Principles

of
Uncomplicated exodontia

DR. MOHIT BINDAL

Senior Lecturer
Department Of OMFS

Dr. Mohit Bindal, Subharti Dental College, SVSU

 CONTENTS
 Definition  Principles and procedure of
extraction
 Indications for removal of teeth
 Contraindications
Mechanical principles
 Presurgical assessment Principles of forceps use
 Medical assessment Role of opposite hand
 Clinical assessment of teeth Procedure for extraction
 Radiographic assessment of
teeth  Specific techniques for removal of
each tooth
 Patient and surgeon preparation
 Post extraction tooth socket care
 Chair position for extractions
 Post extraction instructions
 Pain and anxiety control  Complications
 Infection control  References

Dr. Mohit Bindal, Subharti Dental College, SVSU

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 post operative prosthetic problem created.

“Geoffrey L Howe”

Dr. Mohit Bindal, Subharti Dental College, SVSU

Indications for extraction
Preradiation therapy Tooth associated with jaw fracture

•If tooth is grossly

displaced,severely
mobile, or grossly
decayed – remove

•If tooth is non

carious & appears
secure in alveolar
•Most feared side effect of bone – retain
radiotherapy is osteoradionecrosis.
•Extraction may spare the patient,
months or years of suffering from
osteoradionecrosis.
Contraindications Of Extraction:

Contraindications for Dental Extraction

Systemic Local
 Systemic contraindications
•Cardiovascular problems •Blood dyscrasias
•Uncontrolled hypertension Anemia
•Unstable angina pectoris
Hemophilia
•Recent myocardial infarction
•Uncontrolled cardiac Hemorrhagic purpura
dysrhythmias Polycythemia
Platelet disorder.
•Uncontrolled metabolic
disease
•Brittle Diabetes
•Hyperthyroidism •Patients on medication should be
•Osteoporosis treated with caution
•End stage renal disease •Corticosteroid therapy
with severe uremia

•Malignant disease •Pregnancy is considered a relative

Leukemia contraindication
Lymphoma
Local Contraindications
 Absolute contraindication Teeth associated with central
haemangioma.

 Relative contraindications
 Teeth located within an area of tumor, especially a
malignancy
 History of therapeutic radiation for cancer
 Severe pericoronitis around an impacted mandibular molar
Acute dentoalveolar abscess
 Acute infection - Not a contraindication to extraction.
 If access and anesthesia considerations can be met, the tooth
should be removed as early as possible
 Presurgical assessment
 Medical history: Determination of health status.
Any modification of routine procedure.

 Dental history (history of difficult extraction)

 Patient’s emotional maturity: Level of anxiety

 Clinical examination

 Radiographic examination
 Presurgical medical assessment

 Cardiovascular Problems  Endocrine Disorders

 Pulmonary Problems Diabetes Mellitus
Asthma Adrenal Insufficiency
COPD Hyperthyroidism
 Renal Problems Hypothyroidism
Renal Dialysis  Hematologic Problems
Renal Transplant  Hereditary Coagulopathies
 Hypertension  Therapeutic Anticoagulation
 Hepatic Disorders  Neurologic Seizure Disorders
 Clinical examination
ACCESS TO THE TOOTH
•First factor to be examined that is the extent to which the patient can open mouth.
•Any limitation to the mouth opening compromise the ability of surgeon to do routine
uncomplicated exodontia. Surgeon should plan for surgical approach to the tooth as
well as look for the cause of reduction of opening

TOOTH ALIGNMENT IN THE ARCH

•Location and position of the tooth to be extracted within a dental arch should be
examined.
•Properly aligned tooth has normal access for forceps placement and elevators
•However crowded or malposed tooth present difficulty in placing proper forceps.
 MOBILITY OF TOOTH
Greater than normal Less-than-normal mobility-
mobility-periodontal disease Hypercementosis,
Ankylosis.
CONDITION OF CROWN
•Assessment of crown before extraction is related to the presence of large caries or
restorations as the likelihood of crushing the crown during extraction is increased.

•It is critical to grasp the forceps as apically as possible.

•If the tooth has large accumulation of calculus, it should be removed with the
scaler before extraction as calculus interferes with placement of forceps and
fractured calculus contaminate the tooth socket.

•Assess the condition of the adjacent tooth.

 RADIOGRAPHIC EXAMINATION
 Radiographic examination provides information regarding
 The relationship of the tooth to be extracted to adjacent erupted
and un erupted teeth.
 Primary teeth, the relationship of its roots to the underlying
succedaneous teeth.
 Relationship of Associated Vital Structures

Dr. Mohit Bindal, Subharti Dental College, SVSU

Tooth factors.

 Number of roots of tooth to be

extracted.

 Curvature of the roots and the

degree of divergence
 short conical roots easier to
remove
 long roots with severe abrupt
curves at apical end difficult to
remove

 Size of the root

 bulbous or not
 Level of furcation

 Crown root ratio

Evidence of root caries Root resorption- either
Root caries Rootorresorption
internal external
CONDITION OF SURROUNDING BONE
Bone is more radiolucent, likely to be less dense which
makes extraction easier.
If the bone appears radiographically opaque indicates
increased density with the evidence of condensing osteitis/
sclerosis.
Periapical pathology.
RELATIONSHIP OF ASSOCIATED VITAL STRUCTURES.
MAXILLARY MOLARS:
•Proximity of the roots of maxillary molar to the floor of maxillary sinus.
•Only a thin bone exists between the sinus and roots, the potential for perforation
increases.

MANDIBULAR MOLARS.
Proximity to inferior alveolar canal.

MANDIBULAR PREMOLARS.
Mental foramen.
CHAIR POSITION FOR FORCEPS EXTRACTION
 For extraction of any teeth except right mandibular posteriors -
The operator stands on the right side of the patient.

For extraction of mandibular right

posteriors- The operator stands behind
the patient.
Height of chair
Maxillary teeth extraction Mandibular teeth extraction

The chair adjusted -site of The chair adjusted -the teeth to be

operation is about 8cm (3 inches) extracted- 16cm(6 inch)below the level of
below the shoulder level of the the operator’s elbow.
operator.
Role of opposite hand
Correct grip of forceps
Different techniques.

North American Technique British Technique

 Forceps are usually held with the palm  Forceps always held with palm of hand
of the hand below the handles of the above the handles of the forceps
forceps
 Patient is inclined 15-20o for
 The patient is usually inclined 30-45 extraction in the lower left quadrant &
degrees for all extractions 30 – 45o in the other 3 quadrants

 Dentist stands behind the patient for

 The dentist normally stands behind the extraction in the lower right Q & in
patient in all extractions front of the patient for all other
extractions
GENERAL ANXIETY CONTROL PROTOCOL DURING APPOINTMENT

Non pharmacologic Pharmacologic

 Frequent verbal assurances
 Local anaesthetic of sufficient
intensity and duration
 Distracting conversation

 Nitrous oxide
 No unnecessary noise

 I.V anxiolytics
 Surgical instruments out of patient
sight

 Relaxing background music

 Infection control
 Surgeons prevent transmission of infection –patient
themselves.

 CONCEPT OF UNIVERSAL PRECAUTIONS -All patients

must be viewed as having blood-borne diseases -can be
transmitted to the surgical team.

 Prevention of transmission- surgical gloves, surgical mask, and

eyewear with side shields , surgical gowns and surgical cap.

 Before the surgical procedure-a minimal amount of draping -

decrease the risk of contamination.

 Before the extraction-antiseptic mouth rinse-reduces the gross

bacterial contamination –reduces post operative infection
 MECHANICAL PRINCIPLES OF EXTRACTION.
1.Expansion of bony socket:
 Most important factor
 Achieved by using tooth as dilating instrument.
 Determined by root pattern and the surrounding bone
 Dilation is accompanied by multiple small fractures of buccal plate and
inter-radicular septa.
2. Use of a lever and fulcrum.
 Basic factor governing use of elevators
 To force the tooth or root out of socket along the path of least resistance.
 Three principles
 The lever
 The wedge
 The wheel and axle.
 The lever
A lever -mechanism for transmitting a modest force- The mechanical advantages
of a long lever arm and a short effector arm—small movement against great resistance
 Elevators - used primarily as levers.

 Crane and pick elevate the tooth or a root -using the purchase
point.
 Wedge principle
Wedge principle -used in straight elevator - to luxate
a tooth from its socket.
A small elevator is forced into the periodontal ligament space-
displaces the root toward the occlusion .
 Wheel and axle principle
Wheel and axle principle used in triangular, or pennant-
shaped, elevator.
One root of a multiple-rooted tooth is left in the alveolar process-
pennant-shaped elevator - used to remove the root.
3. Insertion of wedge or wedges.
 Used between the tooth-root and bony socket wall causing the
tooth to rise in its socket.
PRINCIPLES OF FORCEPS USE:
Primary instrument to remove tooth from alveolar process although elevators help in
luxation of tooth.

 The goals of forceps use

 Expansion of the bony socket
 Removal of the tooth from the socket
 Five major motions
 Apical pressure: break the periodontal seal
 Buccal force: expand the buccal plate
 Lingual force: expand the lingual crest
 Rotational force: overall expansion of tooth socket
 Tractional force: deliver the tooth
Apical Force: accomplishes two goals
1. Bony expansion:
 Tooth socket expanded by the insertion of beaks into the PDL space.
 Apical pressure on the tooth causes bony expansion.
2. Centre of rotation:
 Displaced apically.
 Greater movement of expansion forceps at the crest of ridge and less force
moving the apex of tooth lingually.
 Decreased root fracture.
Buccal force:
1. Expansion of buccal plate, at the crest of ridge.
2. Also causes lingual apical pressure.
Lingual pressure:
Expands the linguocrestal bone.
Avoids excessive pressure on the buccal apical bone.
ROTATIONAL PRESSURE:
 Causes internal expansion of tooth socket, more useful for tooth with conical
roots.
 Teeth with multiple roots, especially if its curved more chances to fracture under
this type of pressure.
TRACTION PRESSURE
 Delivers the tooth from the socket once the adequate bony expansion achieved.
 Should be gentle
 Limited to the final portion of extraction process.
Procedure for closed extraction

 Three fundamental requirements for a good extraction

 Adequate access and visualization of the field of surgery
 An unimpeded pathway for the removal of the tooth
 The use of controlled force to luxate and remove the tooth

 Five general steps for the closed-extraction procedure:

Step 1: Loosening of soft tissue attachment from the tooth.

Instrument: Woodson elevator.

Sharp end of no 9 periosteal elevator
Purpose:
 Ensure profound anaesthesia achieved
 Allow proper forceps positioning more apically
Step 2: Luxation of the tooth with a dental elevator
Expansion and dilation of the alveolar bone and tearing of the periodontal ligament
requires the tooth luxation.
 Straight elevator inserted perpendicular to the tooth into interdental space.
 Elevator is turned so that inferior portion rests on alveolar bone, superior or
occlusal portion of the blade turned toward the tooth being extracted.
 Type of force: Strong, slow, forceful turning.
Occlusal side of elevator blade is turned Handle of elevator, turned in opposite
toward tooth direction to displace tooth. accomplished only
if no tooth is adjacent posteriorly
 If the tooth is intact and in contact with stable teeth anterior and
posterior to it- amount of movement achieved with the straight
elevator -minimal.

 The usefulness of this step greater- if patient does not have a

tooth posterior to the tooth being extracted.

 Excessive forces -damage and even displace the teeth adjacent

to those being extracted.

 Tooth luxation with elevator-only the initial step in the extraction

process-the forceps are the major instrument for tooth luxation.
Step 3: Adaptation of the forceps to the tooth
•Proper forceps chosen
•Beaks of the forceps to adapt anatomically to the tooth, apical to the cervical line.
•Lingual beak seated first.
•Once the forceps positioned surgeon grasps handle of the forceps at very end to
increase mechanical advantage.
•Beaks be held parallel to the long axis of tooth for maximal effectiveness in
dilating and expanding the alveolar bone.

 The surgeon -apply force with the shoulder and upper arm
without any wrist pressure.
Different types of adaptation of forceps blades
to tooth
Step 4: luxation of the tooth with the forceps.
 The major portion of the force -toward the thinnest and weakest
bone
 In the maxilla and all but the molar teeth in the mandible-major
movement is labial and buccal.
 Type of force: slow steady force to displace tooth buccally.
 Tooth is again moved toward the opposite direction.
 Alveolar bone expands

Forceps apically reheated with strong deliberate motion

Additional expansion of alveolar bone

Further displaces centre of rotation apically.

Three factors

(1)The forceps apically seated as far as possible and reseated

periodically

(2) The forces- in the buccal and lingual directions -slow, deliberate
pressures -not jerky wiggles.

(3) The force -held for several seconds to-allow the bone time to
expands.
Step 5: Removal of the tooth from the socket
 Once the alveolar bone expanded sufficiently and the tooth luxated- slight
tractional force-buccally used.

 Major role of the forceps - not to remove the tooth but rather to expand the
bone so that the tooth can be removed.
 SPECIFIC TECHNIQUES FOR REMOVAL
OF EACH TOOTH
Maxillary incisors
Maxillary canine
Maxillary first premolar
Maxillary second premolar
Maxillary molars
mandibular anteriors
Mandibular premolars
Mandibular molars
Policy for leaving root fragments
3 conditions must exist for a Risks is considered greater
tooth to be left in the alveolar when
process

 Root fragment must be  Removal cause excessive

destruction of
small surrounding tissue
 Root deeply embedded
in bone  Endangers vital structures
 Root must not be
infected  Attempts of recovering
the root can displace it
into the maxillary sinus or
tissue spaces
 Surgical plan for full mouth extraction
 Maintain the vertical dimension

 Best to perform surgery in opposing quadrants

 Maxillary teeth should be removed first

• Infiltration anesthesia has more rapid onset

• Debris may fall into empty sockets of lower teeth

• Teeth removed with a major component of buccal force

• Disadvantage – hemorrhage may interfere with visualization

 Extract the most posterior teeth first, anterior teeth last ones to be extracted.

 2 teeth most difficult to remove are the first molar and canine
POSTEXTRACTION CARE OF TOOTH
SOCKET

 If a periapical lesion is visible on the preoperative radiograph -no

granuloma attached to the tooth when it was removed- the periapical
region curettage- to remove the granuloma or cyst.

 If any debris obvious(calculus, amalgam) or tooth fragment

remaining in the socket-gently removed with a curette.

 If neither periapical lesion nor debris present- the socket should not
be curetted.
 The expanded buccolingual plates -compressed back to their
original configuration.

 It prevent bony undercuts caused by excessive expansion of the

buccocortical plate.
 In periodontal disease, there is accumulation of excess
granulation tissue around the gingival cuff.

 Removing this granulation tissue-a curette or haemostat –avoid

chances of excessive bleeding.
 The bone palpated through the overlying mucosa-check for any sharp, bony
projections.

 The mucosa reflected and the sharp edges smoothed- bone file.

 Initial control of haemorrhage- moistened 2X2 inch gauze-over the

extraction socket.

 Biting the teeth together on the gauze –pressure transmitted to the socket-
haemostasis.
Postoperative instructions

 Do not remove the cotton for half an hour

 Avoid rinsing, spitting, and touching the site of extraction

 Avoid consuming hot beverages, maintain soft diet for 24 hours.

 Take the medication properly

 Use warm saline mouth rinse after 24 hours.

Methods of performing pre-radiation extraction

 Principles of atraumatic exodontia apply

 Good portion of alveolar process along with teeth removed to achieve primary soft tissue
closure
 Extraction done in a surgical manner with flap reflection with atraumatic handling of flap
 Bur/ files used to remove smooth bony edges
 Ensure rapid soft tissue healing
INTERVAL

7-14 days between extraction and radiotherapy

If possible following extraction to ensure sufficient soft
tissue healing
Delayed if local wound dehiscence occurs
 ORAL SURGERY DURING PREGNANCY
 Defer surgery until after delivery if possible
 Consult the patients obstetrician
 Avoid radiographs
 Avoid drugs with teratogenic potential
 Use local anaesthesia
 Avoid keeping the patient in supine position
 Allow frequent breaks
 Second trimester-period of choice for elective operations.
 ATRAUMATIC EXTRACTION BY USE OF ELASTICS
 Alternative extraction technique avoids bone exposure
 Indications:Hemophilic patients
Bis phosphonate treated patients
Technique:
 Elastic/orthodontic band placed around cervical part of affected tooth
 Elastic slide from cervical to lesser apical perimeter of root
 Band moved apically cause PDL destruction
 Extrusive movement of tooth
 Fresh band added around the root once a weak thus pushing the previous elastic apically
 Crown protrudes beyond bite plane,its ground allowing additional extrusive movement.
Mandibular premolar and molar
Extrusion of the mesial root
before the procedure

Sockets after exfoliation of both

Exfoliation of first molar and the teeth
extrusion of second molar
Dentin bulge preventing the
band move apically

•Technique suitable for

conical roots
•Multiple divergent roots-split
and placed on each split root
•RCT required before
sectioning, in case of vital
tooth
 complications
Intraoperative Postoperative
 SOFT TISSUE INJURY
 Tearing mucosal flap
 Haemorrhage
 Puncture wound of soft tissue  Ecchymosis & hematoma
 Abrasion injury
 Swelling
 COMPLICATIONS WITH TOOTH BEING EXTRACTED
 Root fracture  Pain
 Root displacement  Dry socket
 Tooth lost into oropharynx
 INJURY TO ADJACENT TEETH
 Infection
 Fracture of adjacent restoration
 Luxation of adjacent teeth
 Extraction of wrong teeth
 INJURIES TO OSSEOUS STRUCTURE
 Fracture of alveolar process
 Fracture of maxillary tuberosity
 INJURIES TO ADJACENT STRUCTURE
 Nerve
 TMJ
 ORO ANTRAL COMMUNICATION
Soft tissue injury Complications with tooth being
extracted

 Puncture wound: Due to instrument  Root fracture: long, curved, divergent

slip from the surgical field roots in dense bone most common to
fracture
 Prevention: minimal force for
retraction  Root displacement:

controlled force to be used tooth-maxillary molar root into antrum

Use of supporting fingers  Displaced fragment 2 or 3mm with

no pre existing infection, then irrigate
 Treatment: Prevent infection and through small opening in the socket
healing by secondary intention. apex. This flushes the root out of the
sinus.
 Large root or entire tooth –Caldwell
Luc approach into sinus in the canine
fossa
 Tooth lost into oropharynx:
Patient turned toward dentist, mouth
down position. Patient encouraged to
cough and spit the tooth.
 INJURIES TO OSSEOUS
INJURY TO ADJACENT TEETH STRUCTURE
 Fracture of adjacent restoration:  Fracture of alveolar process
 Recognise potential to fracture large  Site:
restoration
 Warn preoperatively Buccal cortical plate over maxillary canine and first molar
 Employ judicious use of elevators Floor of maxillary sinus
 If restoration dislodged-remove from the max tuberosity
mouth so that it doesn't fall into the empty
socket.
Labial bone on mandibular incisors
 Luxation of adjacent teeth:
 Prevention:
 Common in crowding cases
 Prevention: Thorough pre-op clinical and radiological examination
Thin forceps Do not use excessive force
Judicious use of elevators
Use of surgical extraction when required
 Treatment:
 Treatment:
Reposition the tooth into appropriate
position Bone completely removed with the tooth then not to be
If needed stabilise with suture that crosses replaced-smooth the sharp margins suture the soft tissues
occlusal table and sutured to adjacent
gingiva back
Rigid fixation-external resorption If attached to the periosteum then carefully separate it from
the tooth and then replaced back to the socket
INJURIES TO ADJACENT ORO ANTRAL COMMUNICATION
STRUCTURE
 Be aware of nerve anatomy in  Conduct thorough preoperative
surgical area radiographic examination
 Avoid making incision or affecting  Use surgical extraction early and
periosteum in nerve area. section roots
 Support mandible during extraction  Avoid excess apical pressure
 Do not open mouth too widely
Postoperative bleeding
 Causes:  Treatment:
 Tissues are highly vascular  Check for the bleeding from bone.
Isolated vessel bleeding, then
 Extraction leaves open wound
foramen can be crushed with closed
 Almost impossible to attain dressing end of haemostat.
material with enough pressure
 Regenerated cellulose
 Patients tend to plat with the area
 Liquid preparation of topical
and dislodge the clot
thrombin
 Tongue cause secondary bleeding by
 Collagen
creating negative pressure
 Prevention:
 Obtain history
 Use atraumatic surgical technique
 Obtain good haemostasis at surgery
 Provide proper instructions
Delayed healing and infection Dry socket
 Rare complication after routine  PRESENTATION
 Persistent dull boring pain
dental extraction  2 to 4 days of extraction,
 Radiates to ear and not relieved by oral
 Wound Dehiscence: analgesics.
 Foul odor and taste.
Soft tissue flap replaced and sutured  Clot has dirty gray colour ultimately leaving
without bony foundation yellow bony socket.
 Exposed bone extremely sensitive.
If sutures placed under tension  Edema of surrounding gingiva, region
 TREATMENT
 Prevention:  AIM: Relief of pain+speeding of resolution.
Irrigate the socket with warm normal saline.
Use aseptic technique
Loose dressing: zinc oxide+eugenol on cotton
Perform atraumatic surgery wool tucked into socket.The gauze
packing replaced every 24 hours
Close incision over intact bone until symptoms subside.
Prescribe NSAIDS or narcotic based preperations
Suture without tension Metronidazole 400mg for 5 days

 WHAT NOT TO DO?

 Curettage:Predisposes to spread of
infection,destroys at any previous attempt at
normal healing.
 No antibiotics unless there is systemic
infection
To conclude,
The surgeon should
Have thorough anatomical knowledge of oral structures,

Know pharmacology of anaesthetics and medicines,

Evaluate the level of anxiety,

Determine the health status ,

Do the necessary modifications of routine procedures,

Apply the exact mechanical principles,

Provide proper postoperative instructions and care.

Prevention of complication should be a major goal of surgeon
Dr. Mohit Bindal, Subharti Dental College, SVSU