2Maxillary 2nd molar:Location in Mouth: distal to both maxillary 1st molar and mesial to maxillary 3rd molar in permanent while it’s the last tooth in deciduous dentition.Function: chewing and grinding
3Anatomy:Cusp: usually 4 cusp on maxillary molar , 2 on buccal side and 2 on palatal sideRoots: usually 3 roots, 2 buccal and 1 palatal root.Palatal root- straight or bucally curved.Mesial root- distally curved.Distal root- straight or mesially curved.Root Length: average 20mm.
4Deciduous Tooth Numbering System universal notation:right deciduous max 2nd molar is Aleft deciduous max 2nd molar is JInternational notation:right deciduous is 55 and left deciduous is 65.
5Permanent Tooth Numbering System: Universal notation:right permanent maxillary 2nd molar is 2left permanent maxillary 2nd molar is 15International notation:right permanent max 2nd molar is 17 & left is 27.
6EXODONTIAExtraction of a tooth includes principles of surgery as well as principles of physics and mechanics when they are applied correctly tooth is usually removed without untoward force or sequelae. There are 1. Uncomplicated exodontia (closed extraction) 2. Complicated exodontia (open surgical extraction)
7PRE EXTRACTION EVALUATION Complicated exodontiaCompromised access e.g. trismus.Tooth is ankylosedHypercementosisNon vital endodontic ally treated or amalgam desiccated tooth.Uncomplicated exodontiaAdequate accessTooth shows normal or hyper mobility
8RADIOGRAPHIC EVALUATION Proximity of roots of the molar with the floor of the maxillary sinus.If only thin layer of bone exist b/w roots and floor of the sinus go for open surgical extraction.Look for surrounding bone densityMore dense & sclerosed difficult to extract go for open extraction.
9Look for root configuration. Excessively curved widely divergent rootLong root with abrupt curvesBulbous hypercementosed rootsRoot cariesRoot resorptionLook for apical pathologiesPeriapical radiolucencies cyst or granuloma.
10INDICATIONS OF EXODONTIA Severely carious un restorable tooth.Failed endodontically treated tooth.Excessive bone loss, hypermobile tooth.Cracked painful unmanageable tooth.Impacted & supernumerary teeth.Teeth associated with pathological lesion.Extraction for orthodontic reason for correction of crowding or angle class 2 malocclusion.Malpositioned teeth.Injured infected or laxated tooth in the line of fracture interfering proper reduction should be removed.
11CONTRAINDICATIONS OF EXODONTIA Uncontrolled diabetes.Uncontrolled leukemia/lymphoma.Uncontrolled cardiac disease.Unstable angina/recent MI.Severe bleeding disorder/ hemophilia.Patients on anticoagulants.Patients on steroids or immunosuppressant's.1st and 3rd trimester of pregnancy.Extraction of teeth within tumor cause dissemination of malignant cells, so contraindicated.
12CHAIR POSITION FOR MAXILLARY 2ND MOLAR Correct chair positioning allows adequate access visibility and maximum controlled force will be delivered with arms and shoulders. For maxilla chair should be tipped back so that maxillary occlusal plane is at 60 degree angle to the floor. Height of the chair should be such that the height of patients mouth is at or slightly below operator’s elbow level. Hand and forcep positioning is same in both standing and sitting position.
13OPERATOR POSITION FOR MAXILLARY TEETH 7 o’ clock position to the front of the patients head9 o’ clock position to the side of the patients head10 to 11 o’ clock, to the back of the patient’s head12 o’ clock position, directly behind the patient’s headFOR MAXILLARY TEETH:Right front of the patient i.e. 7o’ clock position.
14Position based on Sextants of the Arch: The Operator should be positioned 9 o’ clock to 12 o’ clock position which is depicted in green color.Operator positioning for teeth depicted in Blue color is 10 o’clock to 12 o’ clock position.
15CLOSED EXTRACTION TECHNIQUE STEP 1Loose soft tissue attachment from cervical region of toothSTEP 2Tooth is luxated with dental elevatorSTEP 3Adaptation of forcepSTEP 4Tooth is luxated with forcepSTEP 5Remove tooth out from the socket
16Lingual or palatal pressure 5 MAJOR FORCEP MOTIONSApical pressureBuccal forceLingual or palatal pressureRotational pressureTractional forces
17CLOSED EXTRACTION:Profound administration of local anesthetic solution, wait till it become effective.Loose soft tissue around cervical portion of toothInsert straight elevator perpendicular to tooth’s long axis.Strong slow and forceful movement of elevator apically to luxate the tooth.Adapt molar forcep 53R or 53L as apically as possible.Apply stronger buccal force than palatal forceRemove tooth out from the socket.
18Open surgical extraction: Profound administration of local anesthetic solution, wait till it become effective.Reflect standard envelop flap.Remove small portion of crestal bone to expose trifurcation area.Section mesiobuccal and distobuccal root from crown portion of tooth.Remove crown portion along with palatal root in buccal direction.Luxate buccal roots with small straight elevator.Remove root with straight or cryer elevator in mesiodistal direction, only slight apical pressure.
20If crown of maxillary 2nd molar is missing or fractured, roots are sectioned into 2 buccal and single palatal root and are delivered separately by straight or cryer elevator.Maxillary root forcep or upper universal forcep can also be used to deliver roots.
21REMOVAL OF FRACTURED ROOT TIPS & FRAGMENTS: Fracture of apical 1/3 of root can occur during closed extraction & it is removed by:A. Irrigationvigorous irrigation and suction with small tip.(antral lavage)B. Closed technique:by using root tip pick inserted in PDL space and teased out of the socket.
22REMOVAL OF FRACTURED ROOT TIPS & FRAGMENTS: C. Open technique: 2 types1. Flap raised, buccal bone is removed with bur, root delivered with straight elevator and then sutured.2. Open window technique:Flap raised, round bur used to remove bone overlying tooth apex, expose fractured fragment, root tip pick or small elevator is inserted in window and root is displaced out of the socket.
23Give patient post extraction instruction and analgesics for post extraction pain and discomfort.
24Complications: Chronic oroantral fistula. Infection Dry socket Immediate complicationsDelayed complications:Prolonged bleedingSwelling & bruisingMaxillary tuberosity fracture.Maxillary sinus perforation.Root fractured and displaced into sinus due to excessive apical pressure. Remove root by Caldwell luc approach.Chronic oroantral fistula.InfectionDry socketNerve injuryDelayed healingtrismus