in a”sweeping” fashion.Rotational movement of root with forceps Atraumatic removal of the tooth
  92. 92. Presurgical clinical presentation Powertome® blade advanced down PDLExtracted segments of maxillary canine
  93. 93. Presurgical radiograph Presurgical clinical presentation
  94. 94.  Piezosurgery is an innovative bone surgery technique that producesa modulated ultrasonic frequency of 24 to 29 kHz, and amicrovibration amplitude between 60 and 200 mm/s. The amplitude of the vibrations created allows a very clean andprecise surgical cut. It works selectively, without harming soft tissues such as nerves andblood vessels even with accidental contact with the cutting tip. The surgical control of the device is effortless compared withrotational burs or oscillating saws because there is no need for anadditional force to oppose rotation or oscillation of the instrument.
  95. 95.  Despite the longer time of the procedure, the investigators alsonoted that the piezoelectric osteotomy reduced postoperativefacial swelling and trismus. Uses of piezosurgery device to cut and elevate a precisely definedbone lid on the lateral cortex of the mandible to provide access tothe teeth needing extraction or even a lesion that needs to beexcised. The bone window is then elevated with the help of a curvedosteotome. After the visual confirmation of an undamaged IAN and adjacenttissues, the bone lid is placed back into its original position andfixated with absorbable miniplates.
  96. 96.  For the surgical extraction of the teeth, the covering bone was firstablated, layer by layer, using the Er:YAG laser. In the case of the fiber-optic Er:YAG [erbium:yttrium-aluminumgarnet ], laser the fiber is closely guided around the teeth, creating anarrow gap with minimal bone loss. The benefits of laser therapy include the creation of a bloodlesssurgical field and thus improved visualization during surgery,decreased postoperative pain, and limited scarring and contraction. Time consuming, sound and smell, significantly inhibition thelaser cutting because of the overall volume of irrigation and bloodcovering the bone surface.
  97. 97.  Third molars in close proximity to the IAN have a significantnegative impact on recovery for pain and oral function. The advantage of this technique is that the risk of direct traumato the nerve is eliminated, due to both the increased distancebetween the roots and the mandibular canal and the decreased needfor surgical manipulation during the extraction.
  98. 98.  A potential problem with this technique is soft tissue damage fromimpingement on the mucosa of the cheek and the gingiva. In addition, working in this area of the mouth presents greatdifficulty, and the action of the masseter muscle leads to cheekcompression against the orthodontic appliances. This technique will be of no value for a tooth that cannot movebecause of ankylosis. This technique should be used only in carefully selected cases inconjunction with an orthodontist, being certainly difficult, timeconsuming, and not always successful.
  99. 99. © 2010 American Association of Oral and Maxillofacial Surgeons0278-2391/10/6802-0032$36.00/0doi:10.1016/j.joms.2009.07.038J Oral Maxillofac Surg 68:442-446, 2010
  100. 100. Panoramic radiograph at initial consultation. The mandibularthird molars are mesially impacted with the roots close tothe alveolar canal.
  101. 101. Postoperative radiograph after second sectioning ofthe right mandibular third molar. A pulpotomy has been performed.More space was created distal to the right mandibular secondmolar to allow further migrationPostoperative radiograph after the right mandibularthird molar was surgically sectioned. The spacedistal to the second molar would allow mesialmigration of the impacted tooth.
  102. 102. 3 months after odontectomy. Thethird molar moved mesially.However, the mesial root was stillin contact with the alveolar canal.A second sectioning was required.Periapical radiograph obtained 2 months aftersecond sectioning. At that time, the roots wereaway from the alveolar canal, and a risklessextraction could be scheduled.
  103. 103.  The Physics Forceps uses first-class level mechanics to atraumaticallyextract a tooth from its socket. One handle of the device is connected to a “bumper,” which acts as afulcrum during the extraction. Together the “beak and bumper” design acts as a simple first-classlever. A squeezing motion should not used with these forceps. By contrast, thehandles are actually rotated as one unit using a steady yet gentlerotational force with wrist movement only. Once the tooth is loosened, it may be removed with traditionalinstruments such as a conventional forceps
  104. 104. GMX-100R - Upper Right - Extracts Teeth 2 to 5GMX-100L - Upper Left -Extracts Teeth 12 to 15GMX-100A - Upper Anterior - Extracts Teeth 6 to 11GMX-200 -Lower Universal -Extracts Teeth 18to 31
  105. 105. 1*,3Oral and Maxillofacial Surgery, Oral and MaxillofacialDepartment, Guys Hospital, Floor 23, Great Maze Pond,London, SE1 9RT; 2Restorative Dentistry, Guys Hospital,Floor 26, Great Maze Pond, London, SE1 9RT*Correspondence to: Dr Vinod PatelEmail: PaperAccepted 29 April 2010DOI: 10.1038/sj.bdj.2010.673©British Dental Journal 2010; 209: 111–114BRITISH DENTAL JOURNALVOLUME 209 NO. 3AUG 14 2010• Coronectomy is a technique that shouldbe considered for mandibular third molarswhen it is felt there is an increased risk ofinjury to the inferior dental nerve.• Coronectomy is oral surgery’s approachto minimal interventional dentistry.
  106. 106.  Coronectomy can be beneficial but success requires both good patientselection and operator technique. Renton et al.reported no IDNI in 58 successful Coronectomy patientsand a 19% IDNI rate in those having traditional extractions. Leung et al. showed nine (5%) patients in the control group presentedwith IDNI, compared with one (0.06%) in the Coronectomy group. Hantano et al. reported that in the extraction group six patients (5%)suffered IDNI, of which 3 patients were diagnosed with permanentinjury, where as in the Coronectomy group one patient (1%)complained of altered sensation post-operatively which resolved withinone month. The retrospective analysis of O’Riordan consisted of 52 patients thatunderwent Coronectomy. In this study there were 3 cases of transientIDNI which showed resolution one week post operatively. One patientdeveloped permanent IDNI, which was thought to be as a result ofperforation of the canal due to operator error rather than theCoronectomy technique itself.
  107. 107. 1, deviation of the canal 2, narrowing of the canal3, periapical radiolucent area 4, narrowing of root;5,darkening of roots 6, curving of root7, loss of lamina dura of canal
  108. 108. Coronectomy: A, cutting crown belowcement-enamel junction (arrow);B, trimming cutting surface to lessthan 3 to 4 mm below alveolar crest.Radiographic imagingshowing pre andpost coronectomy of the rightmandibularthird molar (48)
  109. 109.  To avoid traumatizing the surrounding bone during elevation,implant drills were placed in the root canals to thin the root wallsgiving way to extraction with the application of much less force,thereby decreasing the chance of traumatizing the thin buccal bone.
  112. 112.  Faulty technique Inadequate solution Test the efficacy of anesthesia Tooth could not be removed with intra-alveolar ortrans- alveolar procedure.
  113. 113. Crown / root – Grossly carious Tooth with Endodontic treatment Improper application of forcep One point contact Slip off of forcep Excessive force Hurry Tooth with divergent roots /hypercementosisThen trans-alveolar method is indicated
  114. 114. Remove all the root fragments except –1. 5 mm & requires excessive bone removal – well tolerated.(Simpson 1958)2. Apical 1/3 rd of palatal root of maxillary molars &requires excessive bone removalIf removal is indicated – inform the patientradiographIf root is left in place – pulpectomy should be performed.
  115. 115. Causes – Excessive inclusion of bone within the forcep beaks Extraction of incisors before canine Intact versus torn periosteum Generally during extraction of maxillary 3rd molars Pneumatization of maxillary air cells Gemination
  116. 116. Management – Preoperative radiograph is essential Raise the mucoperiosteal flap Separate the tooth & bone from gingiva Mattress Suture 10 days If tuberosity is excessively mobile –i. Splint the tooth for 6-8 weeksii. Sectioning the crown & pulpectomy.
  117. 117.  Heavily restored adjacent teeth –in the line ofwithdrawal Abutment teeth When used as fulcrum Uncontrolled force Under general anesthesia – gauge & props intubation
  118. 118. Causes – Excessive / incorrectly applied force Pathologic fracture Senile osteoporosisPrecautions – Peroperative radiograph Splint febrication Exraoral supportmanagement – Inform the patient Reduce the fractured segment
  119. 119.  When used as fulcrum Improper use of elevators Give support to adjacent tooth from other hand Don’t apply the elevator mesial to 1st molarManagement – Place the tooth in socket & splint it
  120. 120. Causes – Excessive / incorrectly applied force Improper use of mouth gauge Senile osteoporosisPrecautions – Take history Exraoral support beneath the angle ofmandibleManagement – Reduce it immediately Reduction technique Instructions to patient
  121. 121. Causes – Abnormal root curvature Carious root Roots of premolars & molars involved by sinus Excessive / incorrectly applied force Inadequate grasping of toothPrecautions – Take past dental history Apply the forcep on sufficient tooth structure Leave uninfected apical 1/3rd of root Never force the root towards sinus Transalveolar method
  122. 122. Causes - Maxillary posterior teeth Involvement of sinus lining by – Periapical pathologyDiagnosis – Increased intra nasal pressure – air coming out frommouth can be heard Amount of blood will be doubled Wisp of cotton wool will be deflected
  123. 123. Management – Mucoperiosteal flap rising Decrease alveolar height Interrupted horizontal suture Protect the clot with – acrylic, denture base, impressionmaterial Give incision in sinus membranePrecautions – Mouth rinsing with antiseptic solution before closure oforoantral communication Passage of instruments from mouth to sinus should beavoided.
  124. 124. Diagnosis – Air bubbles from socket Cotton wool deflection Fluid taken from oral cavity noseManagement – Take radiograph . Blow the air through nose Under general anesthesia – stop the general anesthesiawait till regaining the cough reflex Suction + irrigation ½ inch wide iodoform gauze Sometimes incision in sinus membrane Caldwell-Luc approach
  125. 125.  Mostly maxillary third molarsManagement – Extend the incision posteriorly Blunt dissection Grasp the tooth carefully Or wait for several weeks until it becomes somewhatencapsulated.
  126. 126. Reflect the soft tissue flap on lingual aspect of mandible asforward to the premolarsgently dissect the mucoperiosteumDetach the mylohyoid muscle.
  127. 127. If the root is not appearing in the oral cavity/pressure pack Ask the patient to cough & spit Turn the patient towards the operator & position with themouth towards the floor. Radiograph of alveolar socket/ sinus/ chest Re-examine the patient after 3 days Patient is asked to report immediately- fever, cough,chest pain occurs.
  128. 128. Perioperative hemorrhage – Oozing of blood during operationManagement – Wipe Sucker Hot 50 degree celcius for 2 min. Hemostate Local anesthetic solution having vasoconstrictor Gelatine sponge oxidized cellulose After tooth removal – moist pressure pack for 10min.horizontal mattress suture
  129. 129. Postoperative hemorrhage – Instructions to the patients –1. Pressure pack2. Less talk for 2-3 hrs.3. Tea bag4. No smoking for 12 hours5. No staneous exercise Psychological approach Determine site & amount of hemorrhage Remove excess blood clot Provide firm gauze pack with tannic acid
  130. 130. Horizontal mattress suture into mucoperiosteumWait for 5 minutes after placing gauze pressure on sutureGelatin / fibrin foam&All post extraction instructions and avoid frequent aggressivemouth rinsing
  131. 131. GingivaLower lip – mechanical & thermal injuryTongue & floor of mouth
  132. 132. Causes – Compression with clot or bone debris Partially or completely tornPrecautions – Preoperative radiograph Elevator should not be forced below tooth Resect 1 root before tooth elevationManagement – Reposition the ends at closeapproximation Decompression Microsurgical reanastomosis Nerve grafting
  133. 133. Causes – Transalveolar extraction of premolarsPrecautions – More Bone reduction mesial to 1st premolar & distalto 2nd premolar Retraction of nerve with mental retractor
  134. 134.  Burs Management – drilling the groove around it .
  135. 135.  Submucosally & subcutaneously Older patients – increased capillary fragilitydecreased tissue toneweaker inter cellular attachments Onset 2-4 days Resolve within 7 – 10 days
  136. 136. Cause – Suture without adequate bony foundation Suturing the wound under tension Mostly in the region of mandibular 2nd & 3rd molar(internal oblique ridge)Management – Leave the projection – slough out within 2-4 weeks Smooth it with bone file under local anesthesia.
  137. 137. 1. Due to traumatized hard tissue – Bruising from bone during intrumentation Excessive heating from bur Sharp bony edges Avoidance of tissue toileting2. Due to traumatized soft tissue – Incision only through mucous membraneragged flap - heals slowly Too small flap – much traumatic retraction Injury from bur.
  138. 138. Synonyms : alveolar osteitis (AO), localized osteitis, postoperative alveolitis, alveolalgia, alveolitis sicca dolorosa, septic socket, necrotic socket, localized osteomyelitis, fibrinolytic alveolitis
  139. 139. Postoperative pain in and around the extraction site, whichincreases inseverity at any time between 1 and 3 days after theextractionaccompanied by a partially or totally disintegrated blood clotwithinthe alveolar socket with or without halitosis.I. R. Blum: Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization,etiopathogenesis and management: a critical review. Int. J. Oral Maxillofac. Surg. 2002; 31: 309–317. 2002International Association of Oral and Maxillofacial Surgeons
  140. 140.  Mostly 1–3 days after tooth extraction . Within a week - In 95% and 100% of all cases. Unlikely - before the first postoperative day.because the blood clot contains anti-plasmin that must beconsumed by plasmin before clot disintegration can take place. The duration of alveolar osteitis varies to some degree, depending onthe severity of the disease, but it usually ranges from 5–10 days.
  141. 141. 1. The denuded alveolar bare bone may be painful and tender.Initially blood clot appears dirty gray disintegratesgrayish yellow bony socket bare of granulation tissue2. Some patients may also complain of intense continuous painirradiating to the ipsilateral ear, temporal region or the eye.3. Regional lymphadenopathy (occasionally).4. unpleasant taste (occasionally).5. Trismus is a rare occurrence in mandibular third molar extractionsprobably due to lengthy and traumatic surgery.
  142. 142.  Multifactorial origin Following have been implicated most commonly as etiological,aggravating and precipitating factors:1. Oral micro-organisms - Treponema denticola2. Difficulty and trauma during surgery3. Roots or bone fragments remaining in the wound4. Excessive irrigation or curettage of the alveolus after extraction5. Physical dislodgement of the clot6. Local blood perfusion & anesthesia7. Oral contraceptives - estrogens, like pyrogens will activate thefibrinolytic system indirectly.8. Smoking
  143. 143. 1. Previous experience.2. Deeply impacted mandibular third molar (risk factor is directlyproportional to increasing severity of impaction) .3. Poor oral hygiene of patient .4. Active or recent history of acute ulcerative gingivitis or pericoronitis.5. Associated with the tooth to be extracted .6. Smoking (especially >20 cigarettes per day) .7. Use of oral contraceptives .8. Immunocompromised individuals .
  144. 144.  BIRN : (BIRN H. Etiology and pathogenesis of fibrinolytic alveolitis (‘dry socket’). Int J OralSurg 1973: 2: 215–263.)
  145. 145. FactorXIIaCLOTTINGSYSTEMKININSYSTEMFIBRINOLYTIC SYSTEMCOMPLEMENTSYSTEMFactor XIICONTACTThis conversion isaccomplished in the presence of tissueorplasma pro-activators and activators.
  146. 146. PlasminogenActivatorsIndirectDirect1. Factor XIIdependentactivator2. urokinase,1. Tissue plasminogen activators2. Endothelial plasminogen activators1. streptokinase2. staphylokinaseplasminogenactivatorcomplexIntrinsicExtrinsic
  147. 147. Fibrinolytic systemPlasminogen activator(kallikrein, XIIa, leukocytes,endothelium)PlasminogenPlasminC3 C3aFibrinFibrinsplitproducts
  148. 148. References in the literature correlating to theprevention of alveolar osteitis can be dividedinto1. Non-pharmacological and2. Pharmacological preventive measures.
  149. 149. Non-pharmacologicalmeasures1. Use of good quality current preoperative radiographs2. Careful planning of the surgery3. Use of good surgical principles4. Extractions should be performed with minimum amount oftrauma and maximum amount of care5. Confirm presence of blood clot subsequent to extraction(if absent, scrape alveolar walls gently)
  150. 150. 6. Wherever possible preoperative oral hygienemeasures to reduce plaque levels to a minimumshould be instituted7. Encourage the patient (again) to stop or limit smokingin the immediate postoperative period .8. Advise patient to avoid vigorous mouth rinsing for thefirst 24 h post extraction and to use gentletoothbrushing in the immediate postoperative period .9. For patients taking oral contraceptives extractionsshould ideally be performed during days 23 through28 of the menstrual cycle .10. Comprehensive pre- and postoperative verbalinstructions should be supplemented with writtenadvice to ensure maximum compliance .
  151. 151. 1. Antibacterial agents -2. Antiseptic agents and lavage Chlorhexidine (CHX)3. Antifibrinolytic agents - para-hydroxybenzoic acid (PHBA),4. Steroid anti-inflammatory agents - polylactic acid (PLA)5. Obtundent dressings6. Clot supporting agents
  152. 152. 1. Remove any sutures to allow adequate exposure of the extraction site.Asthe socket may be exquisitely tender local anaesthesia may be required.2. Irrigate the socket gently with war sterile isotonic saline or local anaestheticsolution, which is followed by careful suctioning of all excess irrigationsolution.3. Do not attempt to curette the socket, as this will increase the level of pain.4. Prescription of potent oral analgesics.5. The patient is given a plastic syringe with a curved tip for home irrigationwith chlorhexidine solution or saline and instructed to keep the socket clean.6. Once the socket no longer collects any debris, home irrigation can bediscontinued.
  153. 153.  Under block anesthesia The clot devoided socket is thoroughly curetted, both from thefloor of the socket as well as from the bony walls. The sharp margins were trimmed, rounded. Any foreign bodies if present were thouroghly removed. The detached gingival margins were also scraped. The desired medications as well as precautions . Patient was not only without pain, but was also comfortable bothphysically as well as psychologically from the very next day.S.C.Anand,V. Singh, M. Goel, A.Verma, B. Rai: Dry Socket An ApriasalAnd Surgical Management. The Internet Journal of DentalScience.2006Volume 4 Number 1. DOI: 10.5580/e31
  154. 154.  Normal oedemaAfter multiple teeth extractionsurgical tooth extraction Traumatic oedemaBlunt instrumentationExcessive extraction of badly designed flapToo tight sutureManagement – Ice pack application Heat application
  155. 155. Subcutaneous emphysema – Air into connective tissue of intramuscular & fascialspaces Swelling is of sudden onset. Crackles can be felt under finger Resolves within 1-2 daysDue to infection of wound – Preoperative antibiotic Prevention of entry of micro-organism into wound Mild infection – intraoral hot saline mouth wash
  156. 156.  It is defined as inability to open the mouth due to musclespasm.Causes – Post operative oedema Hematoma formation Inflammation of soft tissue After mandibular block Traumatic arthritis of TMJ Multiple injections
  157. 157. Management – Treat underlying cause Intraoral heat application Antibiotics & specialist treatment.
  158. 158.  Transient loss of consciousness and postural tonecharacterized by rapid onset, short duration, and spontaneousrecovery due to global cerebral hypoperfusion that most oftenresults from hypotension.Sign & symptoms – dizziness, weakness, nausea skin is cold,pale & sweating.Management – Position Oxygen administration Blood pressure & pulse measurement 250 mg aminophylline is given slowly.
  159. 159.  Skeletal muscle become flaccid pupil dilate widelymanagement – Patient flat on the floor Clean the airway Pull the mandible forward Extend the neck fully Pulmonary resuscitation so that chest is seen to rise every3-4 sec. Brook airway can be inserted over tongue Check carotid pulse & apex beats at regular intervals
  160. 160. Sign & symptoms – Deathly pallor & grayness of skin Cold sweat Pulse & apex beat can be felt Heart sounds can not be audibleChildren - Beginning of heartbeat if the sternum is tapped sharplyAdult –Patient flat on the floorCardiac compression at 1 second interval
  161. 161.  Syncope, respiratory arrest & cardiac arrest complicate thegeneral anesthesia. Management –i. Clear the airwayii. Remove all the packs, debris & apparatus from mouth.iii. Pull the mandible forwardiv. Extend the neckv. Head – downward /forward in dental chair- upward if lying on the floorvi. Oxygenvii. Larygotomyviii. Tracheostomy
  162. 162. RESOURCESText books1. The extraction of teeth by – GEOFFREY L HOWE2. Oral & maxillofacial surgery volume 2 , by – DANIEL M. LASKIN3. Oral Surgery by - FRAGISKOS D. FRAGISKOS4. Contemporary Oral & maxillofacial surgery by- HUPP, ELLIS,TUCKER5. Text book of Oral & maxillofacial surgery by – S M BALAJI.
  163. 163. RESOURCES1. Technological Advances in Extraction Techniques and Outpatient Oral SurgeryAdam Weiss, DDS*, Avichai Stern, DDS, Harry Dym, DDS Dent Clin N Am 55 (2011) 501–513 doi:10.1016/j.cden.2011.02.008 0011-8532/11/$ – see front matter2011 Elsevier Inc.2. Powertome® Assisted Atraumatic Tooth Extraction, The Journal of Implant & AdvancedClinical Dentistry, Jason White, Dan Holtzclaw, Nicholas Toscano, September 2009Volume 1, No. 63. Staged Removal of Horizontally Impacted Third Molars to Reduce Risk of Inferior AlveolarNerve Injury Luca Landi, DDS,* Paolo Francesco Manicone, DDS,† Stefano Piccinelli, DDS,‡Alessandro Raia, DDS, PhD,§ and Roberto Raia, DDS, J Oral Maxillofac Surg 68:442-446,20104. Enhancing Extraction Socket Therapy Robert A. Horowitz, Michael D. Rohrer, Hari S. Prasad,Ziv Mazor, The Journal of Implant & Advanced Clinical Dentistry, Jason White, DanHoltzclaw, Nicholas Toscano, September 2009 Volume 1, No. 65. Coronectomy – oral surgery’s answer to modern day conservative dentistry V. Patel, S. Mooreand C. Sproat, Refereed Paper Accepted 29 April 2010 DOI: 10.1038/sj.bdj.2010.673 ©BritishDental Journal 2010; 209: 111–114, BRITISH DENTAL JOURNAL VOLUME 209 NO. 3AUG 14 2010
  164. 164. RESOURCES6. Atraumatic Teeth Extraction in Bisphosphonate-Treated Patients Eran Regev,DMD, MD,* Joshua Lustmann, DMD,†and Rizan Nashef, DMD‡2008 American Association of Oral and Maxillofacial Surgeons © J Oral MaxillofacSurg 66:1157-1161, 2008 0278-2391/08/6606-0011$34.00/0doi:10.1016/j.joms.2008.01.059