Hebah ra3d ramadneh

Dr. fadi garab

27/6/2013

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Dental extraction
In this surgery curse we will talk about; Local anesthesia (given by Dr. zaid Altamemi) and simple dental extraction (given by Dr. fadi garab). Dental extraction is called exodontia: Exo: taking something out Dontia: the teeth. Types of extraction: 1-Intra alveolar: when I am working without touching the bone labialy or lingualy, we dont make any flaring of h soft tissue, we just get the tooth out simply so its called (simple extraction) 2-Transalveolar: if the tooth fracture or there is any complication and I need to flare the soft tissue and work with bone to get the tooth out so, its called (surgical extraction). Our goal this course to talk about entra alveolar / simple extraction / close extraction / Non-surgical extraction.
NOTE: That means extraction of the tooth

When you received the case you should follow a systematic way: 1. History taking 2. Examine the patient 3. Provide a differential diagnosis 4. Perform special investigations; the most common is radiographs (intraoral periapical) 5. Reach definitive diagnosis 6. Treatment plan
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Indication for extraction of teeth: 1. Advanced caries. Ex: when caries reach or go below the level of the bone. So its non-restorable tooth, we cant treat it by indo procedure
To extract the tooth you should make sure that other preventive and restorable procedure cant help us and there is no other way to tr eat the tooth, the only way is to extract it.

2. 3. 4. 5. 6. 7. 8.

Pulpal necrosis Advanced periodontal disease (grossly mobile teeth). Orthodontic reasons. Trauma of the tooth directly or to the jaw. Supernumerary teeth. Teeth associated with pathological condition like cysts(tumor) Prophylactic extraction: you should extract the tooth to prevent future complication. Ex: osteoporosis case: Its a case when the bone exposed to the radiotherapy which lead to hypo vascular, hypo cellular and hypoxia. So, we extract the questionable teeth in this area because these teeth can harm the bone more, and we should extract it before we start the radiotherapy

9. periapical infection . 10. Pulpal lesions. (Pulp polyp) 11. Teeth in the line of fracture. 12. Prosthetic reasons. 13. Esthetics and economics reasons. 14. Hypoplasia, abrasion, attrition, erosion that caused severe tooth wear. (Non-carious loss of structure)

Steps of extraction: 1- Clinical evaluation of teeth. 2- Radiographic evaluation of teeth.

3- Position of the dental chair and the doctor should be in the proper way
Please take care its a very important topic

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Patient position
Dental chair should be in a semi reclined position. (head, neck and trunk should be in non-vertical way) Head rest supported
For extraction in the maxilla:

For tooth extraction in the maxilla the head should be 45-60 degree. in extracting maxillary teeth the site of operation (patient mouth ) should be 8 cm below the shoulder level
For extraction in the mandible

in extracting mandibular teeth the height should be 16 cm below the level of operators elbow the patient should be up-right position (no 45-60 degree)

Operator position
GENERAL RULE: The operator should stand in the right side of the patient in front of him when extracting teeth from all quadrants BUT there are 2 exceptions for the posterior teeth: if the operator is right handed he will follow the general rule for all the quadrants except in the lower right quadrant he should stand right posteriorly (posterior to the patient behind him - in the right side) if the operator is left handed he will follow the general rule for all the quadrants except in the lower left quadrant he should stand left anteriorly (anterior to the patient - front him - in the left side)

Equipment of extraction:
Instrument of local anesthesia:

Needle
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Dental syringe: we used it to connect the needle with the solution of local anasthesia.

The place of the needle in the top of the syringe

The ampoule where we put the anesthetic solution

Tools of extraction procedure:

dental elevator: they can help us to extract the tooth.

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Dental forceps: Its the most important one. We cant do extraction without it.

The peek: This is the part which differs from one type to other type.

The hinge:
Connect the handle with the peek.

The handle:
they are usually serrated to grasping it tightly.

HOW TO DIFFERENTIATE BETWEEN UPPER AND LOWER FORCEOS:

Upper forceps: straight no angle between the handle and the peak (there are a
slight curves in the handle).

Lower forceps: right angel between the handle and the peak.

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HOW TO DIFFERENTIATE IF THE FORCEPS FOR MOLAR OR PREMOLAR OR ANTERIOR TEETH: If it contain notch that means its for molar because the molar have bifurcation area but if it is not then its for premolar and anterior teeth.

This notch tell you that this forceps is for molar teeth

NOTE
The maxillary forceps the peek and the handle are in the same level but sometime we have additional part (curve/angle) to reach the posterior teeth in the maxilla. Its called bayonet forceps.

Its help to reach the posterior teeth specially the maxillary 3rd molar. In the maxilla.

How many notch we expect to have? In the mandibular teeth we have 2 roots >> 1 bifurcation area in each side >>>So, we have 2 notches (the 1st notch touch the tooth buccaly and the other one lingualy) In the maxillary teeth we have 3 root (mesiobuccal, destobuccal and palatal root) >> 1 bifurcation area >> 1 notch buccaly. HOW WE CAN DIFFERENTIATE IF THE FORCEPS IS FOR RIGHT OR LEFT SIDE:

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 In the mandible the right and the left forceps are the same. Because we have 2 notch in both side buccaly and lingualy. In the maxilla there is deference between right and left because we have one notch and we should put it buccaly. And the concave part of the maxillary forceps handle should face the palm of the hand.

HOW WE CAN KNOW IF IT FOR ROOT OR TOOTH WITH CROWN: We look to the top of the peek, if it closed completely that means its for the root (tooth with fracture crown). But if there is a very small space that means its for tooth with crown

There is a small space. So, its for the tooth with crown.

Its completely closed. So, its for extract the root.

NOTE There is no rule to know if the forceps is for premolar or anterior teeth. Because
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We need to see both of them beside to each other because we depend on the size of the blade; its bigger in the premolar than the anterior teeth. THE MECHANICAL PROCEDURE OF EXTRACTION: 1* Local anesthesia 2* Detachment of the gingival attachment:
Separating the gingiva as much as you can and the PDL fibers from the tooth, allowing area for the placement of the forceps. Then you can apply the forceps as much as you can apically. (You should inter the peek as apical as possible below the cement-enamel junction). Luxation of the tooth with an elevator which help us in extraction. We should apply the forceps below the level of the cement-enamel junction (on the root) that means you make something called wedging. Wedging: create a space between the tooth and the socket. This forced the tooth to go outside. 3* fitting force:

You apply the forceps on the tooth in a proper way: Open the peek Apply the peek on the lingual surface Finally apply the peek on the bucal surface You should make a firm fit NOT strong fit Firm fit: you put the forceps in the proper way as apically as possible, so the tooth and the forceps move as one unit. Strong fit: you catch the tooth but not in the proper way so you may fracture it. 4* moving the tooth: We start move the tooth by push it inside to release the periodontal ligament then move it bucco-lingually with increase the force in each time repeating the movement so the socket expand. We have an exception for the * upper central incisors and * lower premolars because they have a conical root so we move it in a rotational movement in
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addition to the bucco-lingual movement. (the 2nd premolar need mor rotation than the 1st premolar) In all teeth we go buccaly more than lingualy except in the lower 2 nd and3rd molar we go lingually more because the bone buccaly is thinner in this area. So, its movement called lingo-buccal movement. Again we should fit apically as possible as we can; to make the center of rotation go apically more. So; the chance of fracture decreased. 5* -squeeze (compress) the socket, the expanded socket is compressed between the left thumb and forefinger, this helps to prevent infection, aids in homeostasis, and reduce distortion

THE JOB OF THE OPPOSITE HAND: You will use your 2 hands:

One to do the extraction as we said before Other one help you in:
Reflect and protect the soft tissue Support and stabilize the patient head and jaw Transmit tactile information to the operator about the movements Control our work so we dont fracture the tooth

Anatomy of the teeth:

Its important to know the anatomy of the teeth to decide which forceps I will use and what the type of movement I need. Upper central incisor it has single, strait and conical root labial alveolar bon is thicker than palatal bone
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 Relation-nasal floor: so if you use more force you may push it to the nasal floor. Movement: - Bucco-lingual movement - Rotational movement

Upper lateral incisor It has single root but it go to palatal side and sometime it contain palatal curve. So if I do rotation the palate will be fracture. Its thicker than the central incisor and its thilabialy than the palatal side. Bucco-lingual movement Upper canine Its locate between the nasal floor and maxillary sinuses It has single, long and strong root Bucco-lingual movement Upper first premolar

The king of fracture. More than 50% has 2 roots It has a thin and tapered root Bucco-lingual movement

Upper second premolar

Its easier to extract than 1st premolar

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 It has thin alveolar bon around it especially in the buccal side Mostly single root Bucco-lingual movement

NOTE The closest tooth to the maxillary sinuses is the palatal root of the 1st molar, so its the most common one to go inside it. Lower incisor Single root but it isnt conical Bucco-lingual movement

Lower canine The root is shorter than maxillary one so its extraction is easier. Bucco-lingual movement

Lower premolars Single conical root Movement: - Bucco-lingual movement - Rotational movement - The 2nd premolar is more rotational than the first premolar

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NOTE : From the mandibular second premolar, we go lingually more than buccaly. When we work in the mandible we should support it to prevent the dislocation: - Index labialy. - Thump in the lower border of the mandible. - Middle fingers lingually.

In the maxilla we should support it also, lingually and labialy.

Done by: hebahra3d ramadneh

Life is like a piano, the white keys represent love and happiness, and the black ones represent sorrow and sadness, to hear a beautiful music of life. You should play

both!
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Summary for this lecture

Types of extraction: Intra alveolar (do nothing with the bone) Trans alveolar (work with the bone)
Indication of tooth extraction: *advanced caries, PDL disease, pulpal necrosis, orthodontic, trauma, cyst/tumor, peripical infection, fracture, prosthetic, esthatics reason. Patient position: Dental chair should be semi reclined and the head set supported. For the maxilla the head should be 45-60, in the mandible its up-right. In the maxilla the tooth should be 8cm from the operator shoulder, in the mandible its 16cm below the elbow. Operator position: In all teeth he should stand in front of the patient in the right side except: If the operator is right handed > the exception is the lower right >> the operator should stand posteriorly to the patient in the right side. If the operator is left handed > the exception is the lower left >> the operator should stand anteriorly to the patient in the left side. If the operator is right handed > the exception is the lower right >> the operator should stand posteriorly to the patient in the right side.

The forceps: Its the most important instrument in the extraction procedure, its composed of: 1) The handle 2) the hinge 3) the peek this part is defer from tooth to other-. Upper forceps has strait angle and the lower has right angle. Bayonet forceps contain additional curve to reach upper 3rd molar.
Upper forceps contain 1 notch, the lower contain 2 notches. Lower right and left forceps are the same, but the upper right and left different from each other, we differentiate between them by: *we should put the notch buccaly. *And the concave part of the maxillary forceps handle should face the palm of the hand.
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If the peek blades completely closed that means its for extract the root, if not they are for the crown.

There is no rule to know if the forceps is for premolar or anterior teeth. Note: to extract the tooth we should do: gingival detachment and wedging. So, you should put the
peek lingually then buccaly and close it to get firm fit.then we start moving the tooth: All teeth should move bucco-linually , buccaly more than lingual except in the lower 2nd and 3rd molar, we go lingually more than buccaly. Upper central incisor and lower premolar should move in rotational movement 2nd premolar more rotational than 1st premolar. The job of the opposite hand:

Reflect and protect the soft tissue Support and stabilize the patient head and jaw Transmit tactile information to the operator about the movements Control our work so we dont fracture the tooth

Note:
The closest tooth to the maxillary sinuses is the palatal root of the 1st molar, so its the most common one to go inside it. The king of fracture is the upper 1st premolar. When we work in the mandible we should support it to prevent the dislocation: - Index labialy. - Thump in the lower border of the mandible. - Middle fingers lingually.

In the maxilla we should support it also, lingually and labialy.

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