Anaesthesia & Exodontia Third Year

1. ‫سبحان ال وبحمده سبحان ال العظيم‬
Principles of Exodontia
Dr. Adel I Abdelhady
)BDS, MSC, (Eg) Phd (USA , Eg
.Oral and Maxillofacial Surgery Dept
.College of Dentistry,, KSA

2. Rules of using Dental
Forceps & Elevator
Dr. Adel I Abdelhady
)BDS, MSC, (Eg) Phd (USA , Eg
.Oral and Maxillofacial Surgery Dept
.College of Dentistry,, KSA

3. Vaccination of the students

Vaccination of Hepatitis B virus for the
students is mandatory before starting any clinical
exposure or dealing with the patients.

4. Specific Objectives and Outlines
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Preparation of the patient prior dental extraction
Know the proper position and stance either for the
patient or for the operator
Know how to prepare the dental chair for the specific
tooth extraction
How to select the proper forceps
Know the difference between the forceps used for
extraction of teeth of upper as well as lower jaw
Know the different extraction movement
Know how to grib the tooth using extraction forceps
either for maxillary or mandibular teeth.

5. General considerations
:Factors complicating dental extraction
1.
Restriction by the lips and cheeks.
2.
Movement of the tongue.
3.
Movement of the mandible.
4.
Restriction of the mouth opening
5.
Communication of the mouth with the pharynx and larynx.
6.
Flooding of the oral cavity with micro-organisms.
7.
The related structures such as floor of the mouth, tongue,
hard and soft palate.
8.
The location and position of the tooth to be extracted

6. 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 Flaps technique with
bone removal and tooth sectioning

7. CLINICAL EVALUATION OF
TEETH BEFORE EXTRACTION
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Access to Tooth
Mobility of Tooth
Condition of Crown

8. RADIOGRAPHIC EXAMINATION
OF TOOTH
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The relationship of the tooth to be extracted to
adjacent erupted and unerupted teeth should be
noted.
Relationship of Associated Vital Structures
Configuration of Roots
Condition of Surrounding Bone

9. CHAIR POSITION FOR FORCEPS
EXTRACTION


The positions of the patient, chair, and operator
are critical for successful completion of the
extraction.
The correct position allows the surgeon to keep
the arms close to the body and provides stability
and support; it also allows the surgeon to keep
the wrists straight enough to deliver the force
with the arm and shoulder and not with the hand.

10. CHAIR POSITION FOR FORCEPS
.EXTRACTION cont
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For a maxillary extraction the chair should be tipped
backward so that the maxillary occlusal plane is at an
angle of about 45-60 degrees to the floor.
The height of the chair should be such that the height
of the patient's mouth is at or slightly below the
operator's elbow level.
During an operation on the maxillary right quadrant,
the patient's head should be turned substantially toward
the operator, so that adequate access and visualization
can be achieved .

11. PATIENT AND SURGEON
PREPARATION

Infection control is
mandatory

12. Preparations of dental chair,
operator and assistant

13. 
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For extraction of teeth in the maxillary anterior
portion of the arch, the patient should be
looking straight ahead.
The position for the maxillary left portion of the
arch is similar, except that the patient's head is
turned slightly toward the operator

14. 

For the extraction of mandibular
teeth, the patient should be
positioned in a more upright
position so that when the mouth is
opened widely, the occlusal plane
is parallel to the floor
The chair should be lower than for
extraction of maxillary teeth, and
the surgeon's arm is inclined
downward to approximately a 120degree angle at the elbow which
provides a comfortable, stable
position that is more controllable
than the higher position.

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

16. Extraction of teeth with forceps
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
These have two blades with
sharp edges to cut the
periodontal fibers. The blades
are wedge-shaped to dilate the
socket and are hollowed on their
inner surface to fit the roots
The blades are hinged which
allows them to close and grasp
the root the handle act as a lever
which gives the operator a
mechanical advantage. The
farther from the blades the
surgeon grasps the handles the
less effort he will have to make to
apply force to the tooth.
20/01/14

17. 
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In order to drive the forceps blade
straight up the long axis of the tooth
the shape of the handle is varied
Lower forceps have handles at right
angles to the blades
Upper forceps are straight for anterior
teeth and cranked ‫ ملتوية‬for the
posterior one, for the upper third
molars the beaks and the handle are
bent.

18. Extraction of teeth with
forceps
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The extraction of teeth is a surgical operation based
primarily on an anatomical appreciation of their
attachment in the jaw. First the soft tissues of the
gingival attachment and periodontal membrane are cut
to separate the tooth from the bone .
Next the socket is dilated by moving the root to
expand its bony socket .Finally when the tooth is loose
it may be drawn out of the alveolus .When completed
with forceps extractions are performed in two
movement.
20/01/14

19. Requirement of the Dental Forceps
INTRA-ALVEOLAR EXTRACTION
Dental extraction forceps has
three components which is
blades and handles united
together by a hinge joint.
1-The serrated 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.

20. INTRA-ALVEOLAR EXTRACTION
 2- The wedge shape 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
angulations design of the
blades in relation to the
joint and handles should be
made to facilitate gripping
of the tooth at CEJ

21. 
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

22. FORCEPS PARTS
BLADES
JOINTS
HANDS

23. 
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Upper Forceps
Upper Anterior central;
lateral incisors and canine
teeth
Upper Premolar
Upper Left Molar
Upper Right Molar
Bayonet Forceps for upper
third molar
Lower Forceps
Lower Anterior
Lower premolar
Lower molar

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

25. Forceps Style
American

26. English

27. Forceps design
Upper forceps

28. Lower Forceps

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

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

31. PRINCIPLES OF FORCEPS USE
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The primary instrument used to remove a tooth
from the alveolar process is the extraction
forceps.
The goal of forceps use is twofold:
(1) expansion of the bony socket by use of the
wedge-shaped beaks of the forceps and the
movements of the tooth itself with the forceps,
(2) removal of the tooth from the socket

32. 
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The forceps can apply five major
motions to luxate the teeth and
expand the bony socket:
1-The first is apical pressure,
which accomplishes two goals the
tooth socket is expanded by the
insertion of the beaks down into the
periodontal ligament space and
causes bony expansion. A second
accomplishment of apical pressure is
to make the fulcrum more farther
apically

33. 
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If the fulcrum is high a larger
amount of force is placed on the
apical region of the tooth, which
increases the chance of fracturing the
root end.
If the beaks of the forceps are forced
into the periodontal ligament space,
the center of rotation is moved
apically, which results in greater
movement of the expansion forces at
the crest of the ridge and less force
moving the apex of the tooth
lingually. This process decreases the
chance for apical root fracture.

34. 
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2-The second major pressure
2or movement applied by
forceps is the buccal force.
Buccal pressures result in
expansion of the buccal
plate, particularly at the crest
of the ridge
3-Third, lingual pressure is
3similar to the concept of
buccal pressure but is aimed
at expanding the
linguocrestal bone and, at
the same time, avoiding
excessive pressures on the
buccal apical bone

35. 
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4-Fourth, rotational pressure, as the name
4implies, rotates the tooth, which causes some
internal expansion of the tooth socket. Teeth
with single, conical roots, such as the maxillary
incisors, and mandibular premolars
5-Finally, tractional forces are useful for
5delivering the tooth from the socket once
adequate bony expansion is achieved. Tractional
forces should be limited to the final portion of
the extraction process and should be gentle

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

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

40. Proper function and Position of Left Hand- 4

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

42. Extraction
movements

43. PROCEDURE FOR CLOSED
EXTRACTION
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The three fundamental requirements for a good
extraction remain the same:
(1) adequate access and visualization of the field
of surgery,
(2) an unimpeded pathway for the removal of
the tooth, and
(3) the use of controlled force to luxate and
remove the tooth.

44. Five general steps make up the
closed-extraction procedure
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Step 1: Loosening of soft tissue attachment from the
tooth. The first step in removing a tooth by the closed
extraction technique is to loosen the soft tissue from
around the tooth with a sharp instrument,
Step 2: Adaptation of the forceps to the tooth. The
proper forceps is then chosen for the tooth to be
extracted and the forceps is then seated onto the tooth
t
so that the tips of the forceps beaks grasp the root
underneath the loosened soft tissue (Fig. 7-56). The
lingual beak is usually seated first and then the buccal
beak.

46. ‫سبحان ال وبحمده سبحان ال العظيم‬
Principles of Exodontia
Lec. # 4
Dr. Adel I Abdelhady
)BDS, MSC, (Egypt) PhD (USA , Egypt
.Oral and Maxillofacial Surgery Dept
.College of Dentistry, KSA
20/01/14

47. Dental Elevators
20/01/14

48. Dental Elevators
Parts of Elevators:
1-Blade
2-Shank
3-Handle
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49. :Classification
•According to Form.
•According to Use.
Different Forms of Elevators

51. Elevators Classification
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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
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52. Dental Elevators Classification
II-According to Form:
1-Straight elevator S,M,L
2-Curved right and left
3-Angulated right and left
4-Cross bar “ handle at right angle to the shank”
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53. Types of Dental
:Elevators
.Straight e.g. 1
Copland's
.Curved e.g. 2
Cryer’s
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54. Root Elevators
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Used to loosen and frequently remove teeth and
roots.
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a small straight elevator
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a large straight elevator
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55. Dental Elevator
”Cross bar “winter
Hospital pattern
Straight and
curved
Curved apexo
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56. Choice of elevators
Choice of elevators according to:
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Remaining tooth structure
Space available
Availability and position of solid fulcrum
Direction of the required movement
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57. Characteristics
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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
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58. Indications of use
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Breaking down the periodontal attachment
Luxation or removal of full tooth
Luxation and removal of remaining roots
Bone removal
Mucoperiosteal elevation
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59. Mechanical Principles

To obtain maximum mechanical advantage of the
elevator the fulcrum should be near the point of
resistance and the effort arm should be longer than
resistance arm (Principle of class I levers )
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60. Rules of Use of Elevators VIP
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1-Palm grip and finger guard
2-Don’t use the neighbouring
tooth as a fulcrum
3-Don’t use the buccal or lingual
plate of bone as a fulcrum
4-Use the left hand for reflection,
guard and support
5-Take care of the surrounding
vital structures
6-Follow respectfully, root
curvature
20/01/14

61. Handling and Application of the Elevator

62. Principles of Use of Elevator
VIP
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Wedge principle: straight elevator
Lever principle: Copland elevator, straight elev.
Axel and Wheel principle: Cryer’s elevator
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63. 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
20/01/14

64. 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
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65. 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
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66. Wheel & Axle
Wedging

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

68. 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

20/01/14

69. Elevation of teeth
Wedge elevator between
tooth and bone at neck of
tooth and rotate handle with
slight twisting, quarter-turn
movement
Observe for tooth movement
Do not use excessive force
•Crown fracture
•Loosen adjacent teeth
As tooth loosens, move
elevator more into bone
towards root end
20/01/14

70. Elevation of teeth
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Uses leverage at a mechanical
advantage point used to
luxate tooth in alveolar
socket
Movement of tooth expands
alveolar bone to allow tooth
to be removed
Start with smaller elevator
and move to larger as tooth
luxates
20/01/14

71. Principles of Extraction of
Maxillary and Mandibular
Teeth

72. Anatomical Considerations
The Upper Anterior
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. The combined use of forceps and elevators
The supporting Hand
The jaws should be adequately supported
by free hand of the operator this particularly
important in the lower jaw. the other
function of supporting hand is retraction of
the cheek, tongue and lip .This done by
placing the finger and thumb one on each
side of the gum on the buccal and lingual
or palatal aspects of the tooth ,and also the
operator is able to feel that the blades of
the forceps are under the m.m. and the
watching finger can feel any slipping of the
forceps or any tendency of the adjacent
tooth to move
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79. Extraction of Deciduous Teeth
In general deciduous teeth are much easier to
extract than the permanent ones
But some factors may complicate their
extraction:
1-Small mouth of the children patient
2-Permanent premolars are enclosed within the
roots of their predecessors , deciduous molars
have no root mass and caries often invades roots
making it difficult to grip them

20/01/14

80. Extraction of Deciduous Teeth
3-Pediatric forceps should be used
4-Care must be taken not to place the
beaks of forceps deep down on the
root of D. teeth because great
possibility of removing the partially
formed permanent teeth.
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81. Hazard of Extraction
of Primary teeth

When this inadvertently happens, the partially
formed tooth should be carefully freed from the
primary roots and replaced in the alveolus , the
soft tissues are then sutured over the alveolus to
hold the bone and the tooth in position
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82. Modifications for extraction of
primary teeth
•
•
Thin diverged roots
Resorbed roots
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83. Modifications for extraction of
primary teeth
•
•
•
•
Successors
Inferior alveolar nerve
Resilient bone
Restricted access
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84. Point to remember in
extraction of teeth
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
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
20/01/14

85. Mechanical principles involved in
tooth extractions
•
•
20/01/14
Removal of bone surrounding the root
Sectioning the tooth

86. Policy for leaving root fragments
Benefits
bone removal
Maxillary sinus
Tissue spaces
Nerve injury
Risks
Small size <5 mm
Very deeply seated
No pathosis
Inform the patient Follow up
20/01/14

87. 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

20/01/14

88. 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
20/01/14

89. Reason of Root Breakage
1-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
20/01/14

90. 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.
20/01/14

91. 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
20/01/14

92. 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
20/01/14

93. 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

20/01/14

94. 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
20/01/14

95. Extraction of teeth



Extraction of teeth related to a malignant
tumors
Extraction of teeth related to a line of fracture
Extraction of teeth in a patient received
radiotherapy