11

Contra – indications for exodontia

Contra – indications :
In general ,the contra- indications are divided into groups :
1- Local contra- indications .
2- Systemic contra- indications .

Local contra- indications (L.C s) :

There are several L.C s to extractions :
1- Acute and uncontrolled infection :
Extraction in the presence of acute and uncontrolled infection may lead to spread of infections locally or systemically leading to many complications some of them are dangerous and life threatening (e.g. cavernous sinus thrombosis , Mediastinitis , Ludwig`s angina ,Acute periapical abscess and facial abscess especially in medically compromised patient. In addition to that limitation of mouth opening .

2- Previous radiotherapy :

Previous therapeutic radiation in oral and maxillofacial region for treatment of cancer lead to fibrosis and decreased vascularity of the tissue or area of extraction and end with a condition in the bone called osteoradionecrosis .
3- Teeth located within area of tumor :
Especially malignant tumor should not be extracted because extraction may lead to dissemination of the tumor , unhealed socket and postoperative complications , for example , bleeding postoperatively and intraoperatively .

Systemic contra- indications :

Systemic contra- indications preclude extraction because the patient`s systemic health is such that the ability to withstand the surgical work may be compromised .So extraction should be postponed until the severity of the problem has been resolved and maybe arranged after consultation with physician to perform extraction safely without complications so caution is advised in the following conditions :


• Sever uncontrolled metabolic disease , e.g. uncontrolled diabetes , end- stage renal disease .
• Uncontrolled leukemia's and lymphomas .
• Sever uncontrolled cardiac disease. e.g. myocardial infarction, unstable angina pectoris , dysrhythmias .
• Sever uncontrolled hypertension .
• Pregnancy .
• Bleeding disorder e.g. hemophilia, platelet disorder , patient on anticoagulants .
• Patients who take a variety of medications e.g. patient on steroid and immunosuppressive drugs, cancer and chemotherapy .
• Uncontrolled epilepsy .

Per- extraction evaluation :

P.E.E is very valuable and necessary for successful extraction practice . Harry and inadequate P.E.E of the case may lead to many embarrassing intra – operatively for the operator , in addition to the postoperative problems to the patient , P.E.E include :
1- Clinical preoperative evaluation .
2-Radiological evaluation

1-Clinical P.E.E also includes :

• General evaluation .
• Local evaluation .
General evaluation includes :
• General impression of the patient .
• History of general diseases . Nervousness , orientation .
• General of hygiene .
• Gingival inflammation , calculus , neglected mouth .


Local factors or evaluation includes :
Clinical examination to the acused tooth .
• Adjoining structures .
• Access to the tooth . This includes the mouth opening, location of the tooth (e.g. buccally malposed , instanding ) may present difficulty in positioning the dental forceps for extraction , so you may remove such a tooth surgically .
• Tooth mobility : The mobility of the tooth to be extracted should be assessed preoperatively , greater than normal mobility is frequently seen with sever periodontal disease but sometimes it maybe because of the underlying pathology like neoplasm .

Condition of the crown : e.g.

a- Carious destruction
b- The presence of large restoration .
c- Presence or absence of the adjoining teeth .
d- Non – vitality .
e- State of the supporting tissue .
f- Shape , position , long axis and size of the crown .
g- Attrition .
Good P.O.E resulted from correction of data collected from history ,clinical examination , radiographs and laboratory aids in addition to that P.P.E need good knowledge and experience in the basic sciences e.g. anatomy , physiology .

In general , P.O.E may help you in :

a- Determine the method of extraction and type of anesthesia .
b- Reduce the time spend for extraction .
c- Reduce the intra and post operative crisis and complications .


2-Radiological evaluation
Preoperative clinical assessment maybe supplemental some times by preoperative radiographs , and the positive indications for preoperative radiograph are :
1- History of difficult or unsuccessful extraction .
2- Crown of extensive caries , large restorations , non-vital tooth when diagnosis is not certain and tooth is mal-posed .
3- A tooth which is abnormally resistant to forceps extraction .
4- If after clinical examination you decide to remove the tooth surgically .
5- Any tooth which is in close relation to important or vital structures like neurovascular canal , maxillary sinus , mental nerve , nasal cavity .

6. Attritioned teeth in elderly patient (maybe associated with hypercementosis )

7. If a tooth is partially erupted or completely unerupted or retained root .
8. Any tooth which has been subjected to trauma , fracture of the root and / or alveolar bone maybe present .
9. An isolated maxillary molar especially if it is unopposed and over-erupted . The bony support of such a tooth is often weakened by the presence of maxillary sinus and this may predispose to certain of oro-antral communication or fracture of the maxillary tuberosity .
10. Whenever , underlying bony pathology is suspected e.g. cystic lesion , tumors .

• Any systemic condition which may predispose to dental or alveolar abnormality like :

a- Ostetitis deforms (Paget`s disease ), in which the root hypercementosed, ankylosis leading to difficult extraction , infection of the socket .
b- Cleido – cranial dystosis , for pseudo – anadontia (multiple impactions, hooked roots occur , supernumerary teeth ) .
c- Patient who have received therapeutic irradiation to the jaw who may have to predispose to osteoradionecrosis .
d- Osteopetrosis (marble bone disease ), which cause extraction very difficult and predispose to chronic osteomyelities .

• A good radiograph and careful interpretation may give or aid the operator to many factors that may cause difficult extraction , e.g. :
1- Abnormal number of roots, and shape of roots .
2- An unfavorable root pattern .
3- Caries extending to the root mass .
4- Fracture or resorption of the root .
5- Hypercementosis of the root .


6. Ankyloses ( there is no space in periodontal ligament ) , and sclerosis of the bone .
7- Germination ( the development of two teeth from one bud ).
8- Impaction
9- Bony sclerosis and pathological lesions .

Also careful interpretation of the radiograph may also reveal or show the possibility of the following complications :
1- Involvement of , and damage to inferior dental nerve and mental nerve e.g. on extraction of impacted lower 8 .
2- The creation of oro-antral fistula or or- nasal communication
3- The retention of intra- bony pathology e.g. cyst .
4- The displacement of root or tooth into maxillary sinus .
5- Fracture of maxillary tuberosity .

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