Extraction+Procedure

=*Informed Consent= =1) Local Anesthetic And Confirm Profound Anesthesia= =2) Sever PDL Attachment Periosteal Elevation= =3) Place Oropharyngeal Screen= =4)Elevation:=
 * Use a Periosteal Elevator (#9 Molt or Woodson) Push apically into PDL space until it stops and rotate a little in order to sever PDL attachment
 * **Safety Tips:**

>> **Single Rooted Teeth:** =5)Forceps= =6)Flap=
 * DO NOT pry off adjacent structures. ONLY rest elevator on the bone and the tooth that is being extracted.[[image:6safetygrasp3.jpg width="240" height="143" align="right"]]
 * Safety Grasp to prevent stabbing patient. You rest the finger next to the shaft on the tooth
 * Maxillary Pinch grasp to feel the expansion of the buccal and lingual plates
 * Mandibular Sling Grasp to protect the TMJ
 * Place periosteal elevator parallel to the long axis of tooth and sever the PDL. Next, remove the periosteal elevator and place the size #301 elevator in the space created by the periosteal elevator. Continue to increase size (next should be #34)
 * Note: if there is a curve to the root, do this on the convex side of the curve
 * **Multi-Rooted Teeth:**
 * Place on mesial side because roots will be curved distally
 * Push elevator in at an angle, push distally, then rotate and and pry at the same time
 * Grasp tooth as apically as possible. If crown is gone you may need to grasp on the buccal plate to get sufficient traction.
 * First apply force apically
 * Second apply rotational forces even in multi rooted teeth (less likely to fracture crown that buccal lingual lunation)
 * Lastly Luxate buccally and lingually with slight pulling motion (very minimal on pulling)
 * Hold for 5 seconds in each direction to allow time for the alveolus to expand
 * Once you have removed the tooth place pressure with 2 fingers on buccal and lingual plate to approximate and return closer to original location.
 * ===Flap Design:===
 * **Broad Base** - The apical portion of flap must be larger than the coronal aspect to supply adequate vascularity
 * **Adequate Size** - It is better to have a large flap whose tissue is not mangled than a small flap incision and the tissue is traumatized
 * **Full Thickness** - Incision should go all the way to the bone this means the periosteum is included. This will help you avoid cutting vessels etc...
 * ===Warnings:===
 * ====Incision should be over intact bone====
 * [[image:overbone.jpg width="239" height="83"]]
 * ====Avoid Vital Structures====
 * Mental Nerve - No Vertical Incisions Near bicuspids
 * [[image:mental nerve.jpg width="174" height="132"]]
 * Lingual Nerve - Never make a vertical incision on lingual side of mandible and never a straight distal incision distal to mand. 2nd molar
 * [[image:lingual.png width="167" height="228"]]
 * ====Include the entire papilla and do not extend incision over K9 eminence if possible====
 * [[image:ldfskajdf.jpg width="418" height="114"]]
 * ===Different Types===
 * Envelope - 2 teeth forward and 1 tooth back
 * [[image:envelop.jpg]]


 * Triangular - 1 tooth forward 1 tooth back
 * [[image:tri 3.png width="180" height="65"]]


 * Rectangular - 1 tooth forward 1 tooth back
 * [[image:rect 4.jpg width="162" height="73"]]

=7)Section - Bone Removal=
 * ===Protocol===
 * Flap
 * Remove facial bone to level of furcation (so can see top of furcation)
 * Take bur and at level of furcation or close to it, cut almost all the way through the crown M-D wise
 * Then take crown off
 * Bur out remaining tooth that is in furcation area to release all roots as separate
 * ===Warning===
 * Do not cut through the mandibular lingual plate near 2nd and 3rd molars. The lingual nerve sits just .5mm beyond.
 * [[image:lingual proximity.jpg]]