EXODONTIA

OR
UNCOMPLICATED
EXTRACTION
 INDICATIONS
 Caries
 Pulpitis
 Periodontal diseases
 Periapical Inf / Alveolar Abscess
 Tooth fracture
 Restorative /Endodontic fracture
 Dental erosion, attrition, Abrasion
 Root resorption
 Orthodontic reasons
 Prosthetic Considerations
 Impacted teeth
 Tooth involved with cyst ,tumour, fracture line
 Tooth in line of radio therapy
 PRE OPERATIVE ASSESSMENT
(CLINICAL)
 Mobility
 Crown
• Alignment
• Carious/fractured
• Restoration
• calculus
• Attrition-brittle/sclerosed bone
 PREOPERATIVE ASSESSMENT
(RADIOGRAPHIC)
 Root
• No ,Length ,width
• Shape ,Short conical /Long curved
• Hypercementosis ,Ankylosis (H/O RCT)
• Fracture , Resorption (Int / Ext)
• Restoration
 Bone
• Bone level, resorption
• Bone density
 Radiolucent –Less dense
 Radiopaque –Increased density
• Adjacent structures
 IAN , mental foramen , Max antrum
• Apical Path –Cyst , Granuloma
 INDICATIONS OF
RADIOGRAPHS
 H/o difficult / failed extraction.
 Abnormal resistant to forcep extraction.
 Surgical extraction
 Teeth close to Antrum / IAC
 All Mand 3rd Molars
 Impacted ,Misplaced, Supernumerary
teeth
 Non Vital teeth
 Trauma- fracture root suspected
 Lone standing Max Molar-Oro Ant fistula
 Systemic or local Bone disease
 ASSESSMENT OF PATIENT
 Level of cooperation
• Age, Mentally retarded
 Mouth opening
 Medical History
• Immuno Compromised
• Bleeding tendency
• High risk patients
 Infective endocarditis
 Osteo radio necrosis
 Recent MI
 PATIENT /SURGEON
PREPERATION
 Cross infection
 Surgeons dress
 Patients dressing
 Antiseptic rinse
 Gauze placement
 PRINCIPLE OF USE OF
ELEVATORS
 Elevators help in luxation
/Removal of tooth
 Adequate size of tip
 Self grasp/ hold
 Fulcrum always on bone in
periodontal space
 Principles of use
 Wedge
 Lever & Fulcrum
 Wheel & axle
 MECHANICAL PRINCIPLES OF
EXTRACTION
 Applying displacing forces to tooth
• Direct application - Dental Forceps
• Indirect application (fulcrum)- Elevators
 Expansion of Socket
 Removal of adjacent Bone
 Sectioning the tooth
 METHODS OF TOOTH
EXTRACTION
1. Forceps Extraction or Intra alveolar
Extraction
2. Surgical or Trans Alveolar Extraction
 FORCEPS EXTRACTION
OR
CLOSED EXTRACTION
OR
INTRA ALVEOLAR EXTRACTION
 POSITION OF PATIENT /
OPERATOR
 Position of patient
• Mand teeth- upright position, occlusal
plane parallel to floor
• Max teeth- semi recumbent position
occlusal plane 60 to floor
• Height- lower teeth
 elbow height

 upper teeth shoulder height

 Position of operator
• For lower right quadrant- behind the patient
(11 O clock)
• Rest- front of patient
 Arm close to body & force delivered with arm &
shoulder – not with hand
 ROLE OF OPPOSITE HAND
 Soft tissue reflection
 Protect other teeth
 Stabilize patients head
 Stabilize Jaw
• TMJ arthritis
• Support from assistant
 Accesses amount of force delivered
 PRINCIPLES OF USE OF
FORCEPS
 Forcep Apical pressure
• Disruption of periodontal attachment
• Bony expansion
• Centre of rotation of tooth is displaced apically
 less apex movement so decrease chance of fracture

 Movements_
• Buccal pressure in Max teeth , Mand Incisors
& premolars
• Lingual pressure in Mand molars
• Expansion of buccal / lingual /palatal crestal bone
 Rotational pressure
• Internal Exp of socket
 Tractional force
• To deliver tooth
 PRINCIPLES OF FORCEP
EXTRACTION
 Force directed to thinnest (weak) bone
 Max teeth , Mand (except molars )
• Principle movement Buccal
 Slow steady force rather jerky
 Gradually Shift forcep apically
• Expansion of socket
• Centre of rotation apically shifted
 Final rotational movement for socket
expansion
 Tractional force directed buccaly for tooth
delivery
 PROCEDURE OF FORCEP
EXTRACTION
 Cervical soft tissue loosening
• Confirms anesthesia
• Allows more apical placement of forcep
 Luxation by elevator
• Inserted into periodontal space
• Fulcrum over bone
• Avoid damage to adjacent tooth
restoration
 PROCEDURE OF FORCEP
EXTRATION
 Selection of forcep
 Application of forcep
• Blades Along long axis of tooth
• Grasp the root not the crown
• Max contact of blades to root surface
• Most apical placement of forceps tips
 Gripping the forcep
• Heels of hands over handle ends (max force)
• Thumb close to hinge
• Little finger inside the handles
 APPLICATION OF FORCE
MAX TEETH
 Thin Buccal & thick palatal bone
 Apical pressure combined with mostly
lateral with rotational movement
 Predominant Buccal movement except #I
 Central incisor- Rotation
 Lateral incisor- Buccal
 Canine - Remove adjacent teeth first
 Premolars- Pulled out, not pushed
 Last Molar- Mouth half way open & chin
moved towards side of extraction
 APPLICATION OF FORCE
MAND TEETH
 Higher ratio of cortical to cancellous bone
than Maxilla
 More dense bone, so expansion of socket
difficult esp molars(ext oblique ridge)
 Incisor & canine – Bucco lingnal with
rotation
 Premolars - Rotational
 Ist Molar - Bucco lingual with fig of 8
 2nd Molar - Linguol Buccal with figure of 8
 3rd Molar - Lingual with figure of 8
SURGICAL EXTRACTION
OR
TRANS ALVEOLAR
EXTRACTION
 INDICATIONS
 Grossly carious teeth
 Tooth resistant to forceps extraction
 Forceps extraction leading to fracture
 Fractured teeth (cervical line)
 Retained, Buried ,impacted root/ teeth
 Hypercementosed or Ankylosed teeth
 Roots
• Multiple , Dilacerated, hooked
• Unfavorable roots with conflicting path of with
drawl
 Tooth close to antrum ,IAC
 Attrition
 Alvoplasty along with extraction
 SURGICAL PROCEDURE
 Mucoperiosteal flap (To gain access)
• Envelop flap - (2 teeth ant & 1 tooth post)
• Two sided flap – Ant relieving incision
• Three sided flap
• Follow principles of design
 Incision
• NO 15 blade - pen grasp
• Long axis of tooth __ envelop flap
• Full thickness
 Flap Reflection
• From free mucosa , not from attached gingiva
• Subperiosteal
 SURGICAL PROCEDURE
 Bone Removal
• Straight Hand piece, (surgical emphysema)
• 1000---3000 rpm with irrigation
• Round / fissure surgical Burs
• Bone removed approx ½ to 2/3rd the root
length
• Guttering Technique & forceps Application
• Point of Application for elevators (fulcrum)
 Make a purchase point in single rooted teeth
 Tooth Division (Multi rooted teeth)
• Crown sectioning & dividing the roots
 In Mand -- Bucco- lingual
 In Max -- trifurcation cut
• Split crown/roots by St elevator
 Multi rooted teeth behave as premolars
 SURGICAL PROCEDURE
 Elevation of Roots
• Forceps ext
• Purchase point -wheel & axle principle
• Principles of fulcrum
 Debridement of socket
• Trim margins
• Remove loose pieces of bone / sharp edges
• Irrigation with saline
 Suturing
• 19 to 22mm (3/8th of a circle )
 Post op Medicines' / Instructions
 EXTRACTION SEQUENCE
 Max teeth extracted first
• Infiltration anesth more repaid onset & early
recovery
• No chance of dislodgment of amalgam etc into
extracted mand socket.
• Hemorrhage from max socket has to be
controlled
 Most post teeth extracted first
 Ist molar & canine extracted last
 Sequence
• Post Teeth (except Ist molar)
• Ant Teeth (except canine)
• Ist Molar
• Canine
 JUSTIFICATION FOR LEAVING
ROOT FRAGMENTS
 Surgery benefit vs. risk
 Leave root
• < 4 – 5mm
• Deep enough – bone resorption do not expose
• No pre existing periapical infection
• Excessive bone removal required
• Close to antrum / canal.
 Inform, document & radiographic position in
patients record.
 REMOVAL OF ROOT TIPS
 Closed technique(No soft tissue reflection)
• Irrigation & Suction technique
• By root tip pick or crane pick elevator
• By straight elevator - Wedge technique
• By reamers
 Open technique
• More apical extension of routine Surgical
technique
• Open window technique
 POST EXTRACTION CARE
 Socket - squeeze
• Gentle irrigation
• Debridement if granuloma
• Removal of bony sharp edges
 Hemostasis
• Pressure pack (wet)
• Time __10minutes
 Rest
 Food – Drink
• Cold
• Soft, non fibrous
 Analgesic __ paracetamol
 Mouth Bathing
• saline mouth rinses -- reduces swelling
 COMPLICATIONS
 Local complications
 Systemic complications
 LOCAL COMPLICATIONS
(IMMEDIATE)
 Failure to achieve L.A (use other inj tech)
 Fracture of tooth/alveolus /Max tuberosity /mand
 Oro -Antral communication
 Displacement of tooth/ root in
• Buccal soft tissues, lungs ,stomach ,Spaces,
Max sinus , suction
 Sub Luxation / Dislocation of
• Adjacent tooth (If small)
• TMJ
 Damage to
• Soft tissues , lip (Thermal , self biting)
• Nerves
 LOCAL COMPLICATIONS
DELAYED
 Pain , swelling
 Trismus
• Inj/ hematoma of Med pterygoid muscle
 Hemorrhage
• Primary,
• Reactionary (few hrs)
• Secondary (14 days)
 Dry socket (localized Osteitis)
 Acute Osteomylitis
 Oro antral fistula
 Nerve damage
 SYSTEMIC COMPLICATIONS
 Immediate
• Faint (vasovagal attack)
• Hypoglycemia
• Hyper ventilation
• Convulsions /fits
• Myocardial infarction
• Adisonian crises
• Respiratory obstruction
 Late
• Infective endocarditis
• Transmissible viral infections eg hepatitis
POST OP HAEMORHAGE
 POST OP HAEMORHAGE
 Diagnosis
• Light , Suction
• Soft tissues / Bony
 Measures
• Removal of hematoma
• Pressure pack
• Local haemostatic agents
• Stitch
• Medicine
 Investigations
FRACTURE OF MAX
TUBEROSITY
 FRACTURE OF MAX
TUBEROSITY
 Predisposing Factors
• Large Antrum
• Divergent Roots
• Fusion of unerrupted 3rd molar to root of 2nd
molar
 Treatment
• Small fragment removed by raising buccal flap
• Large fragment
 Leave the extraction

 Wait for 8 to 12 week for fracture to heal.

 Remove tooth by surgical resection

NERVE DAMAGE
 NERVE DAMAGE
 Mental
• Over extended vestibular relieving incision
between premolars
• Lip, Chin Paresthesia
 Lingual
• Supra periosteal location , lingual to 3rd molar
• Lingual tissue reflection, Burs, Vibrations
• Lingual Protection
 Inferior Alveolar nerve
• Roots close contact , grooved, perforated
• Radiographic signs of close proximity of canal
& roots
 Radio lucent band over tooth roots -grooved
or perforated
 Deviation of Canal

 Narrowing of Canal

 Loss of Tram lines (Cortical outline of canal)

DRY SOCKET
 DRY SOCKET
 It is localized osteitis involving whole or part of
condensed bone lying a tooth socket (lamina
dura) without association of infection
 Incidence
• 3% of all extractions
• 14 – 37% of lower 3rd molar
 Causes
• Exact not known
• Results from lysis of blood clot before its
replacement with granulation tissue.
• Fibrinolysis
 Tissue activators released from damaged
bone, converts plasminogen to plasmin
causing break down of clot.
 PREDISPOSING FACTORS
 Infection of Socket
• Activates plasminogen to plasmin
 Excessive Socket Trauma
• Devitalization of socket & thrombosis of
vascular plexuses
• Increased release of plasminogen activator
 Dense Bone
• Decreased blood supply. Mand > Max.
 Vasoconstrictor in L.A
 Cigarettes
 Pregnancy & oral Contraceptive drugs
 SIGNS & SYMPTOMS
 Pain.
• 3-4rth post op day
• Dual, throbbing
• Moderate to Sever
 Foetor oris
 Bad Taste
 Empty socket with exposed bone
 Swollen gingival margins
 No Lymphadenopathy
PROPHYLACTIC MEASURES TO
AVOID DRY SOCKET
 Metronidazol for 3 days
 Pre surgical chlorhexidine rinses
 Copious saline irrigation
 Placing antibiotic in socket
 TREATMENT
 Aim .
• Relief of pain &Promotion of healing
 Irrigation – Saline
 Gentle debridment of degenerated clot
 Removal of sharp bony spicules
 White Head varnish pack (on gauze)
• Idoform, Benzoin
 Obtundant Dressing
• Zinc oxide ,topical anesthetic eg Benzocaine
 Analgesics
 No antibiotic
 Hot saline mouth rinses
 PRINCIPLES
OF
MANAGEMENT OF
IMPACTED
TEETH
 DEFINATION
 A tooth which is completely or
partially unerupted and is positioned
against another tooth,bone or soft
tissue so that its further eruption is
unlikely
 Malposed tooth
• A tooth unerupted or erupted which is in
an abnormal position in the area.
 FREQUENCY (IN ORDER)
 Max 3rd molar
 Mand 3rd molar
 Max canine
 Mand premolar
 Mand canine
 Max premolar
 Max central incisor
 Max lateral incisor
 ETIOLOGY
 Local causes
• Inadequate dental arch length.
• Long retention of primary teeth
• Premature loss of primary teeth
• Irregularity in position pressure of adjacent
tooth
• Failure of rotation from & mesio angular to
vertical direction
• The density of overlying or surrounding bone
• Prolonged Ch inflammation of overlying
mucous membrane
 Systemic causes
• Heredity
• Rickets, TB, endocrine dysfunctions
• Anemia, malnutrition
• Cleidocranial dysostosis,cleft palate
INDICATIONS FOR REMOVAL
 Prevention of dental caries
 Prevention of pericoronitis
 Prevention of periodontal disease
 Prevention of root resorption
 Impacted teeth under a dental prosthesis
 Prevention of pain of unexplained origin
 Prevention of jaw fracture
 Facilitation of periodontal healing
 Prevention of odontogenic cyst's & tumors
 CONTRA INDICATIONS FOR
REMOVAL
 Local
• Radiation history
• Sever Pericoronitis
• Acute Dento Alveolar Abscess
 Probable excessive damage to
adjacent structures
• Adj tooth ,Nerves ,Bridge
 Compromised Medical status
• Metabolic Diseases ,Malignancies,
Cardiac problems , Ist+ 3rd
trimester, Bleeding Disorders ,
Drugs.
 CLASSIFICATION
(RADIOGRAPHIC ASSESSMENT)
 According to the angulation
 According to relationship to Anterior
Border of Ramus
 According to relationship to occlusal
Plan
 CLASSIFICATION
 According to the Angulation
• Based on long axis of impacted tooth
with respect to long axis of 2nd molar
• By drawing imaginary lines along long
axis of 3rd & 2nd molars
• Mesioangular, Horizontal, vertical,
Distoangular
• Difficulty index -- DA > MA
• Buccal , Lingual, Transverse Version
 CLASSIFICATION
 According to relationship to Anterior
Border of Ramus
• Pell & Gregory classification
• Based on amount of impacted tooth
within ramus
• Class I,II,III
• Difficulty Index
 class III > class I
 CLASSIFICATION
 According to relationship to Occlusal Plane
• Pell & Gregory classification
• Based on depth of impacted tooth
compared with 2nd molar
• Class A, B, C
• Difficulty Index
 class C > A
 WINTERS LINES
( Based on radiograph)
 Bone coverage
 Depth
 Angulation
 Difficulty Index
 IMPACTED MAX 3RD MOLAR
CLASSIFICATION
 According to angulation
• MA, V, H, DA, inverted.
 According to depth of 3rd molar
• Class A, B, C
 According to relationship with max sinus
• Sinus approximation
• Thin or no bone between root apex &
sinus
• No sinus approximation
 2mm or > 2mm bone between tooth

& sinus
RADIOGRAPHIC ASSESMENT
 Periapical
 OPG
 Occlusal view
• vertex
 RADIOGRAPHIC ASSESSMENT
 Root Morphology
• Root Formation , Length, No, Curved, Fused,
hooked, direction of curvature, period lig
space.
 Size of Follicular Space
• Degree of bone removal
 Density of Surrounding Bone
• Dense / Elastic (age)
 Contact with 2nd Molar
• DistoAngular > Horizontal > MA
 Nature of over lying soft tissues
 Soft tissue impaction

 Partial bony impaction

 Complete bony impaction

RADIOGRAPHIC ASSESMENT
 Inferior alveolar nerve
• Buccal or lingual position
• Grooving
• Perforation
Radiographic signs of close proximity of canal &
roots
 Loss of Tram lines (Cortical outline of canal)

 Radiolucent band over tooth roots –grooved

 Deviation of Canal

 Narrowing of Canal - perforation

 SURGICAL PROCEDURE
(INCISION)
 Envelope Flap
• Better healing but less surgical exposure
• Medial papilla of 1st Molar
→ Distobuccal line angle of 2nd Molar
→ Postero laterallty over ascending
ramus (external oblique ridge)
 Wards / Extended wards Incision (Three
cornered flap with relieving incision )
 Max 3rd Molar
 Envelope incision – 1
st molar →
Tuberosity
 Releasing incision from medial aspect
of 2nd molar
 SURGICAL PROCEDURE
 Reflection of Mucoperiosteal flap
• Reflect from lingual aspect / lingual
nerve protection by periosteal elevator
• Retractor on buccal shelf.

 Removal Of Overlying Bone

• Micromotor, round bur, irrigation
• Bone removal from occlusal, buccal,
distal aspect
• Ditching to expose the greatest crown
diameter
 SURGICAL PROCEDURE
 Sectioning Of Tooth
• At Cervical line up to ¾ of the way towards
lingual surface
• Splitting of tooth by St elevator- lingual nerve
preserved
• Crown removed - cryer elevator
• Roots further sectioned if divergent &
removed separately .
• Max impacted rarely require sectioning except
mesio angular
 Delivery of sectioned tooth
• Making a purchase hole
• Cryer elevator with fulcrum over buccal
cortical plate
• Removal in line of direction of eruption
 SURGICAL PROCEDURE
 Wound closure
• Smooth sharp margins
• Tooth follicle curettage
• Irrigation with saline
• Hemostasis of flap / socket
• Gentle pressure over soft tissue
 Suturing
• Initial stitch distal to 2nd molar
 Post oP medication
• Bupivacaine, Antibiotics, steroid, Analgesics
 COMPLICATIONS DURING
REMOVAL
 Tearing of mucoperiosteal flap
 Fracture Of
• Buccal cortical Plate / alveolus / Max
tuberosity /mand
 Damage TO
• tooth / Root
 Displacement of tooth/ root in
• Buccal tissues, lungs ,stomach
• Spaces, Max sinus , suction
 Sub Luxation / Dislocation of
• Adjacent tooth (If small)
• TMJ
 Damage to
• Soft tissues , lip (Thermal , self biting)
• Nerves / Artery
 Lingual , IAN
 NERVE DAMAGE
 Lingual
• Supra periosteal location , lingual to 3rd molar
• Tooth cutting , Burs, Vibrations, Retraction
• Lingual Protection
 Incision on external oblique ridge

 Lingual tissue reflection & placement of

periosteal reflector lingual to 2nd molar.
 Bucco Lingually 2/3 Tooth cutting

 Inferior Alveolar nerve

• Roots close contact , grooved, perforated
 Surgical resection of roots
 CLASSIFICATION
MAX CANINE
 Class 1
• Impacted cuspid located in the palate.
 Class 2
• Impacted cuspid located buccally.
 Class 3
• Impacted Cuspid located both in palatal
process and buccally .
 Class 4
• Impacted cuspid located in the alveolar
process.
 Class 5
• Impacted cuspid located in an edentulous
maxilla.
 RADIOGRAPHIC EVALUATION
(IMPACTED MAX CANINE)
 Clinical
• Bulge, labially inclined lateral incisor
 Radiograph
• Cone shift technique( Shift Sketch Tech)
 Rule Of SLOB
• Periapical view
• Occlusal view
 vertex
 MAXILLARY IMPACTION
TREATMENT OPTIONS
 Surgical Exposure.
 Surgical exposure followed by slow
orthodontic Traction.
 Transplantation.
 Surgical extraction.
PERICORONITIS
 DEFINATION
 It is infection of soft tissues around
the crown of a partially erupted
tooth.
 Overlying flap is called pericoronal
flap
 PREDISPOSING FACTORS
 Transient decrease in host defence
• Fatigue , stress , URTI.
 Trauma
• Impingement of max 3rd molar.
 Entrapment of food under operculum
 MICROBOILOGY
• Strepto coccus ,pepto Strepto coccus
• Fusobacterium , Bacteroides
• Anaerobes
 COURSE
• Acute
• Subacute
• Chronic
 CLINICAL FEATURES
 General
• FEVER , Malaise
 Pericoranal Tissues
• Swollen , Tender , Ulcerated , Pus
discharge
 Trismus , Painful deglutation
 Foetor oris
 Lymphadenopathy
 Alveolar abscess / discharging sinus
 TREATMENT
• Antibiotics , Analgesics.
• Ext/Grinding of opposite impinging cusp.
• Saline mouthwashes.
• Mechanical cleaning of operculum.
 H2O2 , Chlorhexidine.

 Mechanical removal of debris.

 Liberation of o2  reduced no of anaerobic

bacteria.
• Removal of impaction
• .Operculectomy if suff space & liable to erupt.
• I&D
• Complications.
 Increase incidence of dry socket if SR during
acute Pericoronitis.