Extraction of teeth

Question 1

Some indications for extraction of teeth

Answer 1

• Periodontal disease
• Pulpal disease
• Pathological lesions surrounding the teeth
• Crown and root fracture
• Before radiation therapy
• Orthodontic indications
• Supernumerary teeth
• Impacted teeth
• Malposition of teeth
• Teeth in bone fracture lines
• Caries

Question 2

Systemic contraindications for extractions

Answer 2

• Severe anxiety
• Haemophilia/other coagulopathies
• Uncontrolled diabetes
• Uncontrolled hypertension and cardiac diseases
• Ongoing radio-chemotherapy
• Medications that affect immune system/delay healing

Question 3

Particular attention should be paid to following medications

Answer 3

• Anticoagulants
• Cancer medication
• Glucocorticoids
• Immunosuppressants

Question 4

Local contraindications of extractions

Answer 4

• Acute inflammation or infection(if from pulpal diseases can be resolved by extractions)
• Lower third molar with pericoronitis
• Radiation therapy

Question 5

Reasons why operation contraindicated after radiation therapy

Answer 5

• Necrosis of bone(some cancer meds also cause necrosis of bone after extraction)
• Delayed healing
• Dehiscence

Question 6

Clinical features evaluated before extraction

Answer 6

• Condition of crown
• Tooth and root mobility
• Access to perform extraction
• Pathology of pulp and surrounding tissues

Question 7

Importance of radiographic assessment pre extraction

Answer 7

Evaluates difficulty of extraction by assessing:

• Root anatomy
• Pathology in surrounding bone
• Ankylosis or hyper-cementosis of root
• Proximity of molars to sinus in maxilla
• Position of mandibular canal(relation to third molars)
• Position of mental foramen(where flap is raised to remove premolars)

Question 8

Most common radiograph for extractions

Answer 8

Periapical

Question 9

Radiographs for assessing impacted teeth

Answer 9

• Panoramic
• Scanogram
• Cone beam

Question 10

Sinus rupture results in

Answer 10

Oroantral communication

Question 11

Preoperative mouth rinse can be done with

Answer 11

Chlorhexidine

Question 12

Patient position for extraction of Maxillary teeth

Answer 12

• Patient mouth at same height as dentist shoulder
• 120 ° angle between dental chair and floor
• Occlusal surface of maxillary teeth at 40 ° when open compared to horizontal

Question 13

Patient Chair position for extraction of mandibular teeth

Answer 13

• 110 ° angle between chair and floor
• Occlusal surface of mandibular teeth parallel to floor when mouth open

Question 14

Surgeon position for extraction with forceps for maxillary teeth

Answer 14

-Infront or to the side of the patient

Question 15

Surgeon position for extraction with forceps for mandibular teeth

Answer 15

• Right posterior and anterior teeth→ behind patient
• Left mandibular teeth→ in front of patient

Question 16

Two stages of extraction

Answer 16

• Tooth separated from surrounding soft tissues→ Desmotome or elevator
• Tooth extracted from socket→ forceps or elevator

Question 17

Desmotome use

Answer 17

• Pen grip with dominant hand
• Positioned at bottom of gingival sulcus to sever PDL
• Continuous motion from mesial to distal→ buccally then lingually/palatal
• Non dominant hand→ index finger and thumb positioned on buccal and palatal

Question 18

Elevator Function

Answer 18

Push or reflect gingiva→ allows extraction forceps to grasp tooth beneath cervical line

Question 19

Extraction technique with forceps

Answer 19

• Beaks of forceps at cervical line of tooth→ parallel to long axis of tooth
• Gentle initial buccal then lingual/ palatal movements
• Gradual increase in pressure first at buccal(bone thinner and more elastic)
• Rotational force if roots single and conical
• Slight traction to facilitate extraction but not used at final stage
• Final movement → Maxilla=buccal and curved outwards and upwards

→ Mandible=Buccal direction and curved outwards and downwards

Question 20

Extraction technique of maxillary central incisor

Answer 20

• Initial gentle labial and palatal movements
• Increase in force first at labial
• Rotational forces permitted due to conical root
• Slight traction

Question 21

Extraction technique of maxillary lateral incisor

Answer 21

• Labial and palatal movements with forceps
• Rotational forces not permitted(thin root curved distally)→only very slight rotation at final stage with traction

Question 22

Extraction technique of maxillary canines

Answer 22

• Labial/palatal movements with increasing pressure
• Rotational movements not permitted due to distally curved root→ if used very slight w/ alternating buccopalatal pressure
• Final extraction movement labial

Question 23

Extraction technique for maxillary first premolar

Answer 23

• Initial buccal and palatal movements
• Rotational movements not permitted→ 2 roots w/ slight curve
• Final movement buccal

Question 24

Extraction technique for maxillary second premolar

Answer 24

• Same technique as first premolar
• Easier due to one root
• Final movement buccal

Question 25

Anatomy to consider during extraction of maxillary molars

Answer 25

- Three diverging roots(longest root palatal and two buccal roots w/distal curve) - Tooth firmly anchored to alveolar bone and buccal surface reinforced by extension of zygomatic process - Strong force required for extraction - Risk of oroantral communication→ root tips close to sinus

Question 26

Extraction technique for maxillary first and second molars

Answer 26

- Initial buccal and palatal pressure w/ emphasis on buccal - increasing pressure w/ final movement buccal w/ upwards curved movement

Question 27

Extraction technique for maxillary third molar

Answer 27

- If roots conical (fused)- simple w/ buccal pressure mostly to avoid thin palatal alveolar process fracture - If 3 or more roots→ buccal pressure w/ slight palatal pressure - Final extraction movement buccal -

Question 28

Extraction technique of mandibular incisor teeth

Answer 28

- Extraction easy→ thin alveolar bone and roots not firmly attached to alveolar bone - Labial and lingual movements w/ increasing pressure - Roots slightly curved esp. lateral→ slight rotational movement only

Question 29

Extraction technique of mandibular canines

Answer 29

- Same movements as incisors - Harder to extract than incisors→ longer root and curvature of root tip - Final movement labial curved outwards and downwards

Question 30

Extraction technique of mandibular premolars

Answer 30

- Buccal/lingual movements - Final extraction movement outwards and downwards - Easy extraction as roots straight and conical

Question 31

Anatomy to consider for mandibular first molar

Answer 31

-Two roots(mesial and distal) Mesial root larger, more flattened and curved distally -Distal root straighter, narrower and more rounded

Question 32

Anatomy to consider for mandibular second molar

Answer 32

-More easily removed despite denser bone→ roots smaller and less divergent(often fused together)

Question 33

Extraction of mandibular first and second molars

Answer 33

- Forceps as apical as possible beneath cervical line→ beaks parallel to long axis - Initial gentle buccal and lingual pressure - Gradual increase in force and final movement buccal

Question 34

Anatomy to consider for Extraction of mandibular third molar

Answer 34

- Two roots w/ similar morphology to other molars→ smaller and fused in conical shape w/ wide distal divergence - If one or two roots converge and curve in same direction→ straight elevator can be used - Lingual bone very thin compared to alveolar bone(unyielding in third molar area)

Question 35

Extraction technique for mandibular third molar

Answer 35

- Buccal/lingual pressure - Main force in lingual area to mobilise tooth - Careful pressure to avoid fracture in area of lingual plate

Question 36

Risk involved in extraction of deciduous teeth

Answer 36

May extract bud of permanent tooth(especially under deciduous molar as crown short0

Question 37

How to avoid extraction of underlying tooth bud

Answer 37

Beaks of forceps placed on mesial or distal area of tooth and not central(furcation area)

Question 38

Extraction technique of elevator

Answer 38

- Held in dominant hand w/ index finger along blade - Used buccally(not lingual/palatal) - Concave surface contacts mesial or distal - Alveolar bone used as fulcrum - In maxillary posterior teeth- perpendicular to long axis and in rest→ perpendicular, parallel or at angle

Question 39

Protective measure during elevator use

Answer 39

Cotton wool or gauze between finger and palatal to avoid injury if elevator slips

Question 40

Post extraction care of socket

Answer 40

- Periapical curette used at bottom of socket(removes granulation tissue preventing cyst) - If sharp and bony edges-ronguers forceps or bone file to smooth alveolar margin - Haemostasis aided by pressure on socket w/ gauze for 30-45 min

Question 41

Post operative instructions

Answer 41

- Rest - Analgesia - Edema - Bleeding - Antibiotics - Diet - Oral hygiene