Brief introduction of surgical tooth extraction
surgical tooth extraction 2 alias
dental extraction; Tooth extraction; Tooth extraction; Tooth extraction; Tooth extraction; Surgical removal of tooth 3 classification
stomatology/surgical tooth extraction and alveolar surgery/surgical tooth extraction 4 ICD code
23.91 5 Overview
Surgical tooth extraction is the most basic operation in oral and maxillofacial surgery, and it is also one of the most commonly used treatment techniques. Some systemic or local diseases are treated by extracting the diseased teeth. However, in the process of tooth extraction, surgical trauma may also lead to pain, bleeding, swelling and mental stress, elevated blood pressure, and even induce diseases such as heart and blood vessels. Therefore, while mastering the professional knowledge of oral and maxillofacial surgery, oral and maxillofacial surgeons should fully master and be familiar with clinical medical knowledge, comprehensively consider the indications and contraindications of tooth extraction, and master the operation techniques skillfully to prevent various local and systemic complications.
6 Anatomy related to surgical tooth extraction 6.1 Applied anatomy of teeth
There are two pairs of teeth in a person's life, namely deciduous teeth and permanent teeth. The deciduous teeth begin to erupt at the age of 6 months, and come out at the age of 2 and a half, with 2 * * *, that is, 1 in the upper jaw and 1 in the lower jaw, which erupt symmetrically. There are three types of deciduous teeth: deciduous incisors, deciduous canines and deciduous molars. Permanent teeth are the second set of teeth in life. Children's permanent teeth begin to erupt when they are about 6 years old. By the age of 12, all permanent teeth are basically out except the third molar. The total number of permanent teeth in the whole mouth is 28 ~ 32, with 14 ~ 16 in the maxilla and 16 in the mandible, which are symmetrically arranged on the left and right sides. Permanent incisors (central incisors, lateral incisors), canines, premolars, molars, etc., grow on the alveolar process of maxillary and mandibular from front to back, forming maxillary and mandibular dentition.
teeth are composed of crown and root, and the neck of the tooth at the interface between them. There is a bone cavity in the crown and root of the tooth, which is filled with pulp tissue, called pulp cavity and root canal. The surface of the crown is covered with semi-transparent white hard tissue, called enamel; The root surface is covered with a hard tissue called cementum, and the inner layer of enamel and cementum is composed of dentin, the main tissue of the tooth.
The crown of the incisor is wedge-shaped, with thick neck and thick root, which is a single tooth. The crown of canine teeth is also wedge-shaped, but the top of the crown is a big cusp, which is cone-shaped, and it is also a single tooth. The root is long and thick, firmly located in the alveolar process, and it is the latest tooth to fall off. The premolar, also known as bicuspid teeth, has a cubic crown. The root of the first premolar is a single tooth except for two roots. Molar is the largest kind of permanent teeth, which is divided into the first molar, the second molar and the third molar. The crowns of these teeth are short and wide, and the roots are thick and forked, which makes the teeth firmly fixed in the alveolar bone. However, the crown shape and root number of the third molar vary greatly, and the eruption time is late, which is often blocked by insufficient eruption position, and 2% of them are congenital missing. 6.2 anatomy of alveolar bone
alveolar bone is a protruding part of the upper and lower jaws. The maxillary alveolar process is located below the maxilla and closely adjacent to the maxillary sinus. The alveolar processes on both sides are connected in the middle to form a horseshoe-shaped alveolar bone arch, which is the thickest part of the maxilla. Its bone structure is mainly spongy bone.
The part of the alveolar process containing the root is called the alveolar fossa, and each alveolar process contains 7-8 teeth, and its shape and size are consistent with the shape, size, length and number of the root. Therefore, the alveolar fossa in the posterior tooth area is wider than that in the anterior tooth area, and there is an osseous septum of alveolar bone. However, the alveolar fossa of a single tooth is narrow and deep, and there is no bone septum.
There are 2 ~ 3 small holes in the middle part of the temporomandibular region of the maxilla, which communicate with the alveolar ducts in the maxilla. It is the place where the nerves and blood vessels enter the maxilla, and it is also the place where the nerve block anesthesia is performed. The labial and buccal bone plates of maxillary alveolar process (except the first and second molars) are all loose and porous structures.
Mandibular alveolar process constitutes the upper edge of mandible, which is the structure to accommodate the root of mandibular teeth. The left and right sides are symmetrical, and the alveolar process is connected in the middle to form a horseshoe shape. Here, the alveolar process is slightly thin and narrow, and it widens further back, and inclines to the lingual side of the mandibular body.
The alveolar fossa of mandible is smaller than that of maxilla. The lateral bone plate of mandibular alveolar process is composed of dense, thick and hard hard bone, and the molar area is more obvious. Therefore, when anesthesia of inferior alveolar nerve is performed, inferior alveolar nerve block anesthesia is necessary, but local infiltration anesthesia is difficult to work.
The root is the fixed part of the tooth in the jaw bone, which is fixed in the alveolar fossa of the jaw bone by the outer cementum and periodontal ligament fiber tissue, connecting the tooth with the jaw bone. 6.3 Maxillary anatomy < P > The maxilla is the main skeleton that constitutes the middle part of the face. Its body is hollow, paired left and right, and consists of one body and four protrusions. The alveolar process is located under the maxilla and protrudes downward in a semi-arc shape, which is the place to accommodate the root. Osteoporosis of this process, the bone cortex on the labial and buccal side is thin and has many small holes, which is easy to cause traumatic fractures and facilitate local submucosal infiltration anesthesia.
There is a conical cavity in the maxillary body, which is called the maxillary sinus. The bottom of the maxillary sinus is very close to the roots of the first and second molars (especially the palatal roots), and some roots are separated only by a thin bone plate or mucosa. Therefore, attention should be paid to avoid the roots or teeth from entering the maxillary sinus or causing oral fistula of the maxillary sinus when pulling out the roots or performing surgery in this part (Figures 1.1.1.11 ~ 1.1)
The anterior wall of maxilla is thin and concave, and the labial side above the root of incisor is also slightly concave, which is called incisor fossa (Figure 1.1.1.15).
The posterior wall of the maxilla (below the temporal bone) is a hemispherical shape protruding slightly backward, which is also called maxillary tubercle (Figure 1.1.1.16).
The blood supply of maxilla is very rich, and the arteries mainly come from the posterior alveolar artery, descending palatine artery and sphenopalatine artery of internal maxillary artery. Veins go with arteries. Sensory nerve mainly comes from the maxillary branch of trigeminal nerve. Lymphatic reflux mainly flows into submandibular lymph nodes, deep upper cervical lymph nodes and retropharyngeal lymph nodes. 6.4 Anatomy of mandible < P > The mandible is the main skeleton that constitutes the lower third of the face. It is divided into horizontal mandibular body, vertical mandibular ascending branch and mandibular corner at the intersection of mandibular body and mandibular ascending branch. The mandible is composed of left and right symmetrical sides connected in the lower middle. The middle joint is the mental middle joint, which makes the mandible connect into a horseshoe shape (Figure 1.1.1.17 ~ 1.1.1.19).
there is a small hole near the midpoint of the medial surface of mandibular ramus, which is called mandibular foramen. Mandibular foramen is the entrance of inferior alveolar neurovascular bundle into mandibular canal. The mandibular canal is located in the lower part of the mandibular ramus and the inner structure of the mandibular body, and it is closer to the root of the tooth at the third mandibular molar. When the third mandibular molar is extracted or operated in this area, attention should be paid to avoid damaging the neurovascular bundle of the inferior alveolar (Figures 1.1.1.11 and 1.1.1.111).
The upper edge of the mandibular body is the alveolar process, and there is an alveolar fossa in the alveolar process to accommodate the root. The lingual bone plate of alveolar process is thin and easy to break, so the lingual bone plate fracture should be prevented when the posterior teeth are extracted. 7 Tooth extraction instruments < P > Tooth extraction surgical instruments have their special requirements. Commonly used surgical instruments include: examination instruments, anesthesia instruments, main tooth extraction instruments and auxiliary instruments. The main tooth extraction instruments commonly used are dental forceps, dental tappets, curetters, root clippers, high-speed gas turbine dental drilling machines, and auxiliary instruments such as scalpels, bone gouges, bone files, rongeurs, suture needles, needle holders and vascular forceps. The main tooth extraction instruments are introduced as follows: 7.1 Dental forceps < P > Dental forceps are the main instruments for tooth extraction. It consists of three parts: the beak, the joint and the handle (Figure 1.1.1.112). The forceps beak is used to clamp the crown or neck, the joint is the connecting part of the forceps beak and the forceps handle, and the forceps handle is the grip part. This structure of dental forceps is beneficial to the free opening and closing of the jaws when the operator operates, and different types of dental forceps with jaws can be selected according to different extraction sites, different types of crowns, root shapes and special needs of surgery.
maxillary dental forceps: the long axis direction of the forceps beak is consistent with the direction of the forceps handle or slightly curved (Figure 1.1.1.113). When the jaws of the first and second molars are pulled out, there is a triangular protrusion on the buccal inner surface (which is related to the buccal sulcus and two roots of the crown). When the tooth is pulled out, the tip of this protrusion should be placed at the root bifurcation of the buccal sulcus or buccal proximal and distal root, so that the jaws can be attached to the neck. Therefore, the maxillary posterior teeth forceps can be divided into left and right sides.
Mandibular forceps: The jaws of mandibular forceps are at right angles (posterior forceps) and obtuse angles (anterior forceps) to the handle (Figure 1.1.1.114). The inner side of the jaws of the first and second mandibular molars also has a pointed protrusion, which is convenient for the jaws to cling to the proximal and distal root forks and the neck. 7.2 horn forceps and root forceps
① horn forceps: it is a horn-shaped forceps used to extract the first and second molars of the mandible whose crowns are mostly decayed. The forceps beak is horn-shaped. When in use, the two beaks extend from buccal side and lingual side to between mesial and distal roots respectively. After the two beaks are combined, the decayed (damaged) teeth are directly extracted or extracted separately after the mesial and distal roots are separated.
② root forceps: divided into maxillary root forceps and mandibular root forceps. The jaws of root forceps are slender, and when the two jaws are closed, the tips of the jaws almost touch each other, which is mainly used for root extraction. Because the direction of pulling out maxillary root and mandibular root is different, the beak angle of maxillary root forceps and mandibular root forceps is different. The beak of mandibular root forceps is at right angles to the handle.
see fig. 1.1.1.115 for the holding method of dental forceps. 7.3 Tooth tappet < P > Tooth tappet is an instrument mainly used to loosen root, and it consists of three parts: beak, bar and handle. According to the principle of applied mechanics and actual needs, there are three types of designs: straight, curved, apical, Babbitt and triangular (Figure 1.1.1.116). The principle that the teeth are quite loose is mainly designed according to three forces: lever, axle and wedge. Straightening is the most commonly used in clinical work.
① straight: it can be used for all kinds of tooth extraction. Tooth stand mainly plays the role of breaking periodontal ligament and loosening root. During the operation, the beak of the dental tappet should be inserted into the gap between the root and the alveolar bone, and the periodontal ligament fiber will be broken and the root will move upward with the alveolar ridge as the fulcrum.
② root tappet: the beak of the tappet is slender, paired in the left and right directions, and the tappet is bent at an angle, which is mainly used for loosening residual roots or long broken roots.
③ apical protrusion: the protruding beak is thinner, smaller and sharper than the protruding beak. There are three pairs of left and right, curved struts and straight apical struts, which are combined into a set. Clinically, it is mainly used for root cutting of apical part.
④ triangle: it is also a triangle with a pair of left and right sides and a concave beak. The beak is thick, and it is mainly used to remove the root of mandibular molar, loosen the mandibular third molar or remove alveolar mediastinum.
⑤ Babbitt: A dentate with a concave beak and a curved angle, with a pair of left and right teeth, which is mainly used for extracting the maxillary third molar. 7.4 High-speed gas turbine < P > The application of high-speed gas turbine can reduce some knocking vibration in tooth extraction, relieve patients' fear, reduce surgical trauma and be beneficial to wound healing. High-speed gas turbine dental drills are mainly used for cutting crowns, splitting roots, deboning and removing the obstruction of impacted crowns. The high-speed gas turbine has a special nose, and the angle between the nose and the handle is about 45, and the length of the dental drill used is slightly longer than that of the commonly used drill (split drill) (Figure 1.1.1.117). Indications
With the progress of medical care and the improvement of oral medical level, many teeth with focus or source have been preserved and their functions have been restored after treatment, and some systemic diseases, such as coronary heart disease, ophthalmic diseases and nephritis, can be controlled, so that the indications and contraindications of tooth extraction surgery have changed accordingly. Careful and careful consideration should be made according to the patient's age, health status, residual teeth and the requirements of late denture restoration during tooth extraction.
1. Severe dental diseases? Too much dental crown caries or unconditional treatment, restoration or root lesions are not suitable for post crown and overdenture restoration.
2. Advanced periodontal disease? The diseased teeth in the late stage of periodontal disease are ineffective or unconditionally treated after periodontal treatment.
3. Severe periapical lesions? Periapical diseased teeth that cannot be treated by root canal therapy, apical resection or tooth replantation.
4. Tooth damage and broken teeth that cannot be treated.
5. impacted teeth? The impacted teeth can't erupt, and there is no eruption position, which repeatedly causes pericoronitis or caries of adjacent teeth, hinders the filling treatment of adjacent teeth, or compresses nerves to cause neuralgia and root absorption of adjacent teeth.
6. The displaced teeth and dislocated teeth affect the chewing function and need to be removed for cosmetic or orthodontic treatment.
7. Does the deciduous tooth stay for a long time? Affect the eruption of permanent teeth or cause permanent teeth displacement.
8. the lesion tooth? The presence of diseased teeth leads to oral and maxillofacial inflammation or systemic diseases, and the diseased teeth are ineffective after treatment.
9. Non-functional teeth? The absence of functional teeth causes tooth elongation and inclination, hinders mandibular movement, or hinders denture restoration. 9 contraindications
When determining the indications for tooth extraction, we should pay attention to some relative contraindications, pay attention to the patient's general and local conditions, weigh the advantages and disadvantages, take effective measures and preoperative treatment, so that the operation can be carried out safely.
1. Heart disease? Heart disease of various reasons, and has appeared heart failure, sitting breathing, cyanosis, edema of lower limbs, jugular vein bulging or liver and kidney.