exodontia (NXPowerLite) /fixed orthodontic courses by IDA

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats. Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics, Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call 0091-9248678078

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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com EXODONTIA

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EXTRACTION: Is defined as the painless removal of the whole tooth,or tooth-root, with minimal trauma to the investing tissues,so that the wound heals uneventfully and no post-operative prosthetic problem is created. www.indiandentalacademy.com

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OBJECTIVES: Severe the periodontal attachments carefully Lever the tooth out of the alveolar socket without damaging adjoining structures and anatomical areas. www.indiandentalacademy.com

BASIC REQUIREMENTS::

A good radiograph Adequate anesthesia Instruments Adequate illumination Efficient assistance Suction apparatus BASIC REQUIREMENTS : www.indiandentalacademy.com

PRINCIPLES OF EXODONTIA::

To gain adequate access and to obtain secured grip on the tooth To apply controlled force in a predetermined direction To severe the dentoalveolar bondage with minimum trauma To safely deliver the tooth in- toto out of the socket through an uninterrupted path of removal with minimum pain and discomfort to the patient. PRINCIPLES OF EXODONTIA: www.indiandentalacademy.com

INDICATIONS::

Severe caries or pulpal necrosis Severe periodontal disease Therapeutic extraction in orthodontic Rx Impacted,malposed or supernumerary teeth Teeth prior to irradiation Retained decidious teeth Preprosthetic extractions Teeth in line of fractures Infected teeth or teeth associated with pathologic lesions # tooth/ root,teeth which are foci of sepsis INDICATIONS: www.indiandentalacademy.com

CONTRAINDICATIONS::

ABSOLUTE RELATIVE SYSTEMIC LOCAL CONTRAINDICATIONS: www.indiandentalacademy.com

SYSTEMIC::

Uncontrolled metabolic diseases like diabetes mellitus,end stage renal disease Bleeding disorders like hemophilia,platelet disorders,uncontrolled leukemias,lymphomas Severe MI,unstable angina pectoris,uncontrolled hypertension Acute adrenaline crisis,long term steroid therapy First and third trimester of pregnancy Toxic goitre,liver disorders SYSTEMIC: www.indiandentalacademy.com

LOCAL::

Tooth in irradiated area Tooth in area of malignant tumour Third molars with severe pericoronitis Pathology like AV malformation of bone,central hemangioma Acute abscess LOCAL: www.indiandentalacademy.com

TYPES OF EXTRACTION::

CLOSED METHOD/FORCEPS EXTRACTION/INTRA-ALVEOLAR EXTRACTION-consists of removing the tooth or root by use of forceps or elevators or both OPEN METHOD/SURGICAL/TRANS-ALVEOLAR EXTRACTION-consists of dissecting the tooth or root from bony attachments by removal of some bone investing the tooth/ roots,which are then delivered by use of elevators and/or forceps TYPES OF EXTRACTION: www.indiandentalacademy.com

CLINICAL EVALUATION OF TEETH::

Access to the tooth Mobility of the tooth Condition of the crown of the tooth Condition of the adjacent tooth CLINICAL EVALUATION OF TEETH: www.indiandentalacademy.com

RADIOGRAPHIC EXAMINATION OF THE TOOTH::

IOPA with accurate and detailed information concerning the tooth,its roots,and surrounding tissues is preffered . Relationship of associated vital structures Configuration of roots Condition of the surrounding bone RADIOGRAPHIC EXAMINATION OF THE TOOTH: www.indiandentalacademy.com

POSITION OF PATIENT CHAIR AND OPERATOR::

POSITION OF PATIENT CHAIR AND OPERATOR: EXTRACTION OF MAXILLARY TEETH www.indiandentalacademy.com

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EXTRACTION OF MANDIBULAR TEETH THIRD QUADRANT FOURTH QUADRANT www.indiandentalacademy.com

ROLE OF DENTIST’S LEFT HAND::

In maxilla ,index finger and thumb of left hand is used to support the maxilla and rest 3 fingers to stabilize patient’s head In mandible,index and middle finger is used to retract and support intraorally ,while thumb supports the mandible.If dentist is standing behind the patient then thumb and index finger is used intraorally and rest 3 fingers support mandible. Retraction of lips,cheek and tongue Guiding beaks of forceps onto tooth Couteracting the pressure applied Prevention and protection against slipping of forceps Prevent broken fillings or tooth fragments before it reaches oropharynx Compressing buccal and lingual cortical plates Examination of surgical field for bony edges,undercuts ROLE OF DENTIST’S LEFT HAND: www.indiandentalacademy.com

MECHANICAL PRINCIPLES INVOLVED IN EXTRACTION:

1. LEVER PRINCIPLE OF FIRST ORDER: 3 basic components- fulcrum,effort,load Fulcrum is b/n effort and load Maximum advantage is when effort arm is longer than load arm Used in forceps along with wheel and axle and in elevators MECHANICAL PRINCIPLES INVOLVED IN EXTRACTION www.indiandentalacademy.com

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2. WEDGE PRINCIPLE: Here 2 movable inclined planes with a base on one end and blade on other end Effort is applied to the base of the plane and resistance has its effect on slant side Used to split,expand or displace the portion that receives it Elevators to luxate tooth when applied b/n bone and tooth Forceps when inserted b/n mucoperiosteum and surface of tooth www.indiandentalacademy.com

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WHEEL AND AXLE PRINCIPLE: Effort is applied to circumference of wheel which turns the axle so as to raise the weight Greater the diameter of wheel more is the mechanical advantage Used in crossbar elevators for removal of mandibular roots Forceps –applied in the form of arc www.indiandentalacademy.com

PRINCIPLES OF FORCEPS USE::

Forceps can be applied in five major motions. 1.Apical pressure 2.Buccal pressure 3.Lingual pressure 4.Rotational pressure 5.Tractional pressure PRINCIPLES OF FORCEPS USE: www.indiandentalacademy.com

PROCEDURE FOR CLOSED EXTRACTION::

1.Adequate anesthesia 2.Loosening of soft tissue attachment from the tooth -using woodson elevator or sharp end of no.9 periosteal elevator 3.Luxation of tooth with a dental elevator 4.Adaptation of forceps to the tooth 5.Luxation of tooth with forceps 6.Removal of tooth from the socket PROCEDURE FOR CLOSED EXTRACTION: www.indiandentalacademy.com

BASIC FORCES EXERTED IN EXTRACTION OF MAXILLARY TEETH::

First is the apical force. Central incisors-labial pressure,lingual,then labial with mesial rotation Lateral incisors-labial with mesial rotation Cuspids-labial,lingual,labial with mesial rotation 1 st PM- Buccal,lingual,removal in buccal direction 2 nd PM- Buccal,lingual,removal in lingual or buccal direction 1 st &2 nd molar- buccal,lingual & removal in buccal direction 3 rd molar- buccal & distal rotation BASIC FORCES EXERTED IN EXTRACTION OF MAXILLARY TEETH: www.indiandentalacademy.com

BASIC FORCES EXERTED IN EXTRACTION OF MANDIBULAR TEETH::

First is the apical force. Central & lateral incisors- labial,lingual,slight mesio -distal & removal in labial direction Cuspids -labial pressure with mesial rotation 1 st & 2 nd PM- Buccal pressure with slight mesio -distal rotation 1 st ,2 nd & 3 rd molar- buccal,lingual & removal in buccal direction BASIC FORCES EXERTED IN EXTRACTION OF MANDIBULAR TEETH: www.indiandentalacademy.com

POST EXTRACTION CARE OF TOOTH SOCKET::

Saline or betadine irrigation Thorough curettage in case of periapical lesion Compress bucco -lingual plates with finger pressure In case of severe periodontitis excessive granulation tissue must be removed Sharp bony projections if any must be smoothened with bone file Gauze pressure pack for control of bleeding POST EXTRACTION CARE OF TOOTH SOCKET: www.indiandentalacademy.com

POST EXTRACTION INSTRUCTIONS GIVEN TO THE PATIENT::

Explain the patient effects of LA Hold the gauze in mouth for atleat half an hour Avoid spitting and gargling for the day Warm saline rinses after 24hrs Not to disturb the area with finger or tongue Avoid hot,spicy and hard food Analgesics , antiinflammatory for 3 days Antibiotics if patient is immunocompromised Avoid brushing in the area for 24hrs POST EXTRACTION INSTRUCTIONS GIVEN TO THE PATIENT: www.indiandentalacademy.com

CAUSES FOR TOOTH FRACTURE::

1.Operator’s fault-application of incorrect instrument and force -improper technique of application -improper motions 2.Structural abnormality of tooth-excessively curved roots -RC treated nonvital tooth -teeth with gross filling -extensively carious teeth - ankylosis or hypercementosis 3.Surrounding bone-sclerosis or condensing osteitis 4.Unco-operative patient CAUSES FOR TOOTH FRACTURE: www.indiandentalacademy.com

METHODS FOR RETRIEVAL OF FRACTURED ROOT::

Retained roots might prove as a source of infection,chronic irritation giving rise to neuralgic pain or might interfere with proper functioning of denture Excellent light and suction Closed technique when tooth is well luxated and mobile before fracture Root tip pick,small elevator,forceps with slender beaks,reamers If not then open method should be attempted METHODS FOR RETRIEVAL OF FRACTURED ROOT: www.indiandentalacademy.com

ORDER OF EXTRACTION::

First is usually maxillary teeth as they get anesthetized earlier and prevents fall of enamel or amalgam/debris into mandibular socket Most posterior teeth is extracted first The order is 3 rd molar,2 nd molar,2 nd premolar,1 st molar,1 st premolar,lateral incisor,canine,central incisor. ORDER OF EXTRACTION: www.indiandentalacademy.com

EXTRACTION OF DECIDUOUS TEETH::

Indications-gross caries involving pulp -retained primary teeth interfering with normal eruption of permanent successor - periapical pathology/root fracture Technique -smaller forceps -for U/L anteriors labial pressure with mesial rotation and removed to labial side -for U/L molars buccal pressure ,lingual pressure and removed to lingual side -force applied is less and forcep need not be inserted too deep along the root -care should be taken not to damage permanent successor EXTRACTION OF DECIDUOUS TEETH: www.indiandentalacademy.com

TRANS-ALVEOLAR EXTRACTION:

INDICATIONS: Any tooth which resists attempt at closed extraction Heavy/dense bone,short clinical crown due to attrition Hypercementosis,ankylosis,geminated & dilacerated roots Impacted tooth Retained fractured tooth/roots which cannot be grasped with forceps or elevators Roots in close proximity with vital structures like nerve or sinus Grossly destructed,heavily restored,RCTreated Prosthetic considerations TRANS-ALVEOLAR EXTRACTION www.indiandentalacademy.com

PROCEDURE::

Anesthesia- LA,plan for incision Elevation of mucoperiosteal flap Removal of bone-chisel mallet or bur Division of tooth if required Removal of tooth and roots Control of bleeding Alveoloplasty if required Toileting of the alveolar socket Suturing of flap PROCEDURE: www.indiandentalacademy.com

MUCOPERIOSTEAL FLAP::

The term local flap indicates a section of soft tissue that Is outlined by a surgical incision Carries its own blood supply Allows surgical access to underlying tissues Can be replaced in the original position Can be maintained with sutures and is expected to heal MUCOPERIOSTEAL FLAP: www.indiandentalacademy.com

DESIGN: -Base of flap must be broader than free gingival margin -must be of adequate size to provide access & visibility -long,straight incision over intact bone -full thickness flap -6-8mm away from bony defect to prevent collapsing of flap into it -preserve vital structures -vertical releasing incision is oblique incision which cross free gingival margin at line angle of tooth and not on facial aspect or papilla. :

DESIGN: -Base of flap must be broader than free gingival margin -must be of adequate size to provide access & visibility - long,straight incision over intact bone -full thickness flap -6-8mm away from bony defect to prevent collapsing of flap into it -preserve vital structures -vertical releasing incision is oblique incision which cross free gingival margin at line angle of tooth and not on facial aspect or papilla. www.indiandentalacademy.com

TYPES OF MUCOPERIOSTEAL FLAPS::

TYPES OF MUCOPERIOSTEAL FLAPS: 1. ENVELOPE FLAP:most common flap -2 teeth anterior and one teeth posterior to area of surgery -releasing incision 1 tooth ant and 1 tooth post -3 cornered or 4 cornered 2. SEMILUNAR :to approach root apex -avoids trauma to papilla & gingival margin -limited access,used in periapical surgery -should not cross canine eminence 3. Y INCISION:palatal tori,preserves greater palatine artery www.indiandentalacademy.com

TECHNIQUES FOR DEVELOPING MUCOPERIOSTEAL FLAP::

-no.15 blade is used on a no.3 scalpel handle and held in a pen grasp -blade is held at an angle & incision is made posteriorly to anterior in gingival sulcus - smooth,continuous stroke with blade in contact with bone -if vertical incision is to be placed ,tissue is apically reflected,with opp hand tensing the alveolar mucosa TECHNIQUES FOR DEVELOPING MUCOPERIOSTEAL FLAP: www.indiandentalacademy.com

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-start reflecting from papilla using woodson elevator or sharp end of no.9 periosteal elevator -carried out in pushing stroke,posteriorly and apically -once reflected flap is held with seldin or minnesota or austin retractor retsing firmly on sound bone. www.indiandentalacademy.com

BONE REMOVAL::

Bone removal must be limited carried out with dental burs or chisel with hand or mallet pressure CHISEL & MALLET: Quicker and cleaner Maxillary buccal and lingual plates can be removed Limiting cuts are placed vertically and then joined by horizontal cut If force is not controlled it might lead to fracture of basal bone or adjacent teeth DENTAL BURS: Used for dense mandibular bone Round bur no.8 or rose head burs are used,cut efficiently,do not clog,easier to control. BONE REMOVAL: www.indiandentalacademy.com

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flap must be held away from the site with a retractor Bur must not be allowed to overheat during bone removal,frequent irrigations with sterile normal saline should be used to prevent this and also removes debris and prevent bur from clogging Bone might be removed by either simply cutting it away or by bone guttering. A row of small holes is made with small bur along buccal crest and joined with fissure bur or chisel cuts.A gutter is formed.This is called postage stamp method. In case of lower PM,bone removal should be maximal medial to 1 st PM and distal to 2 nd PM to minimize damage to nerve & vessels traversing mental foramen www.indiandentalacademy.com

TOOTH SECTIONING::

Accomplished with a straight hand piece with a straight bur such as no.8 round bur or fissure bur no.557 or no.703 Sectioning is done from below upwards so that operator knows when the roots are completely divided TOOTH SECTIONING: www.indiandentalacademy.com

TECHNIQUE FOR OPEN EXTRACTION OF SINGLE ROOTED TEETH::

TECHNIQUE FOR OPEN EXTRACTION OF SINGLE ROOTED TEETH: www.indiandentalacademy.com

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TECHNIQUE FOR SURGICAL REMOVAL OF MULTI-ROOTED TEETH::

TECHNIQUE FOR SURGICAL REMOVAL OF MULTI-ROOTED TEETH: www.indiandentalacademy.com

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REMOVAL OF FRACTURED ROOTS BY OPEN METHOD::

REMOVAL OF FRACTURED ROOTS BY OPEN METHOD: www.indiandentalacademy.com

POLICY FOR LEAVING ROOT FRAGMENTS::

Root fragment must be small,not more than 3-4mm It must be deeply embedded in bone,to prevent subsequent bone resorption from exposing tooth root & interfering with prosthesis. Must not be infected & no radiolucency around root apex than The risk of surgery must be greater than benefit such as: Removal causes excessive destruction of surroundin tissue,bone or gingiva Endangers vital structures like inf alveolar nerve There are chances of displacing root into tissue spaces or into maxillary sinus Patient must be informed about the judgement and consent must be obtained. POLICY FOR LEAVING ROOT FRAGMENTS: www.indiandentalacademy.com

POST EXTRACTION CARE::

Check for sharp bony edges and filng has to be done. Currettage if there is periapical lesion Thorough irrigation with normal saline/ betadine . Most inferior portion of flap is common place for debris to settle especially in mandibular extractions which causes delayed healing or even small subperiosteal abscess in 3-4 days Flap is then set in original position & sutured in place with 3-0 black silk sutures Pressure pack is placed POST EXTRACTION CARE: www.indiandentalacademy.com

POST EXTRACTION INSTRUCTIONS::

Similar to that for closed method Inform the patient about swelling Antibiotics & analgesics Cold pack application may be advised Recall the patient after 5 days for suture removal and access the healing. POST EXTRACTION INSTRUCTIONS: www.indiandentalacademy.com

CONCLUSION::

Presurgical assessment of the patient includes evaluation of level of anxiety,determination of health status and necessary modifications of routine procedures,evaluation of clinical presentation of tooth to be removed,and radiographic evaluation of tooth root and bone. All four factors must be weighed when estimating difficulty of extraction and least traumatic and efficient tooth removal should be performed. CONCLUSION: www.indiandentalacademy.com

REFERENCES::

CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY-4 th ed;LARRY.J.PETERSON THE EXTRACTION OF TEETH- GEOFFREY.L.HOWE ORAL AND MAXILLOFACIAL SURGERY-5 th ed;W.HARRY ARCHER TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY- BALAJI REFERENCES: www.indiandentalacademy.com

Thank you…:

Thank you… www.indiandentalacademy.com www.indiandentalacademy.com Leader in continuing dental education

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