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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 diseaseErosion Attrition Abrasion Hypoplasia

INDICATIONSTrauma 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 HypothyroidismHyperthyroidism

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 jawTeeth 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 extractionAdequate 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 - Loosening of soft tissue attachment from the tooth Luxation of tooth with a dental elevatorAdaptation of forceps to the tooth Luxation of the tooth with the forcepsRemoval 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 crownLarge 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 rootsLong 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 Expansion of the socket The use of lever and fulcrum The insertion of a wedge

Chair Position Maxillary extractionMandibular 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 pulplessHypercementosed 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 complicationscorrect choice of extraction technique

Surgical removal of tooth Steps of trans alveolar flaps

Muco periosteal flaps: Bone removal Tooth divisionSocket 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