EXODONTIA

Definition:

Ideal tooth extraction is painless removal

of whole tooth or tooth root with minimal
trauma to investing tissues so that wound
heals uneventfully & no post-operative
problem is created.
Indications for Extraction:
Periodontal disease when support is destroyed.

Dental caries & its sequale (teeth cannot be restored).

Individual teeth with acute /chronic pulpitis.

Periapical disease.

Tooth mechanically interfering in the placement of

partial denture & bridges.

Over retained deciduous tooth.

Therapeutic extraction – orthodontic treatment.

Impacted teeth responsible for malocclusion.

Supernumerary teeth.

Teeth with fractured / infected root & root fragments.

Teeth causing trauma to soft tissue.

Teeth responsible for focal sepsis causing systemic

disorder eg: endocarditis, obscure facial pain, rheumatic
disorders & kidney infection etc.
Teeth involving cyst eg: dentigerous cyst.

Teeth that cause bony pathology eg: osteomyelitis,

neoplasm.

Endodontic failure.

Failure of large restoration.

In patient of oral malignancy where radiation therapy

is to be given.
• Teeth that will cause trauma to the soft tissues esp. if
treatment of tooth viz grinding or orthodontic
movement does not prevent this trauma.

• Serial extraction : to provide enough space for

permanent successors to attain its position in the
dental arch & achieve stability of the dental arch.
In Primary Teeth
Teeth that are hopelessly carious.
Extensive decay which results in death of pulp & infection reaching
into bifurcation.
When primary teeth interfere with normal eruption & alignment of
their permanent successors.
1. Improper resorption of root causing deflection of erupting tooth.
2. Irregular resorption of the roots of molars, one root being
resorbed more than the others.
3. Retained primary teeth when a permanent tooth is present & in
normal position to erupt.
• When there is a sinus opening through the

mucoperiosteal membrane overlying the root

• Periapical pathosis

• Root fractured as result of trauma with subsequent

development of infection

• Suprenumerary teeth (mesiodens)

Contraindications:

1. Local :

Acute infection like stomatitis, vincents infection & herpetic

stomatitis, it could result in bacteremia.

– Exception of this condition is acute dentoalveolar abscess

with cellulitis which requires immediate extraction.
• Malignancy – trauma enhances the speed of growth & spread
of infection whereas extraction are strongly indicated if jaw
or surrounding tissues are to receive radiation therapy.
• Acute pericoronitis –as 3rd molar area has direct

access do deep facial plexus of neck .

• Extraction of tooth if irradiated jaws develop

osteoradionecrosis.

• Acute infection in max. premolar & molar area in

acute sinusitis.
2. Systemic factors:

Cardiac problems
– Hypertension, coronary artery disease, ischaemic heart
disease ,congestive heart failure, valvular & septal
defects.

Uncontrolled diabetes mellitus

– Infection of the wound & thereby absence of healing is
encountered.
Pregnancy
– 1st trimester –nausea & vomiting
– 3rd trimester –risk of premature delivery, supine
hypertensive syndrome.

Bleeding disorders
– Anaemia, haemophilias, leukaemia & purpura.
• Patient on steroid therapy
- Such patient may not have sufficient adrenal
cortex secretion to withstand the stress of
extraction & need additional steroids.
• It is advisable to double the dose of steroids one
or 2 days preoperatively & continue the same 2
days postoperatively.

• Renal failure
- Can create a formidable problem in preparing pt.
for extraction.
Psychosis & neurosis
Can complicate extraction.

Patient on anticoagulant therapy

Can lead to prolonged postoperative bleeding .

Toxic goitre

Uncontrolled leukemis & lymphoma.

Absolute contraindications:
Haemangioma, Arteriovenous fistula,
Patient refusal
Requirements for extraction:
A good radiograph to frame diagnosis & study the

size, shape & number of roots.

Adequate anesthesia (local/general).

Adequate light, efficient assistance, good

instruments & suction apparatus.

Chain of sterilization & aseptic technique should be

maintained throughout the procedure.

Principles of extraction :

• Expansion of the bony socket.

• The use of a lever & fulcrum.

• The insertion of a wedge between the

tooth root & the bony socket wall.

Chair position for extraction:
Position of the operator
 Except for the right mand. cheek teeth, the operator
stands on the right hand side of the patient.
 For removal of rt. Mand. cheek teeth, the operator
stands behind the pt. sometimes on a raised platform
to achieve optimal working position.
Height of the dental chair
 For max. tooth - 3 inch below the shoulder level of
the operator.
 For mand. tooth -6 inch below the level of operators
elbow.
Types of Extraction:
1. Forceps / intra alveolar.

2. Transalveolar.

Instruments used in extraction:

1. Forceps

2. Elevators

3. Probe
Forceps:
maxillary mandibular
 The use of dental forcep
makes it possible for the
operator to grasp the root
portion of a tooth & dislocate
it out of it socket by exerting
pressure.

Long axis of the blades

should be either on or
parallel to the long axis of
the tooth root.
Dental forceps are designed to grasp the root.

[Link]: Straight forcep.

[Link]: Mirror image

blades for both right & left.

[Link]: 2 blades of molar forceps are different.

Mand. Incisor, premolar & roots: Lower root forceps

with fine blade.

[Link],large roots: Heavier blades.

[Link]: buccal & lingual blades of forceps are

similar in design.
Displacement of the tooth from its socket:
A firm grip of the root is taken & buccolingual & linguobuccal
movements are made in that order.
This pressure should be firm, smooth & controlled, & is applied
by the operator moving his trunk from the hips.
After few lateral movements-tooth is felt to loosen & begin to
rise out of its socket, after this rotatory or figure of eight
movements will effect delivery of the tooth in a very short
period.
The expanded socket is compressed between the left thumb &
fore finger.
Grip of forcep:
The position of the thumb just below the joint of the forceps

& the position of the forcep handles in the palm of the hand.

Little finger is placed inside the handle & used to control the

opening of the forceps blades.

When the tooth is gripped ,the little finger is placed outside

the handle .
Application of forceps blade to the tooth :
Forceps blades are applied to the buccal & lingual
surfaces of the root with their long axis parallel to that
of the tooth.
The blades are pushed through the PDL between the
tooth root & the investing alveolar bone towards the
apex.
Firm pressure upon the forceps is used to drive the
blades along the surface of the root.
In carious tooth –blade should be applied to the
carious side first & the first movement made towards
the caries.
Rotation of teeth:
Only max. central incisor & mand.2 nd premolar have
straight conical roots.

Rotatory movements are useful in completing the

removal of teeth loosened by other means.

By the use of this secondary rotatory movements the

gross distortion of the buccal plate resulting from
excessive lateral movements are avoided.
Common errors in forcep
extraction:
1. Failure to grip the root firmly
in forcep blade.
2. Grip crown in the forcep
blades instead of root.
3. Incorrect alignment of the
forceps blade to the long axis
of the root.
Elevators:
used on the lever & fulcrum principle to force the tooth or
root along the line of withdrawal.
Line of withdrawal: the path along which the tooth or root will
move out of its socket with least application of force.
The fulcrum used for the elevation of teeth should always be
a bony one.
Elevators may be forced down the PDL either mesially,
bucally or distally to the tooth being extracted.
Classification of elevators:

1. According to use
to remove the entire tooth.
to remove roots broken off at the gingival line.
to remove roots broken off half way to the apex.
to cut bone as well as to remove roots of teeth.
to cut & elevate the mucoperiosteum.

2. According to form
Straight
Angular
Cross bar.
Indications:
• To luxate & remove teeth which cannot be

engaged by forceps.

• To remove roots

• To luxate teeth prior application of forceps.

• To split teeth which have had grooves cut in them.

• To remove intraradicular bone.

Rules:
Never use adjacent tooth as fulcrum.
Never use buccal plate as fulcrum.
Never use lingual plate as fulcrum.
Always use finger guards to protect the patient in case
elevator slips.
Forces applied should be under control & in right
direction.
Parts:
Handle ,shank ,blade.
Principles:
1. Lever
2. Wedge
3. Wheel & axle
4. Combination
Pre-operative preparation of parent &
child:
Parental consent

Discussion with parents

Discussion with parent about post operative

bleeding or pain.

Instruct parent not to discuss with the child what

the dentist will do rather let the dentist do it.
Preparing the child
• Younger children should be told on day of
appointment about procedure.
• 8-10yr child, if told 4-7 days before adjust better.
• Tray containing armamentarium kept behind chair.
• Never hold needle in front of the child,it should be
hidden with a finger.
• Before giving LA explain to child that sensation of
pinching or an ant biting may be felt.
• Realize difference between pressure & pain.
• Explain sensation of numbness.
• When checking for anesthesia by placing the elevator
into gingival crevices, note the eye reaction of child.
Forces exerted in extraction of primary tooth:
Max. anterior (round root cross section):
– Initial forces is apical then slightly to the lingual. this slight
lingual force expands the lingual gingival [Link] next force
is counter clockwise motion that loosens the tooth in an
unscrewing motion then, in a single sustained labial force,
the tooth is delivered from its socket.
[Link] (oval root cross section):
– Initial apical force, direction of force is to the labial in a single
sustained action after tooth is loosened counter clockwise
motion delivers the tooth from its socket.
Max. molars:
– Since the palatal root is curved, the direction of force is
slightly to the lingual. A slight force is applied in order not to
fracture the curved palatal root, then in a single sustained
force to the buccal, the tooth is loosened & counterclockwise
motion delivers the tooth out of socket.

[Link]:
– Rotary motion is contraindicated since cross section of roots is
flat mesiodistally & elliptical. The initial force is slightly to the
lingual then a single sustained force to the buccal until it is
loosened, then a counterclockwise rotation delivers the tooth
from socket.
Permanent teeth:
Maxillary:
Central incisor- slight labial & palatal pressure with mesial rotation
followed by slight traction.
Lateral incisor- slight labio-palatal rocking with mesial rotation is
used followed by traction.
Canine- labial pressure then lingual then again labial pressure with
mesial rotation followed by traction.
1st premolar- buccal pressure, palatal pressure & then extract out to
buccal side. No torsion used.
2nd premolar- buccal pressure & lingual pressure with slight
rotational force is used.
1st & 2nd molar- buccal & lingual rocking is done prior to removal on
buccal side.
3rd molar- buccal pressure along with distal & downward movement is
used.
2. Mandibular:
Central & lateral incisor- labial & lingual rocking & slight
mesial & distal rotation followed by removal to labial
side.
Canine- labial pressure with mesial rotation & vertical
pull yields the desired result.
1st & 2nd premolar- buccal pressure with slight mesio-
distal rotation.
1st & 2nd molar- buccal & lingual rocking with removal
to buccal side.
3rd molar- buccal & lingual rocking with removal to
buccal or lingual side.
Post operative instructions:
1. Wound care:
• Bite firmly on gauze pack for 30 min.
• Donot smoke for 12hrs because this will promote bleeding & interfere with
healing.
2. Bleeding :
• Some blood will ooze from the area of surgery & is normal ,you may find
a blood stain on your pillow.
• Do not spit or suck through a straw.
• If bleeding begins again, place a small damp gauze pack over tooth socket
& bite firmly for 30 min.
• Keep head elevated with several pillows.
3. Discomfort:
• Some discomfort is normal after [Link] can be controlled but not
eliminated by taking the pain pills prescribed.
4. Diet:
• It is important to drink large volume of fluids .donot drink through
straw,since may promote bleeding.
• Eat normal regular food as soon as possible after surgery .cold,soft food
such as icecream or yogurt may be the most comfortable for the first day.
5. Oral hygiene:
• Do not rinse your mouth or brush your teeth for the first 8hr after
surgery.
• After that rinse gently with warm salt water .
• Brush your teeth gently but avoid the area of surgery.
6. Swelling:
• Swelling after surgery is a normal body reaction reaches its
maximum abt 48 hr after surgery &usually lasts for 4-6 days.
• Applying ice packs over the area of surgery for the first 12hr help
control swelling &may help the area to be more comfortable.
7. Rest:
• Avoid strenous activity for 12hr after your surgery.
8. Medication :
• Take regular medication prescribed.
9. Call office if emergency.
10. Stiffness:
• After surgery you may experience jaw muscle stiffness & limited
openingof your mouth .this is normal & will improve in 5-10 days.
Complication of Exodontia
1. Operative:
Fracture of tooth.
Injury to the adjacent tooth.
Fracture of alveolar bone.
Fracture of tuberosity
Oroantral fistula
Displacement of tooth root into max. sinus
Tooth pushed into spaces of neck.
Soft tissue laceration
Excessive haemorrhage.
Nerve damage
Breakage of instrument
TMJ dislocation.
2. Postoperative:
Pain
Swelling
Haematoma
Emphysema
Trismus
Dry socket
Delayed bleeding
Osteomyelitis
bacteremia
Management
Operative;
1. Fracture of tooth/root:
removed by open method if elevator technique
fails.
2. Injury to adjacent tooth
-loosening of adjacent teeth.
-avulsion of adjacent teeth.
-fracture of adjacent teeth.
 Splinting for 2-4 weeks
 Reimplantation of avulsed tooth &check
occlusion
 Endodontic treatment.
 Restore all amount of fracture.
3. Fracture of alveolar bone.
Pieces of bone remain attached to mucosa& are
maintaining their blood supply should be
retained & held in place by suturing the
mucosa.
4. Fracture of max. tuberosity
If a fracture to soft tissue ,place it back & stabilize by splint for 4-6 weeks
thereafter remove tooth by open method.
5. 0roantral communication
If size less than 2mm– no treatment is [Link] should avoid
blowing the nose,violent sneezing,sucking on straws&smoking.
If size 2-6mm– figure 8 suture should be placed over the socket to
maintain blood clot&antibiotic for 7 days
If size more than 7mm– flap procedure.
6. Tooth into soft tissue
Antibiotics
Tooth removed 4-6 weeks later after the fibrosis stabilises tooth in firm
position .
7. Submandibular facial space
Root can be forced back into socket by inserting index finger out of the
lingual aspect of floor of the mouth in attempt to place pressure against
the lingual aspect of mandible .
If this is unsuccessful root tip is removed by reflecting soft tissue flap on
the lingual aspect of mandible
8. Soft tissue laceration
Control of bleeding
The wound is left for drainage & not suutured.
Control of infection.
9. Excessive haemorrhage
Pressure pack 30min postoperatively
If Vessel injury,socket is packed with haemostatic agent &
sutured.
10. Nerve damage
Careful extraction
11. TMJ Dislocation
Immediate reduction
Immobilisation 2-3 weeks to prevent recurrent attack.
Postoperatively soft diet &analgesics .
Postoperative:
1. Pain &swelling
Cold application to the face
Use of analgesic & antiinflammatory drugs
2. Emphysema
Aspiration &decompression.
3. Haemorrhage
a) Soft tissue – digital pressure ,gauze ,suture.
b) Bone – burnishing ,white head varnish,bone wax,gelatin ,sponge .

1) physical –vessel ligation ,haemostatic forcep,splints,postural rest.

2) thermal– ice pack, electrocoagulation ,thermocoagulation
3) chemical-
topical : vasoconstrictor ,adrenaline, nor adrenaline.
absorbable agent : oxidised cellulose,gelatin ,fibrin
foams.
thermoplastic agent : thrombin,russel viper venom.
chemical agent : tincture,silvernitrate ,tannic acid ,ferric
chloride
socket plugs.
3. Haematoma
Pressure
Ligation of the vessel
Cold application
Heat application after 24 hrs
Analgesics & antibiotics
4. Trismus
Antiinflammatory drugs
Muscle relaxants
Physiotherapy
Heat application
Warn saline wash
Forcibly open with gag.
5. Osteomyelitis
Antibiotics
Seqestromy
Saucerization
6. Bacterimia
Preoperatively antibiotics i.e. penicillin 2gms one hour before
surgery&1gm 6hr after surgery.
Or Erythromycin 1gm before surgery &500mg after surgery.
7. Dry socket
Socket irrigation with warm saline.
Remove degenerating blood clot
Sharp bony spicules should be excised with rongers & smoothened
with bone files.
Loose dressing with ZOE/ clove oil.
Analgesics&hot saline rinses & ptatient is asked to report after 3
days.
Other related diagrams: