exodontia / dental implant courses

EXODONTIA
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

1. Introduction
2. Definition
3. Indications
4. Contraindications
5. Presurgical assessment
6. Armamentarium
7. Mechanical principles of extraction
8. Methods of extraction
9. Extraction procedure.
10. Post extraction instructions
11. Sequence of extraction
12. Complications
13. Conclusion
Contents:

Introduction:
Extraction of the teeth is a procedure that combines the principles of surgery
and principles of physics and mechanics. When these principles are applied
correctly, a tooth can be easily removed from a alveolar process without
untoward force or sequelae.

Definition
According to Geoffrey Howe----

1.Carious teeth that is non restorable
2.Periodontally involved teeth
3.Teeth which can’t be restored endodontically
4.Prophylactic removal of teeth for radiation therapy
5.Teeth in the line of fracture
6.Fractured teeth which is non restorable
7.Teeth associated with pathologic lesions
8.Malposed teeth
9.Cracked teeth
10.Impacted teeth

11. Supernumerary teeth
12. Orthodontic reasons
13. Prosthetic reasons
14. Retained deciduous teeth
15. Extraction of teeth for osteotomy.
16. Financial issues

 Most feared side effect of
radiotherapy is
osteoradionecrosis.
 Should teeth be extracted ?
 Extraction may spare the
patient, months or years of
suffering from
osteoradionecrosis

Woman's head undergoing radiotherapy
treatment for basal cell carcinoma
 Attempt is made to remove a good
portion of the alveolar process along
with the teeth & achieve a primary
soft tissue closure
 Traditionally 7 to 14 days between
tooth extractions and radiotherapy
has been suggested
 Radiotherapy should be delayed for 3
weeks if possible to ensure sufficient
soft tissue healing

 If tooth is grossly
displaced, severely mobile,
or grossly decayed –
remove
 If tooth is non carious &
appears secure in alveolar
bone – retain

Contraindications for extraction
Systemic contraindications Local contraindications
Absolute Relative Absolute Relative

Systemic contraindications
Absolute Relative
 Severe uncontrolled metabolic diseases
( Brittle diabetes & End stage renal disease
with severe uremia)
 Uncontrolled leukemia & lymphoma
 Severe uncontrolled cardiac diseases
(severe MI, unstable angina pectoris,
malignant hypertension, recent MI,
CVA
 Pregnancy
 Severe bleeding disorders like
hemophilia or platelet disorder
 Pt. taking certain medications like
corticosteroids, immunosuppressive
agents, cancer chemotherapeutic
agents

Local contraindications
Absolute Relative
 Teeth located in malignant tumor
 Vascular lesions like A-V malformations
& Hemangioma in the vicinity of the tooth
 H/O therapeutic radiation
(Osteoradionecrosis)
 Severe Pericoronitis around
impacted molars

 Medical history
 Dental history (history of
difficult extraction)
 Patient’s emotional maturity
 Clinical examination
 Radiographic examination

Radiographic examination
Condition of the surrounding bone

A B

Armamentarium: Extractionforceps
 Even though elevator can be used to luxate the tooth, it’s
extraction forceps that does most of the work.
 Forceps have blades and handles joined by a hinge joint.
The larger the ratio between the length of the handle and
length of the blades, greater the leverage that can be
exerted upon the root.

Ideally, the blade of the forceps should be sharp and also the
whole of the inner surface of the forceps blades should fit the root
surface. But because of variation in size & shape of tooth from
individual to individual, it is not practicable.
Hence a forceps is termed ideal if two point contact is achieved.

 Expansion of the body socket by use of wedge shaped
beaks of the forceps and the movement of the tooth itself.
 Removal of the tooth from the socket

How a forceps cause luxation of tooth and
expansion of bony socket
 Apical pressure : Helps to wedge the forceps firmly in
PDL space but results in minimal movement of the
tooth
 Care should be taken so that beaks are not placed too
apically and also not above the CEJ.
 Buccal force : results in expansion of buccal cortical
plate.
 lingual force : cause expansion of lingual cortical plate.

 Rotational force : cause rotation of tooth and this
results in internal expansion of the tooth socket.
 This force in used in single, conical rooted tooth.
 Tractional force : used to deliver the tooth from the
socket once adequate bone expansion is achieved.

Dental elevators
Indications:
 To reflect mucoperiosteum
 To luxate & remove teeth which can’t be engaged by the beaks of forceps
 To remove fractured or carious root
 To loosen teeth prior to application of forceps
 To remove intraradicular bone

Rules when using elevators:
 Never use adjacent tooth as fulcrum unless that tooth is to be extracted also.
 Never use buccal plate at the gingival line as a fulcrum, except where
odontectomy is performed
 Never use lingual plate at the gingival line as a fulcrum.
 Always use finger guards to protect the patient in case the elevator slips.
 Forces applied should be under control.
 When cutting through interseptal bone, take care not to engage the root of
an adjacent tooth, thus inadvertently forcing it from its alveolus.

Classification of elevators:
According to use:-
1. Elevators designed to remove the entire tooth( 1L- 1R).
E.g. Cross bar elevator
2. Elevators designed to remove roots broken off at the gingival line(30-4-5)
E.g. Apexo elevators
3. Elevators designed to remove roots broken off halfway to the apex (30-4-5, or
14L-14R, or 11L- 11R)
E.g. Apexo elevators, Cryer elevator, cross bar elevator
4. Elevators designed to remove apical third of the root
E.g. Apical fragment ejectors No. 1, 2 & 3
5. Elevators design to reflect mucoperiosteum
E.g. Periosteal elevator
According to Form:-
1. Straight: wedge type
2. Angular: Right & Left
3. Cross bar( handle at right angle to shank)

Mechanical principles of elevators
LEVER & FULCRUM
PRINCIPLE

WEDGE PRINCIPLE

WHEEL & AXLE
PRINCIPLE

Mechanical principles of extraction
1. Expansion of bony socket

2. Use of Lever & fulcrum
3. Insertion of wedge or wedges B/W root & bony socket wall.

Methods of extraction
Forceps extraction
or
Closed extraction
Trans alveolar extraction
or
Open or surgical extraction

EXTRACTION PROCEDURE
Over garment
Mask
Cap: hair covered
Eye protection

Patient’s & operator’s position
Administration of L.A
Severing of gingival attachment from the tooth
Positioning of Elevators & Forceps for extraction
Role of other hand
Compression of socket
Pressure pack

Patient’s & operator’s position

 Forceps always held with palm of hand above the
handles of the forceps.
 Patient is inclined 15-20o for extraction in the lower
left quadrant & 30 – 45o in the other 3 quadrants.
 Dentist stands behind the patient for extraction in the
lower right quadrant & in front of the patient for all
other extractions.

 Forceps are usually held with the palm of
the hand below the handles of the forceps
 The patient is usually inclined 30-45 degrees
for all extractions
 The dentist normally stands behind the
patient in all extractions

“You have to see well what you do in
order to do well what you see”
G.C Ingham

Position of Elevators & Forceps

Specific technique for removal of each tooth
Maxillaryteeth:
 The left index finger of the surgeon should reflect the
lip and cheek tissue
 Thumb should rest or palatal process.
 Stabilize the patients head and support alveolar
process
 In this position of extraction surgeon can frequently
feel the left palatal root of the molar becoming free in
alveolar process.
 Right side index finger is positioned on the palate
and thumb on buccal aspect.

A
B

Maxillary canine:

Maxillary 1st premolar:

Maxillary 2nd premolar:
D

Maxillary 1st molar:

Maxillary 2nd molar : anatomy is
similar to the first molar except the roots
are short and less diverged. Buccal roots are
more lowerly fused and same techniques
used as 1st molar.
Maxillary 3rd molar has conical root
extracted with no.210s forceps.
 Universal forceps for both right and left
side. Erupted 3rd molar usually extracted
with elevators.

Mandibular teeth:
 Index finger of left hand in buccal vestibule and
second finger in lingual vestibule reflecting lip cheek
and tongue
 The thumb of the left hand is placed below chin to
support the mandible and minimize
Temporomandibular joint pressure
 Bite block on contra lateral side also useful in limiting
pressure on TMJ

 strong buccal and lingual motion used to expand the socket
and allow the teeth to be delivered in buccal-occlusal
direction.
 Lingual bone is thinner in 2nd molar hence can more easily
be removed with stronger lingual than buccal pressure.
 Erupted 3rd molar usually have fused conical roots. care
should be taken not to use large amount of forces.

Mandibular anterior teeth

Mandibular premolars

Mandibular molars

Removal of broken roots

Stobie technique

Alveolar purchase technique
Kruger recommended a unique closed method technique for removal
of anterior teeth or root.
A fractured tooth often can be grasped by root forceps, or anterior
forceps.
Alveolar purchase may be obtained by detaching labial gingival cuff.
Then labial beak of forceps is placed under the tissue on the labial
plate of the alveolar plate of the bone.
The pressure on a forceps grasp the root along with labial alveolar bone
By this technique the root can be delivered with labial alveolar bone
easily. www.indiandentalacademy.com

Role of other hand

Compression of socket:
Pressure pack:
A B
C

 Debride only if necessary-
 Periapical pathology
 Debris
 Compress the expanded buccal and lingual plate
 Granulation tissue of gingiva should be curetted when
required
 Bone margins should be smooth
 Hemorrhage should be controlled

Post extraction instructions
1. Patient should be advised to firmly bite on the gauze piece placed on the
extraction socket for a minimum of half an hour after extraction.
2. Patient should be advised not to rinse his mouth vigorously for the next 24 hours.
3. To avoid any hot food or beverages for the next 24 hours. Patient should take
cold food.
4. Advised to take soft diet on the day of extraction.
5. Not to suck from a straw on the day of extraction.
6. Warm saline rinses & gentle brushing should be advised from the next day.
7. Do not spit.
8. Take prescribed medication on time.

Sequence of extraction
Max. post.
except 1st
molar
Max. ant.
Except canine
Mand. post.
Except 1st
molar
Mand. canine
Mand. ant.
Except canine
Mand. 1st
molar
Max. canine
Max. 1st
molar

Procedure involves reflection
of a mucoperiosteal flap,
cutting of the bone obstructing
the removal of the tooth & if
required sectioning of the roots
& then removal
Forceps extraction of these teeth
resulted in removal of bone & tooth
instead of just tooth

Indications :
1. Attempts at forceps extraction have failed
2.Retained roots, especially those in close proximity to the maxillary
sinus
3.History of difficult or attempted extractions.
4. Heavily restored tooth
5. Hypercementosed & ankylosed teeth
6. Geminated & dilacerated teeth
7. Teeth shown radiographically to have
-Complicated root patterns or
-Roots with conflicting lines of withdrawal

 Heavy buccal plate suggests
difficult forceps extraction
 Teeth exhibiting bruxism
may have denser bone &
stronger PDL attachment

procedure:
 Raising a flap
 Removal of bone
 Tooth division
 Removal of tooth
 Wound toilet
 Primary closure

 Flap must be large enough to allow easy access
without stretching
 Flap must be full thickness and include
periosteum when reflected

 Incisions that outline the flap must be made over intact bone
 The flap should avoid injury to local vital structures
 In the mandible vertical releasing incisions could
damage the lingual nerve & the mental nerve

 Releasing incisions should
be used only when necessary
 When necessary, only single
vertical incision used
 Healing time for a short flap
is comparatively less to that
for a long one

Types of mucoperiosteal flap

 Maxillary bone much more
porous than mandibular
 Mallet should follow with a
sequence of taps
 Advantage
• ease of autoclaving
• no irrigation required

 No: 8 rose head bur
 Rose head burs cut more
efficiently & clog less than
flat fissure burs

 Rose head burs have 3
advantages over flat
fissure burs for removal
of bone
1. More easily cooled by water jet
2. Site of cutting more readily seen
3. Easier to control

Chisel and Mallet
 Quicker and cleaner removal
of bone when used correctly
 No heat production
 Do not require irrigation
 No chances of bone
necrosis
 Not pleasant for the patient
Bur
Slow removal of bone
comparatively
Heat production
Require constant irrigation
Chances of bone necrosis due
to heat
Comparatively pleasant

Particularly useful in
cases where
 Lines of withdrawal of
different roots conflict
 Minimize need to remove
more bone

 Teeth sectioned using either osteotome or powered
hand piece
 Before splitting the tooth, point of application to
elevator facilitate delivery of the roots must be
made
 Separate the root mass of the lower molar from
below upwards

 Progress of healing & the amount of after-pain
greatly influenced by the care with which
postoperative socket cleaning is performed
 Judicious bone removal will speed healing by
reducing the
• amount of bone to be resorbed & remodeled
• Volume of blood-clot which fills the socket

 Surgical defect must be sealed from the oral
environment by replacement of the flap
 The flap acts as a primary dressing & contains the
osteogenic layer of periosteum which will help
promote bone regeneration

 3 conditions must exist for a tooth to be left in the
alveolar process
• Root fragment must be small
• Root deeply embedded in bone
• Root must not be infected

 Removal of root will cause excessive destruction of
surrounding tissue
 Removal of root endangers vital structures
 Attempts of recovering the root can displace it into
the maxillary sinus or tissue spaces

COMPLICATIONS OF TOOTH EXTRACTION
ARE MANY & VARIED
 Some are unavoidable (occurs even when utmost care
is exercised)
 Some are avoidable (if proper planning & surgical
execution done)

Dry socket
Causes:
 Preexisting infection
 Trauma to bone during extraction
 Decreased bleeding due to hemostatic effect of epinephrine or
other vasoconstrictor injected with L.A
 Infection entering into the socket after the tooth has been removed
 Presence of dense bone
 General dehabilitation
 Loss of clot because of rinsing of the mouth or sucking the woundwww.indiandentalacademy.com

Etiology & pathogenesis of fibrinolytic alveolitis [ BIRN’S HYPOTHESIS]

treatment:

Before undertaking the extraction of a tooth, one
should thoroughly evaluate the problems involved
and select the right anesthesia , radiographs and
forceps. The right procedure is selected to yield the
best result.
Hurry always leads to worry
Conclusion:

references
Contemporary oral & Maxillofacial Surgery, 5th Edition
James R. Hupp, Edward Ellis III, Myron R. Tucker
The extraction of teeth, 3rd Edition
Geoffrey Howe
Minor oral surgery Geoffrey Howe, 3rd Edition
Oral & Maxillofacial Surgery, Vol: 2
Daniel M. Laskin
Oral & Maxillofacial Surgery, Vol: 1
W. Harry archer, 5th Edition

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