19 exodontia

1. Exodontia
Instructor –Dr.Jesus George
1

2. Introduction
It is a procedure that incorporates
principles of surgery, physics and
mechanics.
Painless removal of the tooth or root
with minimal injury to the
surrounding soft tissue & bone
2

3. Cont.
Removal of tooth does not require
large amount of force, but fine and
controlled forced in such a manner
that tooth is not pulled from bone but
lifted gently from alveolar process
3

4. Pain and Anxiety control
Local anesthesia
Profound local anesthesia results in loss
of pain, temperature and touch but not
pressure.
When the tooth has pulpitis or
surrounding soft & hard tissues inflamed
or infected, periodontal injection is
given, that gives anesthesia for 15-
20min. If it fails intra osseous injection
can be given.
4

5. Sensory innervation of jaws
Inferior alveolar nerve all mandibular
teeth, buccal soft tissues of PM,
canine & incisors.
Lingual nerve; Lingual soft tissues of
all teeth
Long buccal nerve: Buccal-soft
tissues of molars.
5

6. Cont.
Anterior superior alveolar nerve;
maxillary incisors and canine, buccal
soft tissues of incisors and canines.
Middle superior alveolar nerve: Max.
PM & MB root of 1
st
molar, Buccal
soft tissue of PM.
6

7. Cont.
Post sup. Alveolar nerve: Max.
molars except a portion of 1
st
molar,
buccal soft tissues of molars.
Greater palatine palatine nerve;
Lingual soft tissues molars &
premolars.
Nasopalatine nerve: Lingual soft
tissues of incisors and canines.
7

8. Cont.
Mandibular PM region buccal soft
tissue innervated primarily by mental
branch of IAN and also by terminal
branches of long buccal nerve.
8

9. Duration of Anesthesia
1. Local anesthesia with out
vasoconstrictors:
Max. teeth-10-20min
Mand. teeth-40-60min.
Soft tissue-2-3 HR
9

10. Cont.
2. Local anesthesia with
vasoconstrictors
Max. teeth 50-60 min
Mand. teeth 90-100min
Soft tissue 3-4 HR
10

11. Cont.
3. Long acting local anesthesia with
vasoconstrictors
Max. teeth 60-90 min.
Mand teeth -3HR
Soft tissue 4-9 HR
11

12. Sedation
In case of mild anxiety-proper
explanation of procedure; assurance
that there will not be sharp pain,
expression of concern caring,
empathy will reduce anxiety.
In moderate anxiety: Preoperative
oral diazepam provide rest at night
before surgery and relieve anxiety in
morning.
12

13. Cont.
Sedation by inhalation of nitrous
oxide or IV sedation with diazepam
can be given in severe anxiety.
13

14. Presurgical Medical Assessment
A proper medical history
14

15. Indications for removal of teeth
Severe caries: that can not be
restored.
Pulpal necrosis: if endodontic Rx can
not be performed becoz Pt declines,
or root canal that is tortuous, calcified
or endodontic failure.
Severe periodontal disease: excessive
bone loss and irreversible tooth
mobility.
15

16. Cont.
Mal -opposed teeth; if they
traumatize the soft tissue or can not
be repositioned by orthodontic Rx
(Max. III M. in severe buccal version
and causes ulceration & trauma
on cheek or teeth that are hyper
erupted becoz of loss of teeth in
opposing arch.
16

17. Cont.
Orthodontic reasons: Max. & Mand
PMs Mand. incisors are commonly
extracted.
Cracked teeth: or with fractured root
Preprosthetic extraction: teeth
interfering with design and
placement of full dentures, partial
dentures
17

18. Cont.
Impacted teeth: that is unable to
erupt to functional occlusion.
Supernumerary teeth: Impacted,
interfering with eruption of
succedaneous teeth or causing
resorption and displacement of
adjacent teeth should be extracted.
18

19. cont.
Teeth associated with pathologic
lesions: If maintaining the tooth
compromises, complete surgical
removal of lesion.
Pre -radiation therapy: remove
teeth in line of radiation therapy.
Severe attrition, abrasion or erosion
19

20. Cont.
Teeth involved in jaw #: If tooth is
severely luxated, tooth in # line
should be removed.
Esthetics: Severely stained,
malopposed or protruding teeth are
removed.
Economics: inability of PT to pay or to
take time from work may require the
tooth to be extracted
20

21. Contraindications for removal of
teeth
Systemic contraindications:
Uncontrolled diabetes
End stage renal disease with severe
uremia
Uncontrolled leukemia
Uncontrolled cardiac disease
Unstable angina pectoris
Recent MI
21

22. Cont.
Severely uncontrolled hypertension
Pregnancy 1st and last trimester
Bleeding disorders like hemophilia
Platelet disorders
Patients on anticoagulants
22

23. Cont.
Local Contraindications:
H/o therapeutic radiation-causes
osteoradio necrosis
Tooth in area of tumour: disseminate
cells and cause metastasis
A/c infection
Central hemangioma
23

24. Clinical Evaluation of teeth for
removal
Tooth to be extracted is examined to
assess difficulty of extraction.
Access to tooth: if mouth opening of
PT is compromised-surgical
extraction.
Mobility of tooth: teeth with less than
normal mobility should be assessed
for hypercementosis and ankylosis-
surgical removal
24

25. Cont.
Condition of crown: if large portion
of crown is decayed by caries or
tooth with large amalgam
restoration, forceps is placed as far
apical as possible.
25

26. Cont.
If large amount of calculus is
present on tooth, it should be
removed before extraction
otherwise it will interfere with
application of forceps or
contaminate socket after
extraction.
26

27. Cont.
If adjacent tooth has amalgam
restoration or undergone endodontic
therapy, care must be taken while
using elevators.
27

28. Radiographic Examination of tooth
for removal
IOPA shows portion of crown and root
of tooth under consideration
If it is a I°tooth its relationship with
a succedaneous tooth should be
visible
Relationship of associated vital
structures
For Max. teeth relation with max. sinus.
28

29. Cont.
For Mand. Molars inferior alveolar canal
For Mand premolars relation with mental
foramen
Configuration of roots-If excess
curvature surgical extraction
Length of roots
Hypercementosis
Root # more liable to #
29

30. Cont.
Root resorption liable to #
H/o endodontic Rx -tooth is brittle or
ankylosed -so surgical extraction.
Condition of surrounding bone
If more radio opaque-condensing
osteitis or sclerosis-so difficult to
extract.
Periapical pathologies-should be
removed after extraction.
30

31. Patient & surgeon Preparation
All patients should be considered as
having blood born disease.
Surgeon should wear surgical gloves,
mask, eyewear with side shield, long
sleaving gowns.
If surgeon has long hair it should be
covered with surgical CAP.
31

32. Order of extraction
Lower teeth are removed before the
upper & posteriors are removed
before anteriors to prevent bleeding
from socket obscuring field of
operation (prof.J.Moore)
32

33. Methods of extraction
Closed or intra-alveolar
Open or transalveolar or surgical
Stobie technique –extraction of
multiple mandibular anteriors by
using elevators b/w teeth
33

34. Chair position for forceps
extraction
Best position is one that is most
comfortable to PT & to surgeon.
Correct position allows surgeon to
deliver force with arm and shoulder
and not with hand.
For Max. extraction,
34

35. Maxillary teeth
Position of chair
Height of chair is such that height of
patient's mouth is at or slightly below
operator's elbow.
Chair is tipped backward that
Max.occlusal plane is 60°to floor
35

36. Cont.
Position of patient
During procedures of Max. Right + left
quadrant PT's head is turned towards
operator.
For Max. Ant. Teeth, PT should be
looking straight ahead.
Position of operator
Front & right side of the patient for right
handed operator & reverse in left handed
operator
36

37. Cont.
Position of left arm
Left upper teeth, thumb supports the
palatal alveolar bone & index finger
retract the buccal tissues
Right upper teeth –thumb retracts the
buccal tissues & index finger supports
the palatal alveolar bone
In left handed operator the reverse
37

38. Mandibular teeth
Position of chair
Chair is positioned in such a way that,
Mand. occlusal plane is parallel to floor.
Surgeon's arms are inclined downward at
an angle of 120°at elbow.
Position of patient
In Mand. right post teeth-PT is turned
towards surgeon.
38

39. Cont.
Position of operator
Mand. right post teeth, operator is
behind the pt &
In Mand. left post region, surgeon is in
front of PT.
Left handed operator the position is
reverse
If surgeon chooses to sit, the PT is at a
more lower level than standing and other
position are similar
39

40. Cont.
Position of left arm
Lower left teeth –thumb supports the
mandible &index finger retracts the
buccal soft tissues ,middle finger controls
tongue
Lower right teeth –index finger retract
the buccal tissues, thumb controls the
tongue & other fingers supports the
mandible.
Reverse for left handed operator
40

41. Mechanical Principles Involved
in tooth extraction:
Elevators I°rly works on lever
principle E.g straight elevator
Wedge principle is also used when
elevator is used to luxate tooth.
Wheel and axle principle is used by
triangular shaped elevators
E.g Cryer's elevator
41

42. Principles of forceps use
Use of forceps:
To expand bony socket
To remove tooth
Forceps should be placed below CEJ
Traction towards least resistance
42

43. Cont.
Alveolar purchase
By Kruger
For removal of anterior teeth or roots
After detaching the labial gingiva the
labial beak is placed under the tissues in
alveolar bone &apply pressure
43

44. Major Motions of forceps
1.Apical pressure: Tooth socket is
expanded by insertion of beaks down
into periodontal ligament.
2. Buccal pressure: produces
expansion of buccal plate and lingual
apical pressure
Lingual pressure: Expands lingual
cortical plate and buccal apical
pressure.
44

45. Cont.
Rotational pressure: Teeth with
single conical roots e.g. Max. incisors
Mand. PM, But the roots should not
be curved.
Tractional force: For delivering tooth
out of socket.
45

46. Procedure for closed extraction:
Requirements for extraction
Adequate access and visibility
Unimpeded pathway of removal
Use of controlled force.
46

47. General steps for closed
extraction
Loosening of soft tissue attachment
from tooth
Done by a Periosteal elevator
Helps to assess anesthesia
Allows extraction forceps to be placed
apically.
47

48. Cont.
Luxation of tooth with a dental
elevator:
A straight elevator is inserted to the
tooth into interdental space.
Strong, slow, forceful, turning of
handle moves tooth in posterior
direction causing expansion of bone
Tearing of periodontal ligament
48

49. Cont.
Excess force can damage or displace
adjacent tooth especially if it has a
large restoration or caries
Adaptation of forceps to tooth:
Tips of forceps beaks should grasp root
Lingual beak is seated first.
Beaks must be parallel to long axis of
tooth
Force should be applied with shoulder &
upper arm & not with wrist.
49

50. Cont.
Sterile drape should be put across
Pt's chest
Before Extraction, PT should
vigorously rinse mouth with antiseptic
mouth rinse.
4X4 inch gauze can be placed in to
back of mouth to prevent teeth or
fragments falling into mouth
50

51. Cont.
Luxation of tooth with forceps:
Major force should be directed towards
thinnest portion of bone.
Slow steady force is used.
Removal of tooth from socket:
Done by tractional force usually given
buccally
51

52. Role of opposite hand
Reflect soft tissues of cheek, lips and
tongue, give visibility.
Protect other teeth from forceps.
Stabilize PT's head
Supporting and stabilizing mand. during
mand. extraction.
Supports alveolar process and provide
tactile information about expansion of
alveolar process.
52

53. Role of assistant
Helps to visualize and gain access, by
reflecting soft tissues and tongue
Suction away blood, saliva, irrigating
solution
Stabilize mandible
53

54. Specific Technique for removal
of Each tooth
Maxillary incisor teeth:
They have conical roots.
LI may have a distal curvature for root.
Alveolar bone is thin over buccal side
and thick over palatal side.
After apical Pre. the force is given
buccally, less palatal force followed by
rotational force, no rotational force if
there is curvature.
Tooth is delivered in labial direction
54

55. Cont.
Maxillary canine
Longest tooth in mouth
Root is oblong in C.S.
Bone on labial aspect is thin. So a
fragment of bone usually fractures from
buccal aspect when tooth is removed.
Buccal, palatal and a small amount of
rotational movement and removed in
labio -incisal direction.
55

56. Cont.
If Bone is detached from periosteum, it
should be removed.
If buccal bone is attached to periosteum,
it can be left, normal healing will occur.
56

57. Cont.
Maxillary I PM
Single rooted with bifurcation to bucco-
lingual roots at apical 1/3
Most common root #
Buccal bone is thinner
Tooth should be luxated as much as
possible.
Apical, buccal, palatal movements,
palatal should be less
57

58. Cont.
Maxillary II PM
Single rooted
Thin bone buccally and thick palatally
Buccal, palatal, bucco -occlusal
tractional force.
58

59. Cont.
Maxillary molar
3 roots,2 buccal roots are relatively
closer and palatal is divergent towards
palate.
Buccal cortical plate is thinner than
palatal.
Forceps have projection on buccal beak
to fit buccal bifurcation.
59

60. Cont.
Upper cowhorn forceps is used in teeth
with large caries or restoration.
More buccal force, less palatal force
removed with bucco occlusal tractional
force.
II M similar anatomy except less
divergence for roots and removed in
similar way.
Erupted III M. conical roots
Easily extracted by elevators alone
60

61. Cont.
Mand. ANT. Teeth
Incisor roots are thinner and shorter and
canine roots are longer and heavler.
Bone on labial aspect of canine is
somewhat thicker.
Equal movements labially, lingually &
tooth is luxated by a rotational force &
extracted by labio-incisal tractional force
61

62. Cont.
Mand. PMs
Roots are straight & conical
Bone thinner on buccal & thicker on
lingual aspect.
Buccal, less lingual, rotational and
occluso -buccal tractional force.
If any root curvature rotation is avoided
62

63. Cont.
Mand. Molars
2 roots and widely divergent for IM
Roots may converge at apical 1/3
Most difficult of all teeth to extract.
Apical, buccal, lingual and bucco occlusal
tractional force.
Lingual bone is thinner than buccal so
more lingual pressure
63

64. Cont.
Lower cowhorn forceps is used by
squeezing the bifurcation, buccolingual
movements can also be used.
Erupted mand. III M. Conical roots
lingual plate is thinner, so more
movements are given lingually and
delivered in lingo occlusal direction.
64

65. Modification for extraction of I°
teeth
Similar buccolingual movements
Rotational movement is avoided for
multirooted teeth.
Tooth is delivered in least resistant
path.
If the roots embrace PMT crown,
sectioning of roots should be done
65

66. Post extraction care
If any periapical pathology in
radiograph, and no granuloma
removed with extracted tooth,
periapical area is carefully curetted.
If any debris, calculus, amalgam, tooth
fragment, in socket it is removed with
curette.
Remnants of periodontal ligament &
bleeding bony walls improves healing.
66

67. Cont.
Vigorous curettage delay healing by
causing additional injury
Finger pressure is applied to buccal &
lingual cortical plates to compress the
socket, to prevent bony undercuts
If there is excess granulation tissue
around gingival cuff, it should be
removed with curette or hemostat.
67

68. Cont.
Sharp bony projections should be
smoothed with bone file.
Moistened 2x2 inch gauze is placed
over extraction socket and it should fit
into the space that was previously
occupied by tooth. So that biting force
will give pressure, will cause
hemostasis.
Larger gauze is placed if multiple teeth
extracted of opposing tooth is missing.
68

69. OPEN EXTRACTION
Indications
Failure to remove tooth by closed
method
Unfavourable root pattern
Fracture or caries extending to root
Hypercementosis
Ankylosis
Impacted tooth
Sclerosed bone
69

70. Steps in open extraction
Incision
Raising mucoperiosteal flap
Removal of bone around the tooth or
root
Establishment of point of application
of elevator
Removal of tooth from socket
70

71. Cont.
Trimming the bone
Toileting the wound
Control of bleeding
Repositioning & suturing
Packing
71

72. Planning of an incision
Def.of incision-a cut or wound
deliberately made by an operator in
skin or mucosa using a sharp
instrument, so that the underlying
structures can be exposed for surgical
access.
Incision is placed parallel to
structures without causing damage to
vital structures
72

73. Cont.
Extraoral incisions are planned along
the Langers lines of normal skin
tension or creases, so that min. scar
is formed.
Incision should be placed on sound
bone.
Pen grasp (intraoral) or table knife
(extra oral) grasp is used
73

74. Cont.
Skin or mucosa to be incised to be
stabilized with finger pressure to
guide the passage of blade.
A firm continuous stroke should be
used.
Change in direction is accomplished
by a gradual curve.
74

75. Incisions in oral cavity
Incise through attached gingiva over
a healthy bone.
Incisions placed near teeth for
extractions should be made in
gingival sulcus.
Integrity of interdental papilla should
be maintained.
75

76. Cont.
Incisions involving reflection of
mucoperiosteal flap are direct,
straight-line or curvilinear taking the
shortest distance vertically through
the tissues.
Blood supply to the incision should be
adequate.
76

77. Contraindications for placement
of incisions
Over canine prominence
Vertical incision in mental nerve
region.
Near greater palatine vessels in
palate.
Through incisive papillae.
Over bony lesions
77

78. Cont.
Over freni.
Vertical incision on lingual side of
mandibular arch
78

79. Types of incisions
Horizontal:-given along the gingival
margin either mesially or distally. e.g.
Internal bevel incision & crevicular
incision.
Vertical:-also called releasing incision
Single vertical incision-triangular flap
Double vertical incisions-trapezoidal flap
79

80. Cont.
Incision should extend beyond
mucogingival line to alveolar mucosa.
Vertical incisions should be placed at
obtuse angle to horizontal incision &
should leave interdental papillae intact
80

81. Cont.
Semilunar (curved,elliptical)
Used to maintain attached gingiva intact
& for endodontic surgery.
Horizontal component rest on bone.
5mm gap is present from base of
gingival sulcus to incision.
81

82. Flap design
Complications of flap surgery
Flap tearing
Flap necrosis
Flap dehiscence
82

83. Cont.
Flap tearing:-to prevent this
Incision should be clean,sharp&should
penetrate entire mucoperiosteum.
Flap should be reflected as one unit.
Length of flap should not be more than
twice the width of base.
83

84. Cont.
Flap necrosis:-to prevent this
Base of flap should be wider.
Margins of flap should be either parallel
to each other or converge from base to
apex.
Axial blood supply should be included in
flap e.g.palatal flap based on greater
palatine artery.
84

85. Cont.
Flap dehiscence=separation of flap
margins or gaping of wound.
Causes
Poor tissue handling
Too tight suturing
Hematoma formation
Infection
Prevention
Sutures are placed over healthy bone.
85

86. CONT.
Types of flaps
A.1.Full thickness-mucoperiosteal flap
2.Partial thickness
B.1.Envelop
2.Triangular
3.Rhomboid
4.Semilunar
86

87. CONT.
C.1.Labial, buccal
2.Palatal, lingual
87

88. CONT.
Envelop flap
Most common type
Sulcular incision is made around the
tooth on buccal or lingual aspect
including interdental papillae.
Entire mucoperiosteal flap is
elevated.
Mainly used in surgical extraction of
teeth.
88

89. CONT.
Triangular flap
A vertical releasing incision is made
on one side of envelope flap diverging
towards buccal vestibule.
Vertical incision is made in the
interproximal area not on the facial
aspect of tooth to avoid periodontal
defect.
89

90. CONT.
Flap is reflected towards the base of
the flap.
Rhomboid flap
2 vertical releasing incisions are
made on either side of envelope flap.
Base of flap should be wider.
90

91. CONT.
Semilunar flap
Used in periapical surgery.
Suture line should not be on bony
defect.
91

92. Cont.
Toileting the wound
Irrigation
Debridement of necrotic, foreign
bodies, severely injured tissues.
Antibiotics
Use of medicated mouthwashes after
every food intake.
92

93. Cont.
Hemostasis should be achieved
To minimize blood loss.
Increase visibility
Reduces operating time
Minimizes postsurgical trauma.
93

94. Cont.
it can be achieved by
Intermittent pressure:-with cotton
or gauze sponges. pressure is applied
for 20-30sec for smaller vessels&5-10
min. for larger vessels.
Electrocautery:-for this area around
the vessel is dried thoroughly.Avoid
unnecessary burning.
94

95. Cont.
Suture ligation:-when large vessel
is severed it is grasped with
hemostat. Nonabsorbable suture is
used to ligate the vessel.
Vasoconstrictors:-epinephrine,
thrombin or collagen gel foam
95

96. Cont.
Compression dressing over the
wound:-if there is oozing over a
large area a cotton pad or ribbon
gauze is stabilized over the wound
&secured in position with sutures &
kept for 2-3 days.
96

97. Healing of extracted socket
Hematoma & Fibrin (clot) {0-4 days}
Granulation tissue(3days –3 weeks)
Fibrous tissue –"
Callus -"
Calcification -"
Bone remodeling (after 3 weeks)
97

98. Complications
# of crown or roots of the tooth
being extracted
# of alveolar bone
# of maxillary tuberosity
#of adjacent or opposing tooth
# of mandible
Dislocation of TMJ
98

99. Cont.
Displacement of root into soft tissues,
maxillary antrum
Bleeding
Injury to gums, lips, IAN & its
branches, lingual nerve, tongue, floor
of mouth, greater palatine artery
Dry socket
Osteomyelitis
Infection
99

100. Cont.
Trismus
Hematoma
OAF
100

101. Dry socket or alveolar osteitis
Causes
Undue trauma during extraction
Pre existing infection
Disturbance of clot due to vigorous
mouth wash or curettage
Increased fibrinolytic activity
Localized impaired vascular supply
Smoking
Use of OCP
101

102. CONT.
Clinical features
Continuous throbbing & excruciating pain
h/o extraction 48-72 hrs
Alveolar socket is covered with grayish
necrotic tissues
Denuded alveolar bone
Halitosis
102

103. Cont.
L.A.
Irrigate with warm saline or
chlorhexidine for removal of dead
bone or infected tissues
Do not curette
Obtundant dressing (ZOE with cotton
to cover the denuded bone or
whitehead varnish
Antibiotic, analgesic
103

104. Hematoma
Control bleeding prior to closure
Apply ice extraorally
Antibiotics to prevent infection
Anti inflammatory drugs
104