PROCEDURE FOR CLOSED EXTRACTION
An erupted root can be extracted using one of two major techniques: (1) closed Or (2) open. The closed technique is also known as the simple.. or forceps technique. The open technique is also known as the surgical, or flap technique. This section discusses the closed or forceps extraction technique the open technique is discussed in Chapter 8.
The closed technique is the most frequently used technique and is given primary consideration for almost every extraction. The. open technique is used when the clinician believes that excessive force is necessary to remove the tooth of when a substantial amount of the crown is missing and access to the root of the tooth is difficult.
The correct technique for any situation should lead to an atraumatic extraction the wrong technique may result in an excessively traumatic extraction.
Whatever technique is chosen, the three fundamental requirements for a good extraction remain the same:’ (1) adequate access and visualization of the field of surgery, (2) an unimpeded pathway for the removal of the tooth, and (3) Used of controlled force to luxate and remove the tooth.
For the tooth to be removed from the bony socket, it is necessary to expand the alveolar bony walls to allow the tooth root an unimpeded pathway, and it is necessary to teat the periodontal ligament Fibers that hold the tooth in the bony socket. The use of elevators and forceps as levers and wedges with steadily increasing force can accomplish these two objectives.
Five general steps make up the closed extraction procedure:
Step 1: Loosening of soft tissue attachment from the tooth. The first step in removing a tooth by the closed extraction technique is to loosen the soft tissue firm around the. tooth with a sharp instrument, such a, the Woodson elevator or the sharp end of the no. 9 periosteal elevator (fig. 7-51). The purpose of loosening the soft tissue from the tooth is twofold. First, it allows the surgeon to ensure tbat profound anesthesia has been achieved. Wben this step has been. performed, the dentist informs the patient that the surgery is about to begin and that the first step will be to push the soft .tissue away from the tooth. A small amount of pressure is felt at this step, but no sensation of sharpness or discomfort. The surgeon then begins the soft tissue loosening procedure, gently at first and then with increasing force.
The second reason that the soft tissue is loosened is to allow the tooth-extraction forceps to be positioned more apically without interference from or impingement on the soft tissue of the gingiva. As the soft tissue is loosened away from the tooth it is slightly reflected which thereby increases the width of the gingiva sulcus and allows easy entrance of the beveled wedge tip of the forceps beaks.
If a straight elevator is to be used to luxate the tooth, ‘the Woodson elevator is also used to reflect the tooth’s adjacent gingival papilla where the streight elevator will be inserted (Fig. 7~52). This allows the elevator to be placed directly onto alveolar bone, without crushing or injuring the gingival papilla.
Step 2: Luxation of tile tooth with a dental elevator. The next step is to begin the luxation. of the tooth with a dental elevator, usually the straight elevator. Expansion and dilation of the alveolar bone and tearing of the periodontal ligament require that the tooth be luxated in several ways. The straight elevator is inserted perpendicular to the tooth into the interdental space, after reflection of the interdental papilla (Fig. 7-53). The elevator is then turned in such a way that the inferior portion of the blade rests’ on the alveolar bone and the superior, or occlusal, portion of the blade is turned toward the tooth being extracted .(Fig. 7-54). Strong, slow, forceful turning of the handle moves the tooth in a posterior direction, which results in some expansion of the alveolar bone and tearing of the periodontal ligament. If the tooth is intact and in contact .with stable teeth anterior and posterior to it the amount of movement achieved with the straight elevator will be minimal. The usefulness of this step is greater if the patient does not have a tooth posterior to the tooth being extracted or if it is broken down to an extent that the crowns do not inhibit movement of the tooth.
In certain situations the elevator can be turned in the opposite direction and more vertical displacement of the tooth will be achieved, which can possibly result in complete removal of the tooth (Fig. 7-55).
luxation of teeth with a’ straight elevator should be performed with caution. Excessive forces can damage and even displace the teeth adjacent to those being extracted. This is especially true if the adjacent tooth has a large restoration or carious lesion. It must be kept in’ mind that this is only the initial step in the extraction process, and that the forceps is the major instrument for tooth luxation and removal in most situations.
Step 3: Adaptation of the forceps to the tooth, The proper forceps is then chosen for the tooth to be extracted, The beaks of the forceps should be shaped to adapt anatomically to the tooth.apical to the cervical line, that is, to the root surface. The forceps is then seated onto the tooth so that the tips of the forceps beaks grasp the root underneath the loosened soft tissue (Flg. 7-56);- The lingual’ beak is usually seated first and then the buccal beak. Care must be taken to confirm that the tips of the forceps beaks are beneath the soft tissue and not engaging an adjacent tooth.’ Once the forceps has been positioned on the tooth, the surgeon grasps the, handles of the forceps at the very ends to maximize mechanical advantage and control (Fig. 7-57).
If the tooth is malopposed in such a fashion that the usual forceps cannot grasp the tooth without injury to adjacent teeth, another forceps should be employed. The maxillary root forceps can often be useful for crowded lower anterior teeth (Fig. 7-58).
The beaks of the forceps must be held parallel to the long axis of the tooth so that the forces generated by the application of pressure to the forceps handle can be delivered along the long axis of the tooth for maximaf effectiveness in dilating and xpanding the alveolar bone. If the beaks are not parallel to the long axis of the tooth, it is increasingly likely that the tooth root will
The forceps is then forced apically as far as possible to grasp the root of the tooth as apically as possible. This accomplishes two things First, the beaks ‘of the forceps act as wedges to dilate the crestal bone on the buccal and lingual aspects. Second, by forcing the beaks apically, the center of rotation (or fulcrum) of the forces applied to the tooth is .displaced toward the apex of the tooth, which results in greater effectiveness of bone expansion and less likelihood of fracturing the apical end of the tooth.
At this point the surgeon’s hand should be grasping the forceps firmly with the wrist locked and the arm held against the body the surgeon should be prepared to apply force with the shoulder and upper arm without any wrist pressure. The surgeon should be standing straight with the feet comfortably apart.
Step 4: Luxation-of the tooth with the forceps. The surgeon begins to luxate the tooth by using the motions – discussed earlier. The major portion of the force is directed toward the thinnest and therefore weakest bone. Thus . in the maxilla and all but the molar teeth in the mandible, the major movement is labial and buccal (i.e., toward the thinner layer of bone). The surgeon uses slow, steady.force to displace the tooth ‘buccally, The motion is deliberate and slow, and it gradually increases in force. The tooth is then moved again toward the. opposite direction with slow, deliberate, strong pressure. As the alveolar bone begins to expand, the forceps is apically reseated with a strong, deliberate motion, which causes additional expansion of the alveolar bone and , further displaces the center, of the rotation apically. Buccal and lingual pressures continue to expand the alveolar socket. For some teeth, rotational motions are then used to help expand the tooth socket and tear the periodontal ligament attachment.
Beginning surgeons have a tendency to apply inadequate pressure for insufficient amounts of time. The following three factors must be reemphasized (1) The forceps must be apically seated as far as possible and reseated periodically during the extraction (2) the forces applied in the buccal and lingual directions should be slow, deliberate pressures and not jerky wiggles and (3) the force should be held for several seconds to allow the bone time to expand. It must be remembered that teeth are not pulled rather, they are gently lifted. from the socket once the alveolar process has been sufficiently expanded.
Step 5: Removal of tile tooth from the socket. Once the alveolar bone has expanded sufficiently and the tooth has been luxated, a slight tractional force, usually directed buccally, can be used. Tractional forces should be minimized, because this is the last motion that is used once the alveolar process IS sufficiently expanded and the periodontal ligament completely severed.
It is useful to remember that luxation. of the tooth with the forceps and removal of the tooth from the bone are separate steps in the extraction. Luxation is directed toward expansion of the bone and disruption of the periodontal ligament. The tooth is hot removed from the bone until these two goals are accomplished. The novice surgeon should realize that the major role of the forceps is not to remove the tooth but rather to expand the bone so that the tooth can be removed.
For teeth that are malopposed or have unusual positions in the alveolar process, the luxation with the forceps and removal from the alveolar process will be in unusual directions. The surgeon must develop a sense for the direction the tooth wants to move and then be able to move’ it in that direction. Careful preoperative assessment and planning help to make this determination during the extraction.