Tools.

Testimony and
contra-indications
Extraction of teeth:.
Background of patient,
complication under time
and after an operation,
their treatment and
prevention
 Teeth removal
Tooth removal is one of the most
widespread operations in polyclinic
stomatologic practice. For carrying out
its necessary to know the sequence of
techniques of performance and skills of
possession special instruments.
 Indications and contra-indications to
removal of permanent teeth.
Indications to planned tooth removal:
1.)Unsuccessfulness of endodonthyc
treatment with presence of the chronic
inflammation of periodontium and adjoining
tissues of a bone. This intervention is
especially indicated in case of chronic
intoxications of the patient with odontogenic
intoxication centres (chroniosepsis)
2.) Impossibility of conservative treatment
through considerable crown destruction or
the technical obstacles connected with
anatomic features, treatment errors, caused
by root perforation.
 3.) Total destruction of crown part of the
tooth, impossibility of using the root for
tooth prosthetics.
4.) Mobility of degree and tooth
promotions as a result of resorption of bone
round a cell with presence of heavy forms of a
periodontosis and parodontitis.
5.) Atypically placed teeth which injure a
mouth mucous membrane, tongue, and which
can't be treated by ortodonthic treatment.
6.) Unteethed in time or partially teethed
teeth which predetermine inflammatory
processes in adjoining tissues, which cannot
be liquidated some other way.
 7.) Placed in crisis cracks, teeth do impossible
reposition of fragments and can't be treated
by conservative treatment.
8.) Outstanding as a result of loss of the
antagonist teeth, teeth which convergence
and divergence, disturb embarrass the
process of manufacturing tooth prosthetics.
treatment. For elimination of anomalies of a
bite (occlusion) during the orthodontic
treatment, intact teeth removal is also
indicated.
 Contra-indications. A number of
inflammatory and local diseases, and
also some physiologic conditions are
contra-indications to this intervention.
Removal of tooth at such patients can
be done after preparation and
treatment.
 Relative contra-indications to operations of
tooth removal are:
1.) Cardiovascular diseases (preinfarction
conditions and 3-6 month after the infarction of
a myocardium, hypertonic illness in crisis.
IHD(ischemic heart disease), paroxysm, blinking
arhythmia, paroxysmal tachycardia, acute septic
endocarditis);
2.) Acute diseases of parenchymatosic organs -
liver, kidneys, pancreas (an infectious hepatitis,
(glomerunonephritis);
3.) Haemorragical diseases (a hemophilia, illness
of Verlgof, agranulocytosis, acute leukemia);
4.) acute infectious diseases (a flu, ARVD(acute
respiratoric virus disease), a pneumonia);
 5.) disease of CNS (central neuronic
system), (acute disorder of encephal blood
circulation, a meningitis);
6.) Mental (psychological) diseases in an
aggravation period (a schizophrenia, a
psychosis, an epilepsy);
7.) acute radiation sickness -
degrees;
8.) disease of a mucous membrane of a
mouth (a stomatitis, gingivitis, cheilitis).
 Preparation of tooth removal:

-Inspection.
-Preparation of the patient.
-Preparation of doctors hands.
-Preparation of the operation field.
 Technique of tooth removal:

Tooth removal consists in violent rupture of

tissues which connect root with walls of a
cell and gums, and its deducing from a cell.
During removal of the distorted roots from
a cell, its walls are being replaced and the
entrance to it extends. Tooth removal is
being made by special tools, forceps and
elevators. In certain cases tooth extraction
by using this tool is impossible. Then a drill
for bone removal is used. (operation of root
cutting)
 Forceps and elevetaors for teeth removal:
Forceps. Under the process teeth removal a lever
principle is used. Forceps consists of: cheeks,
handles and the lock. In some kinds of forceps
between cheeks and the lock there is a transitive
part. Cheeks are used to cover the root or a
crown. The handle a part which is used to hold
the forceps. The lock is placed between the
handle and a cheek.
For the best fixing of tooth or a root, cheeks
have fillets with longitudinal cutting from the
inside. The external surface of handles on
significant length is relief, internal - smooth. The
form of forceps is not the same. Construction
depends on anatomical structure of the tooth and
its place in row of teeth.
 Kinds of forceps:

1.) Forceps for removal of teeth and roots

of the top and bottom jaws. Forceps for
the top jaw have prolongated axis of the
cheeks and handles, are coincide or
parallel, or form a corner. With forceps
for removal of teeth on the bottom jaw,
cheeks and handles are placed at right
angle or at an angle which is approached
to it;
 2.) Forceps for removal of teeth with the
kept crown (crown forceps) and for root
removal (root forceps). Cheeks for removal
of a crowned teeth do not converge, for
removal of roots - converge;
3.) Forceps for removal of separate groups
of teeth of the top and bottom jaw. They
differ by width and features of a
structure of cheeks, their placing in
relation to handles, the form of handles;
 4.) Forceps for removal of the first
and the second molars of the top jaw
on the right and at the left. The left
and right cheeks of these nippers are
constructed unequally;
5.) Forceps for removal of teeth of
the bottom jaw in case of the limited
opening of a mouth. They have a bend
of cheeks in a horizontal direction.
 Forceps for maxilla
 Forceps for the roots of maxillar
teeth
 Forceps for mandibula
 Structure of the forceps, about the
surface
 Types of correct forceps handling
 Luxation and rotation during teeth
removal
 Correct and incorrect forceps
positions
 To execute operation successfully, it is necessary to
apply the forceps, which design to anatomic features
of removable tooth.
Removal of the central incisor, lateral incisor and
canine of top jaw, is being done by forceps which
have the direct form, - direct forceps. Longitudinal
axes of cheeks and handles are in one plane and
coincide. Both cheeks are identical by the form, from
the inside fillets, round off the ends. Forceps can
have big and small width cheeks.
Removal of small root teeth of the top jaw is being
made by nippers which have S-like bend. Cheeks are
placed with them at an obtuse angle to handles. Such
form of forceps allows to impose them correctly on
tooth and during its removal to prevent obstacles
from the bottom jaw.
 Removal of the big molars of the top jaw is
being made by forceps which have S-like
bend and are similar by the form to forceps
for removal of small molars. However their
cheeks are arranged differently. They are
shorter and are wider, the distance between
them in the closed condition is greater. Both
cheeks from inside have Deepening. End of
one cheek is round, other one ends by a
thorn, from which, in the middle, from
indside surface lasts small crest.
 During removal of tooth the thorn enters between
cheeks roots, the cheek with the plane end, captures
a neck of tooth from the palatal surface. One
forceps the cheek with a thorn is on the right side, in
the second - at the left. Such structure of a cheek
provides dense coverage of the tooth and makes its
removal easier. Removal of the third big molar of the
upper jaw is being done by special forceps. The
oblong axis of cheeks and an axis of handles at them
are parallel. Two cheeks are equally wide, with thin,
and rounding in edges ends. On inside they have a
dimple; during interlocking, forceps do not converge.
The construction of forceps gives the ability to enter
them deeply into the oral cavity, thus the lower jaw
does not Hinders the operation carrying out.
 Roots of incisors, canines and premolars of the
upper jaw, are being deleted by the same forceps,
as other teeth, only with more thin and narrow
cheeks. For removal of roots of the big molars use
bayonetlike forceps. They have the transitive part
from which long cheeks are going out which
coincide with the thin rounding off end and a fillet
throughout an axis of all internal surface. The
oblong axis of handles at them is parallel.
Depending on width of cheeks distinguish
bayonetlike; with narrow, average and wide
cheeks. They are used for removal of roots of
incosors, canines, small molars and teeth with the
destroyed surface.
 Removal of teeth and roots of the lower jaw
is being made by forceps, which are bent on
an edge and have beaklike form. The axis of
brushes and an axis of handles form a
corner, which is direct or close to direct. All
components of forceps are allocated in a
vertical plane, handles - one over the second.
Cheeks of forceps for removal of incsors
of the lower jaw, are narrow with fillets on
inside, they are rounded on the end, during
interlocking they do not converge. Canines
and small molars are deleted buy such
forceps, but with wider cheeks.
 Forceps for removal of the big molars have wide
cheeks which do not converge. Each of them ends by
triangular bend(thorn). From the inside both cheeks
have a dimple. During superimposing on tooth bends
enter the furrow between front and back roots that
provides good fixing of forceps on tooth.
In case of restricted opening of a mouth,big
molars are deleted by the horizontal forceps, bent on
a plane. They are constructed differently, than
beaklike. Handles and the lock are allocated at an angle
which comes nearer to direct and is in a vertical plane.
A working part of brushes is the same, as the beaklike
forceps for removal of the big molars, bent on an edge.
Roots of all teeth of the lower jaw are deleted by
forceps of the same form, as incisors, canines and
small molars, only by cheecks that converge.
 The position of the doctor during
 Elevators.
Extracting teeth by elevetaors, as well as by
forceps, use the lever principe. Elevator consists of
three parts:
The working part, the connective rod and the
handle. There are many different constructions of
elevetaors, however the most widespread are three
types: straight, angular and beaklike elevator.
Straight elevator. Its working part is a
continuation of the connective rod and together
with the handle are allocated on one direct line.
The cheek on the one hand convex, semicircular,
from the other bent, also looks like a fillet, the
end is refined and rounded.
 Straight elevators are intended for removal
of roots of teeth,of the upper jaw which
have one root. They are intented for removal
of teeth of the upper jaw allocated out of a
tooth arc, rarely - the lower third molar.

Angular elevator. The working part (cheek)

is bent on an edge and allocated to
longitudinall axis by the elevator at an angle,
approximately 120 .
 Cheek small.One of its surface is convex, the second
- slightly bent with longitudinal edges. The concave
surface of a cheek at one elevator is turned to left
(to itself), in others - to the right - from itself.
In an elevator operation time, the concave surface
of a cheek is directed to a root, which is being
deleted, convex - to a cell wall.
Angular elevator is used for removal of the
lower teeth.
Bayonetlike elevator (Lekljuz
Elevator).Connective rod of elevator is bayonetlike,
curve . The working part has spearlike form. It is
narrowed and thiner in finite department. The handle
is round, thicker in the middle part, allocated
perpendicular to connective rod and to working part.
Elevator is intended for removal of the third lower
molar.
Types of elevators:
Lekljuz elevator
 Types of elevators:
 Stages of operation of removal of tooth:
Operations of removal of tooth,are being
led by forceps, also consists of several
serial stages:
1.) Superimposing of forceps
2.) Advancement of forceps
3.) Interlocking of forceps (fixing)
4.) A tooth Dislocation (luxation or tooth
rotation)
5.) Deduction of tooth from a cell
(traction)
 Extraction of teeth, and its roots using drill, hammer
and chisel.
In such cases, when tooth or the root cant be removed by
using forceps or elevator, it is necessary to use drill,
hammer or chisel. as an indication to such operation could
be presence of a root or tooth which was not erupt, or a
root with the curved top, and also expressed
hypercementosis. This method is used more often, when
extracting of the bottom wisdom tooth is needed.

Processing of a wound after tooth removal. After the

termination of operation of removal of tooth it is necessary
to examine it carefully. Presence of keen edges in the root
channel testify a root crisis. Its unallowed to leave the
broken root in a cell, especially if removal was spent
concerning a sharp purulent periodontitis. Root removal
needs to be finished by using hammer, drill, or chisel.
 When ensured, that tooth is fully removed, a sharp spoon is
necessary to clear a cell of small splinters of a bone,
granulations or a bone cover. External and internal edge of a
cell shoud be squeezed by fingers through gauze tampons. On a
wound impose one or several gauze tampons and ask the patient
to compress jaws strongly. In 10-15 minutes a tampon deletes
to make sure of clot preservation. When theres no bleeding,
the patient can leave a medical institution. It is recommended
to eat within 1-2 hours then it is possible to consume cool meal.
In the first day after operation, it is not recommended to
rinse oral cavity by solutions of antiseptic tanks, except those
cases when purulent - inflammatory process is present. Rinsings
by weak solutions furacilimun, chlorheksidinum, hydrocarbonate
sodium, or permanganate potassium is allowed only on 2-3rd
day. Usually the wound after tooth removal heals by a
secondary tension, thanks to formation of blood clot. Putting a
gauze in a sonorous impregnated with a solution of iodoform, is
possible only with the purpose of preventing the infication of a
clot if inflammatory process has developed
 Complication, that can occur during, and after tooth
exraction.
Root crisis can be prevented by using the method of section
and separation of gums, with the following chisel
debridement of cell wall, to one third of length, and also by
using forceps for root extraction.

Damage of soft tissues, occurs during careless, rough

manipulations of physician, disorder of tooth extraction
technique.
When insufficient gums dislayering, before tooth extraction,
rupture of mucous membrane often occurs during operation;
In case of wrong tooth extraction technique, when a doctor
imposes forceps directly on a mucous membrane, dislayered it
not enough from the cell process, or a part.
In case of careless dislocating of roots, by direct elevator,
tissue damage of the bottom of oral cavity, tongue(when
removing the roots of lower molars) and palate(when
removing the roots of upper molars) occurs.
 On a background of the damage of soft
tissues, bleeding occurs, which complicates
the work of a doctor, while tooth
extracting; In postoperative period,
inflammatory complications can occur.
A technique of granting of the urgent
help: a stop of a bleeding and suturing the
wound.
 a fragment break of cell parts (more often on the bottom jaw) - damage
of tisses arises:
- Under condition of an union of a tooth root with cell walls;
- In case of deep imposing cheeks of nippers on cell walls - thus
tooth removes together with a bone tissues.
Technique of granting the urgent medical aid: to smooth down (if
necessary - to remove) sharp, unequal edges of a cell of tooth, to suture
a mucous membrane.
Break of a tuber of the top jaw arises during removal of the third top
molar, as a result of deep imposing forceps cheeks on walls of a cell, or a
rough dislocation of tooth by straight elevator:
In such case, there is a broken off fragment of a tuber of the top jaw
on extracted tooth (roots)
-a considerable bleeding occurs;
-If the maxillar sinus is damaged, vials of air from the extracted tooth
cell occure during attempt to blow air through closed with fingers nose.

The technique of granting urgent help: smoot keen edges of tooth cell
by bone spoon, mobilize and suture tightly a mucous membranem so that
a bone wound would be completely closed. If the stomatologist cannot
independently stop a bleeding, and suture a wound, he put iodoform
tampon and transports the patient immediately in a surgical
stomatologic department.
 Perforation of the bottom of maxillar sinus arises during removal of the
first top molar, sometimes - the second and premolar.
It is explained, that tops of the given teeth are closely located to the
bottom of sinus.

Perforation of the bottom of maxillar sinus can occur, when:

- Traumatic removal of the named teeth (if rough manipulation in a
tooth cell is done), and during careless manipulations;
- Owing to anatomic features, when the root is located under a sinus
mucous membrane;
- When inflammatory process on a top of a root has destroyed a sinus
bottom.
Diagnostics:
During careful tubage of a cell, the instrument gets for the length more
than the deepnes of the cell.
On the basis of passage of the air from the oral cavity, into a nasal
cavity, ot contrary. The patient, having clamped fingers on his nose,
should try to blow the air throughout it. Thus air through an aperture
(perforation) of the bottom of maxillar sinus leaves it with a whistle and
goes into oral cavity, or blood vials of air from a cell of extracted tooth
occur;
Radiological research is conducted (an aim picture).
 Technique of granting urgent medical aid in case of
perforation of maxillar sinus:
- In the presence of a purulent antritis (pus is
goin out from a tooth cell, through a perforated
aperture) in entrance of cell iodoform tampon and
hospitalization of the patient in maxillofacial
deparment;
- In case of pushing a root through in a sinus, its
removal in the conditions of a hospital is indicated;
- In case of a healthy sinus (when radiological
research does not reveal a root in a sinus) it is
necessary to close a perforated aperture (a cell of
extracted tooth) by a mucosial rag, taken from a
vestibular surface of cell process. If the doctor
has not mastered this technique, he should tightly
suture a cell (to Impose 2-3 seams of polyamides).
 The bleeding arises after operation of
removal of tooth. Distinguish early bleedings
and late. Early bleedings, arise right after
removals of tooth (trauma).
Late bleedings can arise:
1) In some hours after tooth removal, for
example in case of adrenaline overdose.
2) For some days after operation which
becomes complicated by an inflammatory
process.
Thank you for attention!