1. BY DR. MANISHA MISHRA 1

2. Tooth extraction Indications: 1. Grossly carious tooth which cannot be restored 2. Acute/chronic pulpitis which can’t be restored by RCT 3. Periodontal diseases More than half of alveolar bone loss 4. Fracture of tooth Root Longitudinal If tooth lies on jaw # line 2

3. Indication cont.. 5. Bony lesion lies over the tooth Cyst, Tumor,OM 6. Impacted tooth 7. Aesthetic indication 8. Orthodontic appliances Teeth crowding 9. Supernumerary and malpos ed teeth 10. Retained deciduous tooth if permanent successor is present 11. If tooth hurting the soft tissue Upper 3 rd molar damaging the lower 3 rd molar gum tissue 3

4. Contraindications: General 1. Cardiac diseases - Valvular heart diseases, RHD, Hypertension,Patients on anticoagulation therapy 2. Blood disorders (Severe anemia, Leukemia, Hemophilia) 3. Liver disease (Vitamin K deficiency, Clotting factor deficiency) 4. DM 5. Pregnancy- 1 st and 3 rd trimester 6. Epilepsy patient 7. Allergic to local anesthesia 8. Psychiatric patient 9. Very old patient 10. Uncooperative patient/ Lack of consent 11. Patient on steroids 12. High grade fever 4

5. Contraindication : Local 1. Acute gingivitis 2. Acute periodontitis 3. Acute pericoronitis 4. Acute cellulitis 5. Acute osteomyelitis 6. Malignancy Any acute infection except Acute pulpitis is not contra indication of tooth extraction but it is rather indication of extraction 5

6. Post extraction instructions: 1. Bite on cotton or gauge for half an hour 2. Don’t spit or rinse as far as possible 3. Don’t take hot water or food at least for 12 hour 4. No physical activity for 24 hours 5. Soft lukewarm comfortable foods 6. Intake of antibiotics and analgesics as prescribed by dentist 7. Cold compress with ice packs 8. No smoking / Alcohol / Tobacco 9. If any bleeding, pain or complications contact hospital or dentist immediately 10. Warm saline wash after 24 hrs for next 2 or 3 days 6

7. 7

8. Complications 1. Fracture of Crown, Root, Alveolar bone, Adjacent tooth 2. Dislocation of TMJ 3. Trauma to Gingiva, Lips, Tongue, Palate 4. Intraoperative and post operative hemorrhage 5. Trismus 6. Infection : local /systemic 7. Anesthesia related complication 8

9. Antibiotic prophylaxis: Under L.A  Amoxycillin 3gm 1 hour before surgery,If allergic to Amoxycillin then give  Clindamycin 600mg Under G.A  Amoxycillin IV + oral 1gm at induction and 0.5 gm 6 hours later,If allergic then  Vancomycin IV infusion1gm over 1 hour+Gentamycin120mg IV 9

10. Position 10

11. Extraction movement  Primary movement: Along longitudinal axis of root  Secondary movement: Main extracting movement Rotatory Buccolingual or labiolingual Mesodistal Lifting the tooth 11

12.  Upper central and lateral incissor Rotation only  Upper canine Rotation initially, some labiolingual movement may be needed  Upper premolar and molar Buccopalatal movement 12

13.  Lower central and lateral incissor Labiolingual movement  Lower canine Rotatory and labiolingual  Lower premolar Rotatory  Lower molar Buccolingual movement 13

14. 14

15. Nerve supply: Maxilla  Posterior superior alveolar nerve: Molars  Middle superior alveolar nerve: Premolars  Anterior superior alveolar nerve: Canines and Incissor  Sensory supply of palate from greater and lesser palatine nerves as well 15

16. Mandibular nerve: Lingual nerve Inferior alveolar nerve : Enters the mandibular canal 16

17. Dental block  Types of blocks Supraperiosteal injection Mental nerve block Anterior superior alveolar (Infraorbital) nerve block Posterior superior alveolar nerve block Inferior alveolar nerve block 17

18. Choice of anesthesia in dental procedure  2% lidocaine/Xylocaine with 1:100,000 epinephrine is a good choice. This provides about 1 hour of dental pulp analgesia 3 to 5 hours of soft-tissue analgesia  For temporary relief of pain, the preferred agent is 0.5% Bupivacaine with 1:200,000 epinephrine 1 to 3 hours of dental pulp analgesia 4 to 9 hours of soft-tissue analgesia  Duration of analgesia is less with supraperiosteal injections than with regional nerve blocks 18

19. Inferior alveolar nerve block  Most widely used anesthetic procedure in dentistry  All mandibular teeth to midline  Anterior 2/3 of tongue  Floor of oral cavity Complication: Infection Patient having tendency to bite tongue or lips 19

20.  Aim is to deposit solution around the inferior alveolar nerve as it enters the mandibular foramen underneath the lingula  The patient's mouth must be widely open, inferior border being parallel to ground  Palpate the landmarks of external and internal oblique ridges and note the line of the ptyerygomandibular raphe 20

21.  Index finger is used to stretch the tissues over the injection site, maximizing visibility and minimizing the pain of the injection.  Orient the syringe so that the barrel is in the opposite corner of the mouth, resting on the premolars  Aim toward your index finger and slowly penetrate the mucosa until bone is contacted, usually a distance of about 2.5 cm  Needle should be parallel to occlusal surface 21

22.  Withdraw slightly and aspirate  If no blood is returned, inject 1.5 to 2 mL of anesthetic  If aspiration is positive, pull back and redirect slightly, then repeat  If a lingual nerve block is required 0.5 ml of LA is injected after withdrawal of 0.5cm of the needle 22

23. Supraperiosteal infiltration  Also called ‘local infiltration’  Teeth affected Any maxillary tooth  Only can anesthetize 2 or 3 adjacent teeth  Poor option for mandibular tooth because of relatively high density 23

24.  The aim is to deposit LA supraperiosteally in as close proximity as possible to the apex of the tooth to be anaesthetized.  The LA will diffuse through periosteum and bone to bathe the nerves entering the apex.  Reflect the lip or cheek to place mucosa on tension and  insert the needle along the long axis of the tooth aiming towards bone.  At approximate apex of tooth, withdraw slightly and deposit LA slowly 24

25. Mental nerve block Apex of the second premolar  Tissue and teeth affected Buccal soft tissues from 2nd mandibular premolar to midline skin of lower lip and chin 25

26. Infraorbital block Just inferior to the infraorbital notch  Teeth affected Incisors Canines premolars 26

27. 27