An ideal extraction of tooth is defined as painless removal of tooth or root of tooth from its bony attachments with minimal injuries to surrounding investing structures such that there will be minimum post operative complications.
1. INDICATION FOR EXTRACTION OF PERMANENT TEETH :
» Grossly decayed teeth which cannot be saved by conservative procedures.
» Teeth that are foci of infection.
» Teeth with non-vital pulp, where root canal is not possible.
» In case of severe periodontoclasia in which excessive bony support of the teeth is » destroyed.
» Teeth in line of radiation therapy.
» Teeth mechanically interfering with placement of restorative appliances.
» Impacted or unerupted teeth.
» Supernumerary teeth.
» Retained deciduous teeth.
» Tooth with fractured roots.
» Malposed teeth not amenable to Orthodontic treatment.
» Roots and fragments.
» Teeth traumatizing soft tissues.
» Teeth associated with cysts and other pathologies.
2. INDICATION FOR EXTRACTION OF DECIDUOUS TEETH :
» Extensive decay resulting in death of the dental pulp.
» Extensive decay which makes pulpotomy and pulpectomy impossible.
» When the deciduous teeth interfere with the normal eruption and alignment of their permanent successor.
» When there is sinus opening through mucoperiosteal membrane.
» When roentgenogram reveals evidence of periapical infection.
» When the root is fractured as a result of subsequent infection.
» Supernumerary teeth.
A. Absolute :
- Central Haemangioma. May cause uncontrolled bleeding.
- A-V malformation.
B. Relative :
When some precautions have to be taken.
SELECTION OF ANESTTHETIC AGENT :
- 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 ].
Choice is determined by :
1. Patient’s desire.
2. Operating dentist’s personal preferences.
3. Patient’s physical condition.
4. Age of the patient.
5. Type of the operation.
6. Condition of the operating site is there any infection.
7. Place of operation.
Local Anesthesia is the choice in majority of cases.
EXAMINATION OF TEETH
1. TOOTH TO BE EXTRACTED :
- Is the tooth carious?
- Is it abraded?
- Does it contain large filling?
- Does the tooth have artificial crown?
- Size of the tooth.
- Formation size and number of roots.
- Hypercementosis present on the root or roots.
- Is there on area of condensing or infective osteitis?
- Condition of roots.
- Position of roots.
- Relationship with adjacent teeth, tuberosity and maxillary sinus, mandibular canal.
2. DENTAL RADIOGRAPHS AND EXTRACTION OF TEETH
- Radiographs are an invaluable aid to the surgeon in preventing untoward incident such as fracture of mandible, tearing of floor of the maxillary sinus.
- Intelligent planning of the proposed surgery.
- Small intra-oral filling are necessary to take extra oral views to completely visualize impacted molars. Also necessary to localize position of the teeth.
3. EXAMINATION OF THE SUPPORTING HARD AND SOFT TISSUES.
4. AGE OF THE PATIENT: IN ELDER PATIENT TEETH IS BRITTLE AND IS MORE DENSE AND OPPOSITE IS THE CASE IN YOUNGER INDIVIDUALS.
5. PREVIOUS EXTRACTION
STEPS IN INTRA ALVEOLAR EXTRACTION :
- Closed [intra alveolar technique]. When using forceps and elevators and exerting force.
- Open [Tran alveolar technique/ surgical extraction]. When a flap is raised, surrounding bone is cut and then taking the tooth out either as a whole. Or in segments.
SURGICAL EXTRACTION :
- Pre extraction evaluation of patient—History, clinical examination, investigation.
- Reflection of attached gingival around the tooth so that there id no trauma to the tooth and also to have a firm grip over the tooth.
- Application of elevators and forceps.
- Withdrawal or removal of tooth.
- Compression of socket—to achieve haemostasis and to bring back the dilated cortical plates.
- Debridement of socket.
- Achieve haemostasis.
- Post extraction instructions.
1. Impacted teeth.
2. When tooth fails to be extracted under intra alveolar method.
3. If tooth is broken at alveolar level or the root is broken.
1. Pre extraction evaluation of patient.
3. Elevation of mucoperiosteal flap.
4. Bone removal — by chisel/mallet or burs.
a. Buccal guttering.
b. Postage stamp technique.
6. Tooth removal.
7. Achieving haemostasis.
8. Wound debridement.
9. Suturing the mucoperiosteal flap.
10. Post extraction instructions.
11. Recall / review after 7 days and suture removal.
POST OPERATIVE INSTRUCTIONS :
Keep the sponge held firmly between your jaw and over the operative site for full half an hour.
Do not use mouthwash for six hours after oral surgery; vigorous use of mouthwash may stimulate bleeding.
In case of mild bleeding place lukewarm water in the mouth. In case of severe bleeding place a warm soaked tea bag over the bleeding and cover it with gauze biting firmly and call your dentist.
In case of swelling and followed by discoloration, patient need not worry because it’s an absolutely normal event.
Pain in case or afterwards of surgical procedure is a normal phenomenon. Post operative pain can be controlled by taking medicine. If severe pain develops accompanied by bad taste then return to your dentist for this treatment.
To control swelling which develops post operatively apply ice pack or towels wrung out of ice water. Day after operation, apply heat to your face.
Rigid cleanliness is necessary of the remaining teeth. Mouth wash in a glass of lukewarm water. This promotes healing.
Avoid meat and food difficult to masticate for a few days. Eat plenty of fruits and drink eight to ten glasses of water, fruit juice and other fluids daily.
POST OPERATIVE VITAMIN THERAPY :
SOME IMPORTANT COMPLICATIONS OF EXTRACTION :
- After oral surgery there is diminished in take of vitamin therapy i.e. Vitamin C & B complex.
- Drugs especially analgesics decrease the level of vitamin C in the body.
- Ascorbic acid is essential for the maintenance of normal cellular material of connective tissues, bone, teeth and blood vessels. If vitamin C level falls, healing is retarded, capillary fragility is increased.
In some unusual cases, there may be:-
a. Failure to secure anaesthesia.
b. Fracture of crown, root, alveolar bone, adjacent tooth, maxillary tuberosity, mandible.
c. Dislocation of adjacent tooth, TMJ.
d. Displacement of root into soft tissues, maxillary antrum.
e. Excessive haemorrhage – during, after completion and post operatively.
f. Damage to soft tissues, adjacent nerves.
g. Post operative pain due to dry socket.
h. Post operative swelling – oedema, haematoma, infection.
i. Trismus – inability to open mouth fully.
k. Oro-antral communication.
l. Respiratory arrest, cardiac arrest.
a. Pressure packs.
c. Styptics—Thrombin, gelatin foam, ethamsylate, botropase, adrenaline, etc.
d. Bone wax.
It is a condition characterized by loss of clot in socket, sever throbbing pain, bad odour, which is usually manifested after 48 hrs following the extraction.
2. Excessive trauma during extraction.
It is more common in mandible than in maxilla and more so in posterior region than in anterior region.
It happens more in females than males. Old age is more prone for this condition. Smokers are affected more than non-smokers.
a. Severe throbbing pain.
b. Bad breath.
c. Empty socket appearance.
d. Cervical lymphadenopathy.
Local dressing in the dry socket. Eg. ZnOE paste, BIPP, Metronidazole gel.
Usually symptomatic, giving antipyretics, analgesics, etc. A course of Metronidazole 400 mg TID is recommended.
1. Minimum trauma during extraction.
2. Avoid smoking after extraction.
3. Chlorhexidine mouthrinse from 2 days prior to extraction.
4. Warm saline mouthrinse 24 hrs. after extraction.
It is sudden transient loss of consciousness secondary to cerebral ischaemia.
Predisposing factors :-
c. Emotional Stress.
d. Sudden pain.
e. Sight of blood.
f. Sight of surgical instruments.
· Non Psychogenic
a. Upright / standing position.
d. Poor physical condition.
e. Hot humid climate.
Critical level of cerebral blood flow required to maintain unconsciousness is 30 ml/100gm of brain tissue/minute. When a patient is still maintained in upright position, ability of heart to pump blood to brain is impaired leading to loss of consciousness.
Early – Feeling of warmth, pale appearance, heavy perspiration, complaint of feeling bad or weak or giddy, nausea, rapid heart rate.
Late — Pupillary dilatation, yawning, coldness in hands, hypotension, bradycardia, visual disturbances, dizziness.
All this eventually leads to unconsciousness.
1. Place patient in supine position with feet elevated.
2. Establish patent airway with chin lifted and head tilted.
3. Check breathing.
4. Loosen clothings.
5. Monitor vital signs like blood pressure, heart rate, respiratory rate.
6. Spirit of ammonia – nose.
7. Spray cold wave.
8. Maintain verbal conversations.
9. If pulse < 30/minute, administer Atropine 0.4 mg IV. It increases heart rate.
10. Transient hypoglycemia—Administer 50 % dextrose in saline IV.