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General Principles of Exodontia

Simple Extractions
Pre-Extraction Preparations

Medical history and physical examination

Radiographic evaluation
Surgical plan
Pain and anxiety control
Patient and surgeons preparations and
surgeon positions
List the indications & contraindications for the
removal of teeth
List the items in a pre-surgical assessment
List the basic sequence in tooth extraction
List the fundamental requirements in exodontia
List the basic forceps movements
List the appropriate forceps used for each tooth
Indications for Tooth Removal
Severe caries
Pulpal necrosis
Severe periodontal disease
Orthodontic reasons
Malopposed teeth
Cracked teeth
Preprosthetic extractions
Indications for Tooth Removal
Impacted teeth
Supernumerary teeth
Teeth associated with pathologic lesions
Pre-radiation therapy
Teeth involved in jaw fractures
Contraindications for Tooth Removal

Unstable systemic disease: e.g. unstable

endocrine, renal, cardiovascular, pulmonary,
or hematologic disease
Local conditions: e.g. radiation therapy,
malignant tumor, damage to vital structures
Pre-surgical Assessment

Medical risk assessment

Emotional condition
Clinical evaluation
Radiographic evaluation
Overall difficulty
Surgical approach
Clinical Evaluation

Status of the support structures
Status of tooth and crown
Adjacent structures
Interpretation of the preoperative
radiograph requires
Knowledge of normal radiographic anatomy
Assessment of the condition of the
surrounding bone
Assessment of the adjacent vital structures
Assessment of the condition of the adjacent
Assessment of the tooth in question

Over garment
Cap: hair covered
Eye protection
Chair and Surgeons Position

Comfortable for both the patient and surgeon

Stand or sit during extraction
Mx: Maxillary occlusal plane 60 to the floor
Mn: Mandibular occlusal plane parallel to the floor
Local anaesthetic
Wait for local anaesthetic effect!
Periosteal elevator: reflect papilla, severe PDL
Elevator: luxate tooth ( deliver)
Luxate to expand socket
Rotate to severe PDL
Traction to deliver tooth
Squeeze alveolus & suture prn; alveoplasty prn
Post-op instructions and meds
Fundamental requirements

Adequate access
Good visualization of the field
Unimpeded pathway of delivery of the tooth
Controlled forces to retract adjacent
structures and remove tooth
Standing or sitting
In front or behind patient
Patient almost supine (back 10 to ground) for
maxillary teeth
Patient almost supine or semi-sitting (back 20 -
30 to ground)
Be comfortable. Back straight. Head not bent
forward blocking light.

Mouth props: bite block, side action mouth

Not usually required in awake patient
Elevation of Mucoperiosteum

Periosteal elevator: #9 molt (moons probe)

Full thickness
Pointy end: initiate flap, elevate papilla, severe
crestal PDL, sub-periosteal dissection
Broad end: sub-periosteal dissection for much
larger maxillofacial surgery flaps; not for
Reflect Papilla & cut PDL
Dental Elevators

Luxate tooth
Deliver tooth
Do NOT lean on adjacent teeth
Alveolar bone used as fulcrum
Controlled, steady forces
Elevator: Luxate Delivery
Elevator: Alveolar Bone Fulcrum
Forceps Extractions
Extraction movement
Primary movement: Along longitudinal axis
of root

Secondary movement: Main extracting

Buccolingual or labiolingual
Lifting the tooth
Lower central and lateral incissor
Labiolingual movement
Lower canine
Rotatory and labiolingual
Lower premolar
Lower molar
Buccolingual movement
Extraction Forceps
Choose handle for access, comfort, and leverage
Choose beaks for adaptation to tooth
Proper placement: apical seating
Controlled, steady forces
Hold at end of handle for greater lever advantage,
more power, more feel
Feel what direction tooth wants to come out and
go with it
Bone Expansion
Wedge Action
Basic Forceps Movements
Maxillary Pinch Grasp
Mandibular Sling Grasp
Trans-alveolar Extraction

It is essentially a technique that includes

dissection of a tooth or root from its bony

It is often referred to as Open method.

Trans-alveolar Extraction
- Indications

Any tooth which resists attempts at intra-alveolar

extraction when moderate force is applied.

Retained roots which cannot be either grasped or

delivered with an elevator.

A history of difficult or attempted extractions.

Hypercementosed and ankylosed teeth.

Trans-alveolar Extraction
- Indications

Any heavily restored tooth, especially when root

filled or pulpless.

Impacted and dilacerated teeth.

Teeth shown radiographically to have a

complicated root patterns.

During immediate denture treatment, where there

is a need to trim some alveolar bone.
A. Formulation of overall treatment plan.

Important components of such a plan are:

1. Incision to gain access to the area

2. Removal of adequate amount of bone
3. Sectioning of the tooth (tooth division)
4. Elevating the tooth or root from its socket
5. Preparing the wound before closure
6. Closure of the wound or incision
7. Postoperative care
Instruments used in
trans-alveolar surgery
Incision to gain access to the area:

Mucoperiosteal flap
1. Envelope Flap :

It is a full-thickness flap.

Incision is made horizontally along the crest of the

ridge or in the buccal gingival crevice.

When incision is made around teeth, it extends at

least one tooth distal and two teeth mesial to the
site of the operation.

Has no vertical incision.

2. Triangular (three-cornered) Flap

It is an envelop flap with one vertical relaxing

The horizontal incision extends from one tooth
distal to the surgical site to one tooth mesial.


It is the next most useful flap for exodontia.

It provides greater access; therefore, it is used
primarily for surgery in the vicinity of the apex of
the tooth or in a deeply impacted tooth.
3. Rectangular (four-cornered) Flap :
It is an envelope flap with two vertical relaxing
It provides substantial access.
However, it have limited anteroposterior
4. Semilunar Flap
Most useful for retrieval of small root tips and
periapical endodontic surgery of a limited extent.
The horizontal component of this incision should not
cross major prominences, such as the canine
The incision should be placed at least 2 mm apical to
the base of the gingival sulcus (4-5mm from gingival
Advantage and disadvantage
No involvement of the gingival sulcus, thus, avoids
trauma to the papilla and gingival margin.
Provides limited access because the entire root of
the tooth is not visible.
Instruments used in
trans-alveolar surgery
Blade Handle

Handles for the

Instruments used in
trans-alveolar surgery
Surgical Blade
#15 is the most commonly used
scalpel blade.

#15 is a smaller version of #10

#11 is pointed (stab incisions

for Incision and Drainage).

#12 is hooked
Instruments used in trans-alveolar surgery
Disposable Blade
2 Reflection of the Flap:

Flaps are reflected with the mucoperiosteal elevators.

Using the sharp pointed end of the elevator interdental

papilla are freed from the underlying bone (using the
tooth as a fulcrum).

Using the broad end of the elevator in a push stroke, the

attached gingiva and alveolar mucosa are reflected to the
desired extent.

Using the mucoperiosteal elevator in a pull stroke can

sometimes shred the periosteum.
A periosteal elevatod the Minnesota or Austin
3 Retraction
retractors for of the Flap:


Minnesota elevator
The retractor should be placed beneath the flap and held
firmly perpendicular on sound bone with no soft tissue
trapped between.

In order not to focus on the retractor rather than the

surgical field, do not force the retractor against the MPF in
an attempt to pull the soft tissue out of the field but rather
the retractor is held in contact with the bone so that the flap
rests on it passively.
3 Bone Removal :

Removal of bone is intended to:

Expose either the tooth or roots before their delivery.
Provide a point of application for an elevator or forceps.
Create a space into which the tooth or root may be displaced.
4 Tooth Sectioning :
1. Bone is insufficiently elastic.
2. Multi-rooted teeth in which the lines of withdrawal of
different roots prevents removal with either the
forceps or buccal application of elevator.
- The roots are separated to be removed along their
individual paths of withdrawal.
- Tooth division may be effected using a bur, an osteotome
or tooth-splitting forceps (tooth shear forceps).
Removal of the tooth Removal of the root
segment with a forceps with an elevator
applicated in a prepared
purchase point
Bone File
7 - Closure of
the Wound: