Patient positioning when extracting teeth

• Maxillary teeth: 3 inch below shoulder level of operator and 45 degree chair angulation
• Mandibular teeth: At elbow level of operator and 90 degree chair angulation
• 1st, 2nd and 3rd quadrant: Right front of patient
• 4th quadrant anterior teeth: Right front of patient
• 4th quadrant posterior teeth: Behind right side of patient/ just right side

Tooth extraction forceps and elevators

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Tooth extraction techniques

Elevator techniques

Elevators works on principles of:

1. Wedge
2. Lever
3. Wheel and axle
4. Combination of the above

1. Wedge principle

2. Lever principle

3. Wheel and axle

Post extraction steps

• Ensure complete tooth and root removal and confirm by showing to patient
• Inspect socket and remove sharp bony margins – if present smoothen with a file
• Compress expanded socket with digital pressure
• Apply pressure pack
• Prescribe analgesics if needed

Post op instructions for patient

• Bite on pressure pack for 30-60 minutes
• Swallow saliva normally
• Do not rinse or spit for 24 hours
• Do not stick finger or tongue at extraction site
• Drink water and fluids normally, do not use straw
• Do not eat until the effects of anesthesia go away
• Eat soft and cold diet
• Apply cold compression/ice pack for swelling
• After 24 hours use salt water rinse
• Avoid smoking for 5 days

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Indications

1. Gross caries
2. Tooth injury and tooth cannot be salvaged
3. Tooth in jaw fracture line
4. Impacted tooth
5. Pre-prosthetic preparation
6. Orthodontics
7. Supernumerary teeth
8. Associated pathology
9. Severe periodontal disease
10. Retained deciduous teeth
11. Patient preference/economic constraints
12. Preparation for radiotherapy

Contraindications

Local:

1. History of irradiation in that area
2. Lack of cooperation or consent from patient
3. Lack of proper equipment
4. Lack of adequate skill
5. Severe infections – control infection first

Systemic:

1. Severe metabolic disease – uncontrolled DM, renal disease
2. Hepatic dysfunction – decreased coagulative factors
3. Coagulopathies – hemophilia, platelet disorder
4. History of CVD
5. Leukemia
6. Pregnancy
7. Steroid therapy

NB:

• Avoid extraction during menstruation – risk factor for alveolar osteitis

Complications

a. Complication due to injection technique and anesthetic solution:

• Needle breakage
• Failure to work
• Allergy
• Syncope
• Hematoma if in vessel

b. Complication pre-op

• Lack of cooperation, anxiety
• Poor access – trismus, decreased mouth opening, crowded/malaligned teeth

c. Complications during surgical procedure

• Difficulty in luxation – root dilaceration, curvature, hypercementosis
• Soft tissue injury
• Damage to adjacent teeth
• Fracture of mandible, alveolus or tuberosity
• Fractured instrument – eg. needle
• Tooth/root displacement into maxillary antrum – Caldwell Luc approach to remove
• Loss of extracted tooth or root – stop everything and look for it, can do chest xray
• Nerve injury:
  • Neuropraxia – temporary conduction loss
  • Axonotmesis – axon and myelin sheath damaged but epineurium, perineurium and endoneurium intact
  • Neurotmesis – nerve transection
  • Paresthesia – tingling/prickling sensation
  • Dysesthesia – abnormal sensation
  • Hyperesthesia
  • Hypoesthesia
  • Anesthesia
  • Formation of:
    • Phantom limb syndrome
    • Anesthesia dolorosa – sense of touch diminished but malfunctioning painful sensation left intact in trigeminal nerve

d. Complications after procedure

• Hemorrhage
  • Primary – laceration of artery, surgery done in infected area with granulation tissue
  • Reactionary – occurs few hours after surgery , failure of coagulation
  • Secondary – 7-10 days after surgery, due to infection + partial division of blood vessel
• Alveolar osteitis
• Infection
• Delayed healing
• Pain