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| IMC Wiki | Course and technique of an extraction

Course and technique of an extraction

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Requirements during extraction

If tooth removal is indicated and the patient has agreed to it, the dentist must proceed lege artis, ie, he/she must use the appropriate technique and appropriate instruments and must do everything carefully to eliminate or at least minimize possible risk to the patient (Gaisbauer 1997).
  • Protect the soft tissues
  • Protect adjacent teeth and antagonists
  • Rotation and luxation – no pulling
  • Support one hand on the alveolar process
  • Talk to the patient to calm him/her
  • Explain each treatment step to the patient before initiating it
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Position and approach of the operator

(descriptions apply to right-handed dentists.)

Aims of the approach
  • Protection of soft tissues against injuries by instruments
  • Stabilization of the alveolar process (fracture protection)
  • Check and see whether tooth has been loosened by feeling it during extraction

Extraction in the maxilla

The dentist is seated or stands in front of the patient.

Right upper quadrant
Thumb and index finger of the left hand grasp the alveolar process of the tooth to be extracted. The right hand guides the instrument.
#pic#
Left upper quadrant
The thumb grasps the alveolar process of the tooth to be extracted palatally, the index finger vestibularly; the right hand guides the instrument.
#pic#

Extraction in the mandible

Left lower quadrant
The dentist stands in front of the patient. The left hand fixes the mandible with the three-finger grip, the right hand guides the instrument.
#pic#
Right lower quadrant
The dentist stands at a 10 o\'clock position (in relation to the patient) and reaches around the patient\'s head, holding it firmly with his left arm.

For the three-finger grip with the left hand the thumb is placed lingually, the index finger in the vestibule, and the middle finger supports the mandible.
#pic#

2. Luxation and rotation of the tooth

  • Detachment of the tooth from its anchorage in the periodontium by tearing of Sharpey's fibers and alveolar extension
  • Loosening the tooth is possible using elevator and forceps
  • Slow movements
  • Correct amount and application of force
  • Luxation in oro-vestibular direction to extend the alveolar wall
  • Only use rotation when cross section of the tooth in the maxillary front and the mandibular premolars is practically round

Use of a straight Bein elevator

Hold the elevator in your right hand.
With your left hand, support and protect the jaw by grasping the alveolar process with your thumb and index finger.
#pic#
Insert the Bein elevator slightly in the direction of the axis of the tooth into the periodontal cleft and carefully extend the alveolar limbus.
#pic#

Use of the forceps

Position of the forceps (within the hand) while positioning them at the tooth
#pic#
Take the forceps in your right hand. Support and hold the jaw with your left hand, grasping the alveolar process with your thumb and index finger.

That way, you will notice movements of the alveolar process or the adjacent teeth, and the patient's head is stabilized and cannot move away.

#pic#
Position the flanges of the forceps along the longitudinal axis of the tooth to be extracted
#pic#

Position the forceps by moving them apically, maintaining permanent contact with the tooth as much as possible towards the root; do not impinge on the gingiva and the alveolar bone.
Position the forceps' flanges parallel and on the surface of the tooth such that they cannot slip
#pic#

Possible mistakes:
  • Flanges that are not curved sufficiently result in too little translation of force
  • Flanges that are curved too much cause the forceps to slip off
  • If the tooth is just grasped with the ends of the flanges, the crown will get clipped off - like if one were using a pair of pliers
    → as the cross-sections of individual teeth vary, forceps with different beak shapes are necessary; the forceps' handles are angled with regard to the respectively varying positions of the teeth in the dental arch
Luxation of the tooth with slow and carefully dosed movements in oro-vestibular direction until resistance becomes perceptible; during this process, keep the oral luxation position for some time, then move in the vestibular direction.
The more generous and the more carefully (more smoothly) the alveolus is extended, the lower the risk of fracturing the tooth.

The looser the tooth is, the less force needs to be applied.
#pic# #pic#
Upper front and canine teeth and lower premolars
Luxation of the tooth with slowly dosed rotation movements until a resistance is noticed; during this process, keep the rightward luxation position for some time, then the leftward.

3. Tooth extraction

#pic# #pic#
  • If the tooth is sufficiently mobile
  • Signs
    • Bleeding at the alveolar process
    • A smacking sound can be heard
  • Movement of combined luxation and force
  • Extraction of the tooth from the alveolus corresponding to the progression the root takes
  • Testing the tooth for entirety
    • "Clicking" sounds during extraction are suspicious
    • Testing the roots for possible signs of breakage - areas that differ from resorption areas because of their shiny fracture area and their sharp edges

4. Cleaning of the wound

#pic# #pic#
  • Alveolar curettage with a curette to remove granulation tissue
    In case of suspicious consistency of the removed soft tissue, or with radiological evidence of a cyst or a bone change, or other conspicuous signs, a tissue sample should be taken and examined patho-histologically
  • Smooth sharp bone edges
  • Following extraction in the maxilla, examine the alveolus for antral perforation.

5. Wound treatment

  • If no complications have arisen during extraction, bi-digital compression and bite pad
  • Adaptation of wound edges with sutures following wound edge excision, gaping wound, serial extractions
  • Local hemostatic measures (collagen, protective plate, tight suture, fibrin glue) where there is tendency to bleed excessively
  • Plastic cover plate in cases of antral perforation or in patients who have had radiation treatment

6. Follow-up

Antibiotic treatment subsequent to radiation until wound is completely healed (approx. 10 days)

see: Rules of conduct for patients after surgery in the oral cavity (in german)