EXODONTIA

Presented by:-
Dr.Sateesh Bhatele
Contents
• Definition
• Indications
• Contraindications
• Mechanical principles of extraction
• Preoperative assessment
• Clinical and radiological evaluation of tooth for
removal
• Chair position
• Techniques for tooth removal
• Specific techniques for removal of each tooth
• Operative Complications
• Post extraction care
• Post extraction Complications
• Healing of extraction socket
 Definition

• Exodontia is defined as
orderly process of removal
of tooth or tooth root in a
painless manner with
minimal trauma to the
investing tissues so that the
wound heals uneventfully
and there is no
postoperative prosthetic
problem.
(Jeffry Howe)
Indications
• Advanced dental caries:-
most common and
widely accepted reason

• Pulpal necrosis:- when

patient declines
endodontic treatment or
root canal is torturous or
calcified, endodontic
failure

• Severe periodontal
diseases
• Retained deciduous
teeth

• Malposed teeth

• Orthodontic reasons
• Preprosthetic
extraction

• Impacted teeth

• Supernumerary
teeth
• Teeth associated
with pathologic
lesions

• Pre-radiation
therapy (teeth in
the line of fire)

• Teeth present in
fracture line
Contraindications
LOCAL
• Acute Oral Infections
• Acute Pericoronitis
• Osteoradionecrosis

SYSTEMIC
• Uncontrolled Dibetes
• Acute Blood Dyscrasias
• Coagulation Defects
• Adrenal Insufficiency
Absolute Contraindication:-

• Tooth associated with Hemangioma

• Tooth associated with malignant lesion.

• 6 months post radiation therapy.

 The mechanical principles of
extraction
The three mechanical principles are –

1. Expansion of the bony socket:-

achieved by using the tooth as the
dilating instrument, and is the most
important factor in ‘forceps
extraction’. To be successful it
requires:-
i) sufficient tooth be present to be
firmly grasped by the forceps blades.
ii) root pattern of the tooth must be
such that it is possible to dilate the
socket sufficiently to permit the
complete
dislocation of the tooth from its socket.
iii) The bone of which it is composed is
sufficiently elastic to permit such
expansion.
2. The use of a lever and
fulcrum:- to force a tooth or
root out of the socket along
the path of least resistance

3. The insertion of wedge or

wedges:- between the tooth -
root and the bony socket wall,
thus causing the tooth to rise
in its socket.
Preoperative assessment
• History

• Clinical examination

• Radiological assessment
History
• Medical history:- hyper/hypotension, bleeding
disorders, diabetes, liver diseases etc.

• Previous difficulty in extraction.

Clinical examination
• Of tooth to be extracted and its supporting structures.

• Tooth:- heavy restoration or grossly decayed, inclined

or rotated, firm or mobile, accessibility of the tooth
and the amount & site of sound tooth- substance
remaining.

• Teeth with shallow and broad crowns often have long

roots, teeth with marked attrition usually have
calcified pulp chambers and are brittle.

• Supporting structures:- either diseased or

hypertrophied
Pre-extraction radiograph
• Indications:-

1. History of difficult or attempted extractions.

2. Tooth which is abnormally resistant to forceps

extraction.

3. Tooth in close relationship with maxillary antrum or

IAC

4. Heavily restored tooth or endodontically treated

teeth.

5. Any tooth which has been subjected to trauma.

6. An isolated maxillary molar, especially if it is
unopposed & supraerupted.

7. Any partially erupted or unerupted tooth or

retained root.

8. Any tooth whose abnormal crown or delayed

eruption might indicate the possibility of
dilaceration, gemination or a dilated odontome.

9. Any condition which predisposes to dental or

alveolar abnormality, e.g. osteitis deformans,
cleido-cranial dysostosis etc.
• A good radiograph is wasted unless it is
carefully interpreted. Following factors
causing difficulty should be detected:-
1. Abnormal number and shape of roots
2. Unfavorable pattern of roots
3. Extent of caries
4. Fracture or resorption of roots
5. Hypercementosis of roots
6. Ankylosis
7. Impacted teeth
8. Bony sclerosis and pathological lesions
General arrangements:-
• Position of the Operator:-

i) when extracting any tooth except the

right
mandibular molars, premolars, and canines,
the
operator stands on the right hand side of the
patient

ii) for the removal of mandibular right cheek

teeth the
operator should stand behind the patient.
• Height of the dental chair:-

For maxillary teeth:- the chair should be

adjusted so that
the site of operation is about 8 cm (3 in.)
below the
shoulder level of the operator.

For mandibular teeth:- the chair height should

be adjusted
so that the tooth to be extracted is about 16
cm (6
in) below the operator’s elbow.
Exodontic procedure
• Steps followed in tooth extraction are:-
i) Achieve adequate anesthesia
ii) Separation of attachments to the alveolar bone
via the crestal and principal fibers of the
periodontal ligament.
iii) Expanding the alveolar socket
iv) Removal of the tooth
v) Check the tooth and socket
vi) Restore the form of the alveolar process by
finger pressure
vii) Achieve hemostasis
viii)Apply pressure pack and discharge the patient
Techniques for tooth removal
1. Forceps technique

2. Elevator technique

3. Open view technique

 Forceps tech. (Aka closed
method.)
• Most commonly used method.

• Basic principles:-

i) beaks of the forceps should be seated as apically as possible

without compression of the soft tissues. (achieved by
adequately reflecting the cervical gingiva)

ii) place the beaks of the forceps as parallel as possible to the

long axis of the tooth. This contributes to the efficient use of
force and its proper direction, thereby reducing the
possibility
of root fracture.

iii) The application of excessive force should be avoided.

ADVANTAGES OF FORCEPS
TECHNIQUE:
• Causes least trauma
• Sphincter like action of gingival fibers reduces size
orifice created by the extraction & favors rapid
healing by ingrowths of neighboring epithelium

DIADVANTAGES

• Can not be used in cases of apical

hypercementosis
• Deformity of roots
• In cases where crown has been completely
decayed
• Roots are decayed or brittle
ELEVATOR TECHNIQUE:
• Can be used in both, open & closed method of
extraction

• Elevators can be used in three ways:

• LEVER PRINCIPLE

• WEDGE PRINCIPLE

• WHEEL & AXLE PRINCIPLE

 LEVER PRINCIPLE:
• It states that:
• Weight x Weight arm = power x power arm
w
WA PA

F P

•Force is transmitted along the long power arm

(handle) & in a pre determined direction
•Tooth is lifted out of the socket by the short
weight arm i.e. working edge of the elevator.
•Straight & Cryer elevators can be used on lever
principle
WEDGE PRINCIPLE:
• States that when the tip of elevator which is of
wedge shape is forced between the bony socket &
the root , the tooth is gradually displaced out of the
socket severing periodontal attachments

L
P
H
w

Apex elevator is generally used on wedge

principle.
Straight & Cryer elevators can also be used when
whole roots are to be removed
WHEEL AND AXLE PRINCIPLE
• States that greater the diameter of wheel, more is
the mechanical advantage.
• This principle results in bodily rotation of the tooth so
that it is easy to deliver the tooth out of the socket
• Effort x radius of wheel = resistance x radius of axle

RA RW

W
Intra-alveolar Extraction
• Ideally, the whole of the inner surface of the
forceps blades should fit the root surface, but it is
not possible to achieve because of variation in size
and shape of roots.

• The root is gripped by the edges of the blade (‘two

point contact’).

• If there is only a single linear contact, ‘one-point

contact’, the tooth will probably be crushed when it
is gripped.
Correct grip of forceps
• The position of the thumb
just below the joint of the
forceps handles in the palm
of the hand, give the operator
a firm grip on, and fine
control over, the instrument.

• The little finger is placed

inside the handle and used to
control the opening of the
forceps blades during there
application to the root. When
the tooth is gripped the little
finger is placed outside the
handle.
Role of Left Hand
• Displaces the tongue,
cheeks, lips from the site
of extraction to improve
visual and mechanical
access, and to push the
adjacent soft tissues out of
harm’s way.

• Holds alveolus while

extraction
The Extraction of Maxillary
Teeth
• Incisors:-
Canine
First Premolar
Second Premolar
Molars
Mandibular Teeth
Anteriors
Premolars
Molars
Open Beak Technique
Operative Complications
• Failure to secure anesthesia or remove the tooth
with either forceps or elevators

• Fracture of:- crown of tooth being extracted

roots of tooth being extracted
alveolar bone
maxillary tuberosity
adjacent or opposing tooth
mandible

Dislocation of:- adjacent tooth

temporomandibular joint
• Displacement of root:- into the soft tissues
into the maxillary antrum

• Excessive haemorrhage:- during tooth removal

on completion of extraction

• Damage to:- gingiva

lips
inferior dental nerve & its branches
lingual nerve
tongue and floor of mouth

• Subcutaneous emphysema
 Post operative care
• Rest:- patient should remain quiet for several
hours,
• preferably sitting in a comfortable chair or,
• if lying down, keeping the head elevated on
several pillows.

• Diet:- liquid and soft diet for first 24 hrs.,

• they may be warm or cold but not extremely
hot.
• Fluid intake should be greater than usual to
prevent dehydration from limited food intake.
• A normal diet should be resumed as soon as
possible.
• Oral hygiene:- the teeth should be brushed as
usual,
• on the day after surgery rinsing of the mouth
should begin.
• A saline solution (1/2 teaspoon of salt in a
glass of warm water) is best for this purpose.
• Pain:-
• it is the normal response to the unavoidable
trauma of surgery.
• In most cases it lasts no more than 12 to 24
hrs.
• it can be controlled by the use of cold packs
and the proper administration of analgesics.
• The intermittent application of cold to the
surgical site (30 minutes per hour) during the
first 24 hours postoperatively helps reduce
pain in two ways:-
i) diminishes nerve conduction and there by has
an
anesthetic effect.
ii) helps to reduce swelling and thus decrease
swelling and
• Swelling:- the degree of swelling that occurs
postoperatively is generally in direct proportion to
the degree of surgical trauma.

• The application of cold to the operated site reduces

the amount of postoperative swelling. It acts by
producing vasoconstriction and thereby reduces the
exudation of fluid and blood into the tissue spaces.

• It should be used intermittently, because prolonged

use of cold leads to compensatory vasodilatation
and thus defeats its original purpose.

• Pressure dressings are also helpful in limiting

postoperative swelling
• Once swelling has reached its maximum size
(usually 24 to 48 hrs), cold is no longer effective.

• Heat in the form of moist compresses should be

applied.

• It leads to vasodilatation with increased

circulation, more rapid removal of tissue
breakdown products, and greater influx of
defensive cells and antibodies.

• Continued use of heat reverses the desired

hemodynamic effect. It too should be used only
30 minutes per hour.
• The various enzyme and hormone preparations
that have been suggested for the treatment of
postoperative swelling should not be used
routinely.

• The enzymes do not prevent swelling but rather

redistribute the fluid over a wider area by
breaking down the connective tissue and fibrin
barriers.

• In addition to dissipating the edema, this also may

allow the spread of infection.
• Smoking:- should be avoided after extraction

• Increases the incidence of alveolar osteitis (Sweet

and Butler, 1979)

• Precise time has not been established, but it

should be discontinued for 5 days.
 Postoperative Complications
• Hemorrhage
• Ecchymosis and hematoma
• Swelling
• Pain
• Dry socket
• Infection
Hemorrhage
• Primary Hemorrhage:- persistent bleeding that
cannot be controlled by 30-60 minutes of pressure
from biting on gauze pack, requires more
definitive therapy.

• Area is irrigated with saline and excessive clots

are removed.

• Patient is asked to bite on a gauze pack until the

general condition is evaluated.

• Source of bleeding is determined.

• If from soft tissue, pressure application, adr pack
locally or suturing the wound margins. (the object
of suturing is not to close the socket by
approximating the soft tissues over it, but to tense
the mucoperiosteum over the underlying bone so
that it becomes ischemic).

• If the source of bleeding is bone, bone wax,

Whitehead’s varnish etc are used.

• Hematologic studies if required.

Reactionary hemorrhage
• Occurs in 24 to 48 hrs postoperatively.

• Reason:- hypertension, slippage of ligature

• Management:- underlying cause identified and

treated accordingly
Secondary hemorrhage
• Develops several days after surgery.

• Usually due to infection of the wound resulting in

loss of clot or erosion of the vessels.

• Management is similar to primary hemorrhage.

• Wound carefully examined for foreign bodies.

• Antibiotics for infection.

Ecchymosis and Hematoma
• Mild ecchymosis is especially seen in elderly
patients with increased capillary fragility and poor
tissue elasticity, and should not be considered a
complication.

• Extensive ecchymosis and hematoma usually

result from improper hemostasis during surgery.

• Treatment:- intermittent ice packs for 24 hrs after

surgery, followed by intermittent hot moist packs.
Swelling
• Inflammatory or secondary to infection.

• Swelling due to infection develops several days

after surgery.

• Increased skin temp, redness of overlying skin,

usual presence of fever.

• Treatment:- antibiotics, incision and drainage

Pain
• Unavoidable

• If persist more than 24 to 48 hrs – infection is

suspected.

• Analgesics are prescribed for treatment.

Dry Socket
• Most common cause of delayed post operative
pain.

• It is the condition in which there is loss of the

blood clot from the socket. Initially the clot has a
dirty gray or grayish yellow bony socket bare of
granulation tissue.

• The diagnosis is confirmed by gently passing a

small probe into the extraction wound; in alveolar
osteitis bare bone is encountered, which is
extremely sensitive.
• Clinical features:-

1. Pain starts on 3rd to 5th day after extraction

2. Foul odor

3. Suppuration is usually absent

4. Severe radiating pain

5. Throbbing ache caused by chemical and thermal

irritation of the exposed nerve endings in the
periodontal ligament and alveolar bone.
Etiology
• Preexisting infection
• Trauma to bone during extraction
• Decreased bleeding because of vasoconstrictor
• Infection after extraction
• Presence of dense bone
• General debilitation
• Loss of clot because of rinsing the mouth or
sucking the wound
Birn hypothesis (1973)
 Treatment
• Directed primarily toward the relief of pain.

• Accomplished in two ways:-

1. Local therapy:- irrigation of socket with warm
sterile isotonic saline solution to remove necrotic
material and other debris, followed by the
application of either obtudent or a topical
anesthetic.
2. An antipyretic analgesic or a narcotic should be
prescribed for the patient.
• Patient reexamined in 24 hrs.

• If pain stops, no need for further dressing. If it

persists irrigation and dressing is done.

• Curettage should never be employed. This

procedure not only predisposes the patient to the
spread of infection, but also destroys any previous
attempt at normal healing.

• Since the socket is already infected, any new

blood clot formed will subsequently undergo lysis.

• Routine use of antibiotics is not recommended.

 HEALING OF EXTRACTION
SOCKET
• This procedure is divided in 5 stages:-

1. Hemorrhage and clot formation

2. Organization of the clot by granulation tissue

3. Replacement of granulation tissue by connective tissue

and epithelialization of the wound

4. Replacement of the connective tissue by coarse fibrillar

bone

5. Reconstruction of the alveolar process and replacement

of the immature bone by mature bone tissue.
First Stage
• Immediately after extraction hemorrhage results
from tearing of the apical blood vessels and those
in the periodontal tissues.

• Clot formation

• In next 24 to 48 hrs there is beginning of

inflammatory process, which is associated with
hyperemia, exudation of plasma and infiltration of
leukocytes and macrophages.
Second Stage
• On 2nd or 3rd day organization of clot begins.

• Characterized by the proliferation of two types of

cells.
i) Fibroblasts from periphery and adjacent marrow
spaces
ii) Endothelial buds from neighboring blood vessels
to form a capillary network.

• Blood clot becomes replaced with granulation

tissue by about 7th day.

• Osteoclastic resosption begins at the alveolar crest.

Third Stage
• Replacement of the granulation tissue by more
mature connective tissue begins on the third or
fourth day and is completed by about 20th day.

• First signs of bone formation occurs between the

5th and the 8th day.

• Osteoclastic activity continues.

• Epithelialization of the socket begins at the

gingival margin on about the fourth day but is not
completed until about 24 to 35 days or longer.
Fourth Stage
• At least two third of socket is filled with coarse
fibrillar bone by about the 38th day.

• Radiographic examination at this time shows little

increase in density because of the radiolucency of
the immature bone.
Fifth Stage
• A uniform trabecular pattern of mature bone is
established and a layer of compact bone is formed
over the healed area.

• The number and arrangement of the new bony

trabeculae will depend on the functional stress
exerted on the alveolar bone.
THAN
K YOU