Anaesthesia & Exodontia Third Year

2. Extraction of Teeth
((Exodontia

3. Definition
Main Topics
:General considerations
• Factors complicating dental extraction.
• Indications.
• Contraindications.
• Preoperative assessment before extraction.
:Methods and Techniques of dental extraction
• Intra-alveolar (forceps extraction(.
• Trans-alveolar (Surgical extraction(.
Anatomical considerations
.Extraction of deciduous teeth
.Post-extraction procedures
.Complications of dental extraction

4. Definition
.–Tooth extraction
The ideal tooth extraction is the painless removal
of the whole tooth, or tooth-root, with minimal
trauma to the investing tissues, so that the
wound heals uneventfully and no postoperative
.prosthetic problem is created

5. General considerations
:Factors complicating dental extraction
1.
2.
3.
4.
5.
6.
Restriction by the lips and cheeks.
Movement of the tongue and macroglossi.
Movement of the mandible.
Communication of the mouth with the pharynx and
larynx.
Flooding of the oral cavity with micro-organisms.
The related structures such as floor of the mouth,
tongue, hard and soft palate, and even the tonsils
may be damaged.

6. :Indications of teeth extraction
1. Unrestorative teeth because of
anatomical or economical factors,
which may be affected by:
•
•
•
•
•
•
Deep caries.
Severe abrasion.
Acute or chronic pulpitis due to trauma or
infection.
Apical pathological conditions.
Teeth interfering with the stability and fitness of
dental restorations.
Teeth causing chronic trauma or irritation to the
soft tissues.

7. :Indications of teeth extraction
2. Severe periodontal disease.
3. Before radiation therapy in cancer patients.
4. Malposed, supernumerary, and crowded
teeth.
5. Impacted teeth.
6. Traumatic avulsion or intrusion due to
fracture of the alveolar bone.
7. Teeth involved in the fracture lines of the
jaws.

8. Contraindications to the extraction of teeth
Systemic contraindications before consultation with the patient’s
:physician
1. Cardiac pt:
Rheumatic heart disease.
Coronary heart disease.
2. Blood dyscrasias:
.Anemia.
Leukemia
3. Diabetes.
4. Nephritis.
5. Toxic goiter.
6. Jaundice.
7. During pregnancy.
:Local contraindications
1. Acute gingival or pericoronal infection.
2. Extraction of maxillary molars and premolars during acute
maxillary sinusitis.
3. Teeth related to malignant tumors.

9. Preoperative assessment
:Clinical examination
1.
2.
3.
4.
Medical and dental history.
Examination of the side of complaint.
Examine the tooth condition.
Examine the relation of the tooth to related
important structures
5. Examine the condition of the oral hygiene.

10. Requirements of Pre-extraction
Radiograph
A-It should show the whole root structure
B-It should show the bone investing
C It should show the relation to any
important anatomical structure
Types of Radiograph :
A-Intra-oral radiograph
B-Extra-oral radiograph

11. Dental radiographs
Requirements and Indications of dental
radiographs: They are mainly indicated in the
.following conditions
1.History of
difficult
extraction.

12. 2. Tooth abnormally resistant to forceps
extraction.

13. . Teeth related to the maxillary antrum or inferior dental n

14. 4. Third molar teeth.
5. Heavily restored and pulpless teeth.

15. 6. Isolated upper molar for a long time.

17. 7. Any tooth has been subjected to trauma.

18. 8. Partially-erupted and un-erupted tooth.
9. Any tooth decided to be removed surgically.

19. 10. Any condition which predisposes to dental or
alveolar abnormality.

20. .Values of dental radiographs
:Types which commonly used
.Intra-oral. 1

21. .Extra-oral. 2
Panoramic film

22. Postero-anterior (PA( view

23. Lateral view

24. Oblique lateral view
Anterior
Posterior

25. Occipto-mental view

26. . Choice of anesthesia
. Sterilization
: Methods of extraction
• Intra-alveolar.
• Trans-alveolar.
: General arrangements
• Position of the patient.
• Position of the dentist.
• Preoperative preparation of the mouth.
: Mechanical principles of extraction
• Expansion of the walls of the bony socket.
• The use of a lever and fulcrum.
• The insertion of wedge or wedges between the tooth-root
and the bony socket wall.

28. Techniques of Extraction
1- INTRA-ALVEOLAR EXTRACTION
FORCEPS or CONVENTIONAL
This is by using dental forceps and
elevators.
2- TRANS-ALVEOLAR EXTRACTION
This is by using Surgical technique

29. Intra-alveolar extraction
Forceps
Elevator
• Parts of the dental forceps:
A, Blades.
B, Joints.
C, Handles.
• Requirements of the dental forceps

30. Forceps Style
American

31. English

32. Forceps design
Upper forceps

33. Lower Forceps

34. Upper
forceps
Anterior
Premolar
R. Molar
Premolar
Anterior
Bayonet
Lower
forceps
Molar
L. Molar

35. Requirement of the Dental Forceps
INTRA-ALVEOLAR EXTRACTION



All forceps has blades
and handles united by a
hinge joint.
1-The handles must
possess a suitable size to
rest comfortably in the
operator’ s hand and
should long enough to
afford use of strong and
steady extraction
movements. Also it must
be suitable in shape and
design to suit the area of
the tooth.

37. 
Upper Forceps

Upper Anterior
Upper Premolar
Upper Left Molar
Upper Right Molar
Bayonet
Lower Forceps
Lower Anterior
Lower premolar
Lower molar









38. INTRA-ALVEOLAR EXTRACTION
 2- The blades must be
sharp to be introduce
under the free gum
margin. In multirooted
teeth the blades should
be designed to grip the
different root patterns
 The angulation design of
the blades in relation to
the joint and handles
should be made to
facilitate gripping of the
tooth at CEJ

39.  3-The joint of the
dental forceps must
have free movement
for easy manipulation
but must be free from
rolling movement
Parts of dental forceps
A-Blades
B-Joint
C-Handles

40. Tooth Extraction Forceps
 Instruments are varied based on
 Crown
shape
 Root shape
 Tooth size
 Location in the mouth
 Distinguished by
 Angle of and notches on the beak
 Instrument contour
 Number

41. Proper selection of the suitable
forceps
Maxillary teeth
 Mandibular
teeth
 Single rooted
teeth
 Double rooted
teeth
 Triple rooted
teeth


42. Types of Dental
:Forceps
.Straight e.g. 1
Upper anterior
.Curved e.g. 2
All lowers and
upper posteriors

43. Periosteal Elevators
 Used to separate and retract soft tissue
from teeth and bone.
Molt 9
Woodson 1
Freer elevator

44. Rules of using dental forceps
 1-The patient is seated comfortably in the
chair after adjusting the chair to the
appropriate height , the apron fitted
around the patient and aseptic technique
should be followed , inspecting the tooth to
be extracted and the instruments required
for operation are selected

45. Rules of using dental forceps
 2-The forceps are then picked up in the
operator’ s right hand with the thumb
finger supporting it at its joint and the
forceps handles in the palm of the hand
this position gives the operator firm grip
and fine control over the instrument

46. Rules of using dental forceps
 In the upper molar and premolar forceps the
curved side of the handles should rest in the
palm of the hand
 3-In extraction of maxillary teeth , retract the lip
and cheek and support the alveolar process
using the thumb and index finger of the left hand
 4-In extraction of the left mandibular teeth , the
middle and the index fingers of the left hand
grips and supports the alveolar process around
the tooth being extracted, while the thumb is
used to support the mandible

47. Rules of using dental forceps
 In extraction of the right mandibular teeth
the operator should stand at the right side
and behind the chair and the left hand
comes from the other side to support the
alveolus with the thumb and index fingers
while the other fingers support the
mandible

48. Rules of using dental forceps
 The displacement of the tooth from its socket : When the
blades have been forced along the root with firm grip and
the tooth movement buccal outward and lingual inward
with pressure that should be firm smooth and controlled
 Accordingly the outward movement is initiated in the
extraction of all the maxillary and mandibular teeth with
exception of mandibular third and relatively mandibular
second molars .
 Inward movement is initiated in the extraction of lower 2 nd
and 3rd molars due to the fact that the lingual alveolar
bone plate is thinner than in the buccal plate .As a
general rule the movement is initiated towards the least
resistance site.

49. Rules of using dental forceps
 However there might be some deviation
from the general rule , when the tooth is
involved in very deep decay or abnormal
configuration of root .
 In deeply decayed teeth it is advisable to
initiate the extraction movement towards
the decayed side of the tooth and keeping
the force of movement more stressed
towards decayed side

51. Rules of using dental forceps
 In extraction of teeth with conical roots
which usually the upper central incisors
and the lower second premolars and
mesiodens, these teeth could be detached
from their sockets by primary rotatory
movement. If such a tooth felt to resist
rotation it should be moved buccolingually.
 Also rotatory secondary movement could
be used after the tooth has been
completely loosened.

52. Rules of using dental forceps
 The final movement of the tooth: normally after
few buccolingual movements, the tooth is felt to
have been loosened and rising out of its socket ,
when this occurs the final movement should
always be directed outward in order to avoid
traumatizing the teeth of opposing jaw.
 If gum is found to be attached to the tooth this
adhesion should be carefully dissected and
avoid pulling of the tooth by dental forceps to
avoid soft tissue laceration and exposure of the
alveolar bone

53.  Extraction of maxillary
incisors
 A-Apical grip
 B-Labial movement
 C-Palatal movement
 D,E-Dilation of the
socket and final
delivery

54.  Extraction of maxillary
 premolars:




A-Apical grip
B-Labial movement
C-Palatal movement
D,E-Dilation of the
socket and final
delivery

55.  Extraction of maxillary
molars:
 A-Apical grip
 B-Labial movement
 C-Palatal movement
 D,E-Dilation of the
socket and final
delivery

56.  Extraction of mandibular
Incisors :
 A-Apical grip
 B-Labial movement
 C- Lingual movement
 D,E-Dilation of the
socket and final delivery

57.  Extraction of mandibular
 premolar :
 A-Apical grip
 B-Labial movement
 C-Lingual movement
 D-Primary rotatory
movement in 2nd premolar
only
 E,F-Dilation of the socket
and final delivery

58. 




Extraction of mandibular
molar :
A-Apical grip
B-Buccal movement
C- Lingual movement
D,E-Dilation of the
socket and final delivery

60. Rules of using dental forceps
• Catch the root not
the crown
• Parallel to the long
axis of the tooth
• Initial movement
• Deep grip
• Firm grip
• Principal movement
• Final movement

61. Mechanical principles involved in
tooth extractions
Applying displacing
force to a tooth:
Direct
application of a
forceps
Indirect via a
fulcrum
(elevators)
Expansion of the
socket

62. Technique of
Forceps
Extraction
1- Position of
the Operator

64. Grip of the- 2
extraction forceps
Wright
Wrong
Wright
Wrong
Wrong

65. Application of the Forceps - 3
(
(Grip of the tooth

68. Proper function and Position of Left Hand- 4

69. Mechanical principles of forceps extraction
Wedging
Expansion of socket walls

71. Extraction
movements

72. Anatomical Considerations
The Upper Anteriors
Central incisor
Lateral incisor
Canine

73. The Upper Posteriors
First Premolar
First Molar
Second Premolar
Second Molar
Third Molar

74. The Lower Teeth
Incisors
Canine
Premolars

75. First Molar
Second Molar
Third Molar

76. Extraction
of maxillary
molars

77. Extraction of
mandibular 1st
& 2nd molars

78. • Post-extraction Procedures (Recommendations(
• Order of Extraction
• Extraction of deciduous teeth:

79. … Take time to laugh
It is the music of the
!heart

80. Removal of Fractured Root
 Fractured root should be removed at the time of
extraction because it may cause the following
complication:
 1-Large roots in the alveolus will be localized
source of inflammation
 2-It may cause residual infection
 3-RR may act as a mechanical irritant and set up
an inflammatory reaction which may give rise to
neuralgic pain of obscure origin

81. Reason of Root Breakage
1-Faulty application of instruments or
extraction movements, wrong pattern
forceps on a particular tooth may
cause its breakage. Improper grip ,
inadequate extraction movements.
Sudden or jerky extraction movement,
gripping of the crown too superficially
and not at CEJ

82. Reason of Root Breakage
2-Pulpless teeth, badly decayed, teeth with
abnormal root pattern or Hypercementosis
3-Excessive density of the surrounding bone
due condensing osteitis , or isolated tooth
and in old age patient
4-Lake of perfect control of instrument or
interference from the patient

83. Removal of broken single
rooted teeth
• This includes the maxillary incisors and canines
and mandibular incisors, canines and premolars:
• Removal of Roots Broken at the Gingival
Margin:
• A-These root may be extracted with forceps ,
with careful adaptation of the beaks under the
gingival margin
• B-Straight Apexo elevator or Coupland .The
angulated Apexo elevator used to remove
mandibular single rooted teeth apply moderate
force distal as will as mesial of the root till
complete delivery of the RR

84. Removal of the root broken
halfway of the apex
• Generally, these are
the cases which
require the reflection
of mucoperiosteal flap
and removal of buccal
and lingual alveolar
bone what we call it
TRANS-ALVEOLAR
SURGICAL
EXTRACTION

85. Take the time to
… !hear
It is the power of
Intelligence

86. Removal of Roots of Upper and
Lower Molars
• 1-Removal of Broken Root of
Mandibular Molars :
1-When both roots are fractured at the
gingival line , the root trunk is still
present a lower premolar forceps can
be used, its beaks should be inserted
as far under the gingival margin

87. Removal of Roots of Upper and
Lower Molars
• 2-The other technique for removal of such
roots is a drill used to separate the roots
after this Apexo elevator may be used to
loosen the mesial root by inserting it into a
space between the lamia dura and the
surface of the root from the mesial and
distal surfaces until loosening of the root
occur . The other root could extracted by
using Winter or Cryer elevators

88. Removal of Broken Roots of
Maxillary Molars
• Maxillary molars roots may be removed by
grasping the palatal and the distobuccal roots
with the upper roots forceps or with Bayonet
Forceps .
• This procedure will either remove all three roots
or cause breaking of mesiobuccal root which
then can be removed by upper root forceps or
with Warwick James curved elevator inserted
into empty disto-buccal socket

89. Removal of Broken Roots of
Maxillary Molars
• Another technique is first
to separate the fused
roots with drill in the
form of “ Y “ shape and
then remove them
individually by mean of
forceps or by Warwick
James curved elevator
between the separated
roots.

90. … Take time to Love
It is the secret of
!eternal youth

91. Post-extraction care and instructions

92. Post-extraction care
• Inspection of the socket
• Removal of debris and any
tooth fragments
• Squeezing the socket
• Insuring haemostasis (Gauze
pack)
• Remove any septic granulation
tissue or granuloma from the
socket
• Trim and smooth any sharp
edges from the alveolar plate
of bone
• Clean the patient lips and face.

93. Post-extraction Instructions
1-Keep biting on gauze, sponges for about one
hour after extraction, by the time if bleeding is
controlled, discontinue pressure pack
2-No mouth wash for at least 24 hours after
extraction
3-Avoid any hot food or drink for the rest of the day
to prevent bleeding
4-The diet must be cold fluids or soft food to avoid
irritation of the wound
5-Avoid any hard labour and have an adequate
rest

94. Dental Elevators

95. Use of Elevators in Extraction of
Teeth
.Parts of Elevator
:Work Principles
• Levering.
• Wedging.
• Wheel and Axle principle.

96. Wheel & Axle
Wedging

97. Rules
• Palm grip
• Don’t use the neighbouring
tooth as a fulcrum
• Don’t use the buccal or lingual
plate of bone as a fulcrum
• Use the left hand for
reflection, guard and support
• Take care of the surrounding
vital structures
• Follow respectfully, root
curvature

98. Principles of Use of Elevator
• Wedge principle: straight elevator
• Lever principle: Copland elevator
• Axel and Wheel principle: Cryer’s elevator

99. Principles of Use of Elevator
Wedge Principle
Some elevators are designed primarily to
be used as a wedge e.g. Apexo,and
coupland. This elevators are forced
between the root of the tooth and the
investing bony tissue parallel to the long
axis of the tooth

100. Principles of Use of Elevator
Lever Principle:
On applying this principle the elevator is a
lever of the first class the position of the
fulcrum is between the effort and
resistance in order to obtain a mechanical
advantage in a lever of the first class the
effort arm on one side of the fulcrum, must
be longer than the resistance arm

101. Principles of Use of Elevator
Wheel and Axle Principle
The wheel and axle is a
simple machine the effort
is applied to the
circumference of a wheel
which turn the axle so as
to raise a weight. It could
be used as a sole work
principle in removing the
teeth, it is also used in
conjunction with a wedge
or lever principles

102. :Classification
•According to Form.
•According to Use.
Different Forms of Elevators

104. Handling and Application of the Elevator

105. Dental Elevators
• Parts of Elevators:
1-Handle
2-Shank
3-Blade

106. Dental Elevators Classification
• I-According to use:
1-Elevators designed to remove the entire
tooth, straight elevators, hospital pattern
and winter elevator
2-Elevators designed to remove roots
broken off at the gingival line e.g. Apexo
elevator , Coupland and lido lavien
elevators
3-Elevators designed to remove roots
broken off half way to the apex e.g. curved
elevator hospital pattern, winter elevator
and Apexo elevator

107. Dental Elevators Classification
• II-According to Form:
1-Straight all types
2-Curved right and left
3-angulated right and left
4-Cross bar “ handle at right angle to the
shank”

108. Types of Dental
:Elevators
.Straight e.g. 1
Copland's
.Curved e.g. 2
Cryer’s

109. Root Elevators
• Used to loosen and frequently remove
teeth and roots.
– a small straight elevator
– a large straight elevator
–

110. Dental Elevator
”Cross bar “winter
Curved apexo

111. Choice of elevators
•
•
•
•
Remaining tooth structure
Space available
Availability and position of solid fulcrum
Direction of the required movement

112. Characteristics
• Has no joints
• Needs a fulcrum to
work
• Has to be wedged
between bone and
tooth
• Exerts less directional
force on the tooth
• Different sizes and
shapes

113. Indications of use
 Breaking down the periodontal attachment
 Luxation or removal of full tooth
 Luxation and removal of remaining roots
 Bone removal
 Mucoperiosteal elevation

114. Danger in the Use of Elevators





1-Loosening or extracting the adjacent teeth
2-Fracture the alveolar process or fracturing the
mandible
3-Penetrating the maxillary antrum or forcing the
root into the antrum
4-Forcing a root a root of a mandibular molar
through lingual plate of the mandible
5-Damage of soft tissues by slipping of the tip of
the elevator

115. Point to remember in
extraction of teeth
 Never refer to the extraction of tooth as a
“simple extraction”. You may find yourself
in the embarrassing position of trying to
explain to the patient why this simple
extraction taking so much time and effort
 Anticipate breakage by knowing all reason
why root and crown break. Forewarn the
patient of the possibility of breakage or
fracture

116. .Rules in the use of Elevators
.Dangers in the use of Elevators

118. Removal of Fractured Roots
.Reasons for Removal
.Reasons of Root Breakage
.Techniques of Root Removal