PRINCIPLES OF EXODONTIA

1)

Pain and anxiety control.

a) Local anesthesia.
b) Sedation.

2)

Presurgical medical assessment.

3)

Indications for removal of teeth.

a) Severe caries.
b) Pulpal necrosis.
c) Severe periodontal disease.
d) Orthodontic reasons.
e) Malopposed teeth.
f) Cracked teeth.
g) Preprosthetic extractions.
h) Impacted teeth.
i) Supernumerary teeth.
j) Teeth o/w pathologic reasons.
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k) Preradiation therapy.
l) Teeth involved in jaw fractures.
m) Esthetics.
n) Economics.

4)

Contraindications for removal of teeth.

a) Systemic.
b) Local.

5)

Clinical evaluation of teeth for removal.

a) Access to tooth.
b) Mobility of tooth.
c) Condition of crown.

6)

No examination of tooth for removal.

a) Relationship of associated vital structures.
b) Configuration of rests.
c) Condition of surrounding bone.

7)

Patient and surgeon preparation.

2

8)

Chair position for forceps extraction.

9)

Mechanical principles involved in tooth extraction.

10)

Principles of forceps use.

11)

Procedure for closed extraction.

12)

Role of the opposite hand.

13)

Role of assistant during extraction.

14)

Specific technique for removal of each teeth.

a) Maxillary teeth.
b) Mandibular teeth.
c) Modifications for extraction of primary teeth.

15)

Post extractions care of the tooth socket.

16)

Surgical extraction of teeth.

Flap clevation.

Bone removal.

Tooth splitting / endenctomy.

Elevation of tooth pieces.

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Bone filing / alveoplasty.

Irrigation and debridement.

Closure.

Post surgical care.

EXODONTIA: Basic Principles & Methods

1.

Pain and Anxiety control:

-

Removal of a tooth requires profound local anesthesia to

prevent pain during extraction, and control of patient anxiety
is necessary to prevent psychological distress.

Local anaesthesia must be absolutely profound to prevent and

eliminate painful sensations from the pulp, periodontal
ligament and buccal and lingual soft tissues.

LOCAL ANESTHESIA
-

For obtaining profound anaesthesia of the tooth to be

extracted, it is essential for the surgeon to remember the
precise innervation of all teeth and their surrounding soft
tissue and the techniques necessary to anaesthetize those
nerves totally.

It is necessary to remember that in areas of nerve transition.

There is almost always overlap in some areas. Therefore, it
may be necessary to supplement the primary block with
additional infiltration to prevent pain from the transitional
nerve endings from the surrounding tissue area.

Profound local anesthesia results in loss of all pain,

temperature and touch sensations but does not anaesthesize the
proprioceptive fibres of the involved nerves. Thus, the patient
feels a sense of pressure, especially when the force is internal.
One must therefore remember to that the patient will need to
distinguish between the sharp pain and the dull, although
intense, feel of pressure.

Inspite of profound anaesthesia, the patient may continue to

have sharp pain as the tooth is luxated. This is especially
likely when the teeth have pulpitis or the surrounding soft and
hard tissue is inflamed or infected. A technique that should be
employed in such situations is the PDL injection. When this
injection is delivered properly, there is immediate profound
local anesthesia in almost all situations. The anesthesia is
short lined, so the surgical procedures should be one that can
be accomplished in 15 to 20 minutes.

It is important to keep in mind the pharmacology of the

various local anaesthetic solution that are used, so that they
can be employed properly. Following points should be
remembered.
a.

Amount of time they can be expected to provide

profound anaesthesia (Ref. Table 7.3).

b.

Pulpal anesthesia of maxillary teeth after local

infiltration lasts a much shorter time than does pulpal
anesthesia for mandibular teeth after block anaesthesia.

c.

Pulpal anesthesia disappears 60 to 90 mts before

soft tissue anesthesia does.

Maximum dose that can be given safely for the particular

anaesthetic agent in use (Ref Table 7.4). It is wise to
remember that the smallest amount of local anesthetic solution
between sufficient to provide profound anaesthesia is the
proper and safe amount.

Sedation:
-

Management of patient anxiety must be a major consideration

when one performs oral surgery procedures.

Anxiety lessens the pain threshold, and frequently patients are

already in pain and may be agitated and fatigued. This lessens
the patients ability to deal with pain and pain related
situations.

Also, as noted before, although local anesthesia eliminates,

sharp pain, the dull sense of pressure is still present, which
may be come quite intense.

For all of these reasons, it is prudent for a dentist to use a

prospective planned method of anxiety control to prepare
themselves and their patients for the anxiety a/w tooth
extraction and oral surgical procedures.

Various methods of anxiety control:

Proper explanation of the planned procedure, including
assurance that there will be no sharp pain but honest
acceptance that there will be dull discomfort due to pressure.
An expression of concern, caring and empathy is required of
the dentist. For the mildly anxious patient, with a caring
dentist, no pharmacologic assistance is required.
For the more anxious patient it becomes necessary to employ
pharmacologic assistance. Preop orally administered drugs,
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such as diazepam or chloral hydrate may provide a patient

with rest the night before the surgery and some relief of
anxiety in the morning.
However, orally administered drugs are usually not profound
enough to control moderate to severe anxiety once the patient
enters the operative suite.
Sedation by Nitrous Oxide gas and oxygen is frequently the
technique of choice and may be the sole technique needed for
many patient who have mild to moderate anxiety. If the dentist
is skilled in the use of nitrous oxide gas and the patient
requires a routine, uncomplicated surgical procedure, sedation
is frequently sufficient.
An extremely anxious patient who is to have several
uncomplicated extractions may require parenteral sedation,
usually by IV route. It may be necessary to administer IV
sedation with diazepam or other drugs to aid such patient in
tolerating the surgical procedure.
2.

Presurgical Medical Assessment:

When evaluating a patient preop it is critical that the surgeon

examine the patients medical status. Patients may have a variety of

maladies that require treatment modification before the surgery can
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be performed safely. Special measures may be needed to control

bleeding, prevent, infection and prevent worsening of the patients
preexisting state or condition.
3.

Indications for Removal of teeth:

Although it is the position of dental practice to take all

possible measures to preserve and maintain teeth in the oral cavity, it

is sometimes necessary to remove some of them for various reasons.
The following are some such reasons.
a)

Severe caries : When a tooth is so severely caried that it

cannot be restored, it frequently is necessary to remove it.

b)

Pulpal necrosis : Second rationale is the presence of

pulpal necrosis or irreversible pulpitis that is not amenable to
endodontics. This may be caused by a patient who refuses to or
cannot afford endodontic treatment or it may be caused by a root
canal that is tortous, calcified and untreatable by standard
endodontic technique. Also included is the endodontic failure.

c)

Severe periodontal disease : A common reason for tooth

removal is severe and extensive periodontal disease. If severe
adult periodontitis has existed for some time, there is excessive
tooth mobility due to irreversible bone loss leading to pain and
loss of function. There may also be formation of a periodontal
9

abscess. In these situations, the hypermobile teeth should be

extracted.
d)

Orthodontic

reasons:

Patients

about

to

undergo

orthodontic correction of crowded dentition frequently require

the extraction of teeth to provide space for tooth alignment. Most
commonly extracted teeth are the maxillary and mandibular first
premolars, but second premolars or a mandibular incisor may
occasionally need extraction for this same reason.
e)

Malopposed teeth: Teeth that are malopposed or

malposed may require extraction if they traumatize soft tissues
and cannot be repositioned by orthodontic treatment. A common
example is the maxillary 3 rd molar which erupts in buccoversion
and causes ulceration and soft tissue trauma in the check. Another
example is hypererupted teeth due to loss of antagonist tooth.
These may interface with construction of an adequate prosthesis.
Such teeth may need to be extracted.

f)

Cracked teeth: A clear but uncommon indication for

extraction of teeth is when a tooth is cracked or has a fracture
root. The cracked tooth can be painful and is unmanageable by a
more conservative technique. Even endodontic and complex
restorative procedures cannot relieve the pain of a cracked teeth.
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g)

Preprosthetic extraction: Teeth occasionally interface

with the design and proper placement of prosthetic appliances
full dentures, partial dentures or fixed partial dentures. In such
cases preprosthetic extractions may be necessary.

h)

Impacted teeth: These should always be considered for

extraction. If it is clear that an impacted teeth is unable to erupt
into a functional occlusion because of inadequate space,
interference from an adjacent teeth or some other reason, it
should be scheduled for surgical removal unless contraindicated.

i)

Supernumerary teeth: Supernumerary teeth are usually

impacted and should be removed. They may interface with
eruption of succedaneous teeth and have the potential for causing
their resorption and displacement. They are also frequently
involved with cyst formation.

j)

Teeth a/w pathologic lesions: Teeth a/w lesions like

tumors and cysts frequently require extraction unless they can be
retained and endodontic treatment performed. However, if
maintaining the teeth compromises the surgical removal of the
lesion, it should be extracted.

k)

Preradiation therapy: Patients who are to receive

radiation therapy for a variety of oral tumors should have serious
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consideration given to removing teeth in the line of radiation

prior to therapy.
Teeth involved in jaw fractures: Patients who sustain

l)

fractures of the mandible or the alveolar process occasionally

need to have teeth removed. In majority of situations the involved
teeth may be retained but if the teeth is injured or severely
luxated, it may need extraction.
Esthetics: Severely stained, malposed or protruding

m)

teeth may sometimes require extraction.

Contraindications:
These are relative and not absolute, many times extraction can
still be done with use of additional care, modified techniques and
resolution of underlying problem that contraindicate extraction. Two
groups: Systemic and Local.

Systemic contraindications:
In these situations the patients general health is such that it
cannot withstand surgical treatment as the condition may be further
aggravated.

Metabolic diseases e.g. Severe uncontrolled diabetes, endstage renal disease with severe uremia. Patients with mild or
12

well controlled diabetes can be treated as reasonably normal

patients.

Uncontrolled leukomias and lymphomas: extraction may lead

to infection due to non-functional white cells and profound
bleeding due to deficient platelets.

Cardiac disorders: Severe myocardial ischaemic such as

unstable angina and patients with recent MI should not have a
tooth extracted. Patients with severe malignant hypertension
should also have extraction deferred due to risk of persistent
bleeding, acute myocardial insufficiency and cerebrovascular
accidents.

Pregnancy: Patients in first and 3 rd trimester should have

extraction deferred as much as possible. Latter part of 1 st
trimester and 1 st month of 3 rd trimester are just as safe as 2 nd
trimester and extractions can be carried out if necessary, but
more extensive surgical procedures should be deferred until
after delivery.

Severe bleeding diathesis: Coagulopathy should be corrected

by transfusion of coagulation factors and / or platelets. Close
coordination with patients hematologist is needed.

Local Contraindications:
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1.

Therapeutic radiation for cancer: Extraction in irradiated

areas may lead to osteoradionecrosis and therefore must be
done with extreme caution.

2.

Teeth located in an area of a malignant tumor should not be

extracted it would lead to dissemination of cells and
thereby hasten metastatic process.

3.

Patients who have severe pericoronitis around an impacted

3 rd molar should not have extraction until the pericoronitis
has been treated. Non surgical treatment with irrigations,
antibiotics and removal of maxillary 3 rd molar to relieve
impingement on the edematous pericoronal tissues will lead
to resolution of the infection. Otherwise extraction would
lead to severe infection which is potentially fatal.

4.

Acute dentoalveolar abscess: Normally the most rapid

resolution of an infection secondary to pulpnecrosis is
observed when the teeth is removed as soon as possible.
Therefore, acute infection should not be a contraindication to
extraction. However, it may be difficult to extract such a
tooth because the patient may not be able to open his/her
mouth sufficiently wide or it may be difficult to obtain
adequate local anesthesia due to increased pH. With
resolution of acute symptoms, extraction can be done.
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Mechanical principles involved in Exodontia:

Removal of teeth from the alveolar process employs the use of
several mechanical principles and simple machines: The lever, the
wedge and the wheel and axle.
-

Elevators are used primarily as levers. A lever is a mechanism

for transmitting a modest force with the mechanical advantage
of a long lever arm and a short effector arm into a small
movement against resistance. When an elevator is used for
teeth extraction, a purchase point can be made on the tooth
and a straight or crane pick elevator can be used to elevate the
tooth or root from the socket using the alveolar bone as a
fulcrum. The mesial cervical junction of the tooth can also be
used as a purchase point and a small straight elevator can
luxate the tooth.

Secondly, a wedge can be used in several different ways. First,

the beaks of extraction forceps are usually narrow at their tips.
When the forceps are held, they should be forced into the PDL
space to expand the bone and displace the tooth out of the
socket. The wedge is also useful when a straight elevator is
used to luxate a tooth from its socket by forcing it into the
PDL space.
15

The 3 rd machine used is the wheel and axle which is most

commonly identified the Cryers and Winters cross-bar
elevator. When one root of a multirotated tooth is left in the
alveolar process, Cryers elevator can be positioned in the
socket and turned. The handle then serves as the axle and tip
acts as the wheel and engages and elevates the root from the
socket.

Principles of forceps use:

Goals of forceps use are 2 fold:
1. Expansion of the bony socket.
2. Removal of teeth from the socket.
There are 5 major motions that the forceps can apply to luxate
and mobilize the tooth by expanding the bony socket.
a) Apical pressure: Results in a minimal movement of the tooth
in an apical direction and expansion of the tooth socket by the
insertion of the beaks into the PDL space. Secondly, apical
pressure with resultant bony expansion pushes the centre of
rotation more apically which results in a greater expansion of
the socket at the alveolar crest region when the forceps is

16

moved. This prevents fracture of apical segment of the root

and more ideal expansion of the socket.
b) Buccal motion: Results in expansion of the buccal plate,
particularly at the crest of the ridge. It is important to
remember that this also lends to apical pressure and must not
be excess or fracture will occur. Maxillary buccal bone is
usually thinner and the palatal bone thicker, thus maxillary
teeth are removed primarily by buccal pressure.
c) Lingual motion : Similar to buccal motion but in lingual
direction aimed at expanding the lingual crestal bone.
Mandibular molars have thick buccal bone and thin lingual
bone. Thus they are removed primarily by lingual force.
d) Rotational motion: Rotates the tooth which causes some
internal expansion of the bone. Teeth with single cervical
roots like maxillary incisor and mandibular premolars are
most amenable to luxation by this method.
e) Tractional forces: Useful for delivering the teeth from the
socket once adequate bony expansion is achieved.

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Procedure for closed extraction:

An erupted root can be extracted in 2 major ways: closed or
open.
Closed technique is also called as simple or forceps technique.
The closed technique is the most commonly used one and given
primary consideration for almost every extraction. The open
technique is used when there is reason to believe that excessive force
would be required or when substantial portion of the crown is
missing and access to the root is difficult. For the tooth to be
removed from the bony socket, it is necessary to expand the alveolar
bony walls to allow the tooth/ root an unimpeded pathway and it is
necessary to tear the periodontal fibres that hold the tooth in the
bony socket. The use of elevators and forceps as levers and wedges
can accomplish these objectives.

Five general steps in closed extraction procedure:

1.

Loosening of soft tissue attachment from the

tooth:
This is done using the sharp end of a molts No. 9 or Woodsons

elevator. The purpose is two fold:

18

i.

Allow surgeon to assure both themselves and the patient

that profound LA is achieved. Small amount of pressure
will be felt but not a sensation of sharpness or discomfort.

ii.

To allow the tooth extraction forceps to be positioned more

apically without interference from or impingement on the
soft tissue of the gingiva.
If a straight elevator is used to luxate the tooth, the mesial

papilla is detached using the sharp end of the Woodsons molts

elevator, which allows the elevator to be placed directly onto the
alveolar bone without crushing and injuring the papilla.
2.

Luxation of tooth with a dental elevator:

Usually a straight elevator is used. Expansion and dilatation of

the alveolar bone and tearing of the periodontal ligaments ensure

that the tooth be luxated in several different ways. The straight
elevator is inserted perpendicular to the tooth into the interdental
space and then turned so that the inferior portion of the blade rests
on the alveolar bone and the superior portion of the blade is on the
root of the tooth being extracted. With thumb pressure resting on the
mesial tooth, strong, slow, forceful turning of the handle is done to
move the tooth in a posterior direction, which results in tissue
expansion of the alveolar bone. In some instances, the elevator can
19

be turned in the opposite direction and more vertical displacement of

the tooth will be achieved.
3.

Adaptation of the forceps to the tooth:

The proper forceps are then chosen for the tooth to be

extracted. Beaks should be shaped to adapt anatomically to the teeth

apical to the cervical line, on the root surface. Atleast a 2 point if not
complete surface contact should be achieved. The forceps are then
seated onto the tooth so that the tips of the forceps beaks grasp the
root underneath the soft tissues. The lingual beak is usually seated
first, then the buccal beak. Once the beaks have been positioned, the
surgeon grasps the handles of the forceps at the very end to
maximize mechanical advantage and control.
The beaks of the forceps must be held parallel to the long axis
of the tooth so that forces generated by the application of the
pressure are delivered along the long axis for maximal effectiveness
in dilating and expanding alveolar bone. If beaks are not parallel,
fracture of tooth / root may occur. The forceps are then forced
apically as far as possible. This accomplishes 2 things. First, the
beaks of the forceps act as wedge and expand crestal alveolar bone.
Secondly, the centre of rotation is displaced towards the apex of the
tooth with resultant increased effectiveness of bone expansion. At
this point the surgeons hand should be grasping the forceps firmly,
20

with the wrist locked and arm held against the body, the surgeon
should be prepared to apply force with the shoulder and upper arm
without any wrist pressure. He or she should be standing straight
with the feet comfortably apart.
4.

Luxation of the tooth with the forceps:

The surgeon begins to luxate by using the motions described

earlier. As the alveolar bone begins to expand, the forceps are

reseated apically with a strong, deliberate motion; which causes
additional expansion of the alveolar bone. Buccal and lingual
pressure continue to expand the socket and for some teeth rotational
motions are then used to help expand the tooth socket and tear the
PDL attachment. The forces applied should be slow, firm and
deliberate and not jenky. It must be remembered that teeth are not
pulled from the socket but rather gently lifted from the socket once
the alveolar process is sufficiently expanded.
5.

Removal of tooth from socket:

Once the alveolar bone has expanded sufficiently, a slight

tractional force, usually directed bucco-occlusally is used. These

should be minimal and result in removal of the tooth from the
socket.

Role of opposite hand:

21

The opposite hand plays an active role in the procedure. It is

responsible for reflecting the soft tissues of the cheeks, lips and
tongue to provide adequate visualization. It helps to protect other
teeth from the forceps. It helps to stabilize the patients jaw during
the extraction. It is often necessary to apply significant pressure to
expand heavy mandibular bone and such forces can cause discomfort
and even injury to the TMJ unless they are counteracted by a steady
support of the mandible. Finally, the opp hand supports the alveolar
process and provides tactile information to the operator concerning
the expansion of the alveolar process during luxation and tooth
extraction.

22

Post extraction care of the socket:

Socket should be debrided if necessary. If there is a periapical
lesion visible on the radiographs, the periapical regions should be
carefully curetted to remove the granuloma or cyst. Any debris in the
socket like calculus, bone or root fragments etc. should be gently
removed with a curette or suction tip. However vigorous and excess
curettage of the socket produces unnecessary injury and may delay
healing. The expanded cortical plates should be compressed with
gentle pressure, which prevents bony undercuts from forming and
improves healing. Excess granulation tissue if present is removed,
bony margins are trimmed and a moistened gauze pack is placed so
that when the patient bites his teeth together, it fits into the space
previously occupied by the crown of the tooth. This pressure results
in haemostasis and should be kept for half an hour.

Odontectomy and tooth division:

Odontectomy is the surgical removal of a tooth or teeth by the
reflection of an adequate mucoperiosteal flap, removal of an
overlying bone and also bone between the buccal roots of molars by
means of chisels, burs and / or rongeurs. After the removal of bone,
in many cases, tooth division is indicated. In tooth division, one or
many roots are separated from the crown by cross-cut fissure burs or
23

the crown is completely separated from the roots and the roots are
then cut apart. This is followed by application of elevators or forceps
for the extraction of the crown and then the roots.
The advantage of odontectomy are: the reduction in the
number and incidence of fracture crowns or roots during extraction,
less danger of oro-antral fistulation or injuring neuro-vascular
bundles, less possibility of fracture of mandibular or maxillary and
less incidence of tearing out large areas of cortical and cancellous
bone with the tooth during extraction.

Indications for odontectomy and tooth division:

1.

Hypercementosis of rests.

2.

Widely divergent roots.

3.

Locked roots where the roots curve towards each

other and touch or nearly touch such that a portion of bone is
locked between the roots.

4.

Teeth with dilacerated root tips.

5.

Teeth with post crowns.

6.

Extensively decayed teeth, particularly with those with

deep gingival cavities.
24

7.

RCT treated teeth.

8.

When a thick, dense buccal or labial cortical plate or

multinodular exostasis is present on the maxilla or mandible.

9.

When a low antral floor dips between the buccal and

lingual roots of the maxillary molars.

10.

When the maxillary alveolar tuberosity is hollowed out

by extension of the antral cavity.

11.

Thin mandible with bone, standing teeth which excess

forces will be required fracture of mandible.

12.

Malposed, impacted, unerupted supernumerary teeth.

13.

When the forceps pressure that was used so great that

dislocation of the condyles has occurred.

14.

Ankylosed roots.

15.

Variant root pattern that will lead to fracture of roots

during normal forceps procedure.

16.

Where the customary force fails to produce any luxate.

25