MAXILLARY 2ND MOLAR EXTRACTION By: Madiha Khalid EXODONTIA MAXILLARY 2ND MOLAR EXTRACTION By: Madiha Khalid

Maxillary 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

Anatomy: Cusp: usually 4 cusp on maxillary molar , 2 on buccal side and 2 on palatal side Roots: 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.

Deciduous Tooth Numbering System universal notation: right deciduous max 2nd molar is A left deciduous max 2nd molar is J International notation: right deciduous is 55 and left deciduous is 65.

Permanent Tooth Numbering System: Universal notation: right permanent maxillary 2nd molar is 2 left permanent maxillary 2nd molar is 15 International notation: right permanent max 2nd molar is 17 & left is 27.

EXODONTIA Extraction 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)

PRE EXTRACTION EVALUATION Complicated exodontia Compromised access e.g. trismus. Tooth is ankylosed Hypercementosis Non vital endodontic ally treated or amalgam desiccated tooth. Uncomplicated exodontia Adequate access Tooth shows normal or hyper mobility

RADIOGRAPHIC 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 density More dense & sclerosed difficult to extract go for open extraction.

Look for root configuration. Excessively curved widely divergent root Long root with abrupt curves Bulbous hypercementosed roots Root caries Root resorption Look for apical pathologies Periapical radiolucencies cyst or granuloma.

INDICATIONS 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.

CONTRAINDICATIONS 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.

CHAIR 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.

OPERATOR POSITION FOR MAXILLARY TEETH 7 o’ clock position to the front of the patients head 9 o’ clock position to the side of the patients head 10 to 11 o’ clock, to the back of the patient’s head 12 o’ clock position, directly  behind the patient’s head FOR MAXILLARY TEETH: Right front of the patient i.e. 7o’ clock position.

Position 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.

CLOSED EXTRACTION TECHNIQUE STEP 1 Loose soft tissue attachment from cervical region of tooth STEP 2 Tooth is luxated with dental elevator STEP 3 Adaptation of forcep STEP 4 Tooth is luxated with forcep STEP 5 Remove tooth out from the socket

Lingual or palatal pressure 5 MAJOR FORCEP MOTIONS Apical pressure Buccal force Lingual or palatal pressure Rotational pressure Tractional forces

CLOSED EXTRACTION: Profound administration of local anesthetic solution, wait till it become effective. Loose soft tissue around cervical portion of tooth Insert 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 force Remove tooth out from the socket.

Open 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.

Surgical extraction technique

If 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.

REMOVAL OF FRACTURED ROOT TIPS & FRAGMENTS: Fracture of apical 1/3 of root can occur during closed extraction & it is removed by: A. Irrigation vigorous 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.

REMOVAL OF FRACTURED ROOT TIPS & FRAGMENTS: C. Open technique: 2 types 1. 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.

Give patient post extraction instruction and analgesics for post extraction pain and discomfort.

Complications: Chronic oroantral fistula. Infection Dry socket Immediate complications Delayed complications: Prolonged bleeding Swelling & bruising Maxillary 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. Infection Dry socket Nerve injury Delayed healing trismus

Oroantral communication:

Maxillary tuberosity fracture

Tooth root or fragment displaced into maxillary sinus

Questions, comments or queries

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