Tooth extraction

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

Wedge principle

2. Lever principle

Lever principle

3. Wheel and axle

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

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:

Complications

a. Complication due to injection technique and anesthetic solution:

  • Needle brakage
  • 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

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