Principles of Uncomplicated

and Complicated Exodontia

Paul H. Kwon, D.D.S.

Oral & Maxillofacial Surgery
University of Minnesota

Pre-Extraction

READY FOR SURGERY

Preparations

> Over garment

> Mask
> Cap: hair covered
> Eye protection

Medical history and physical

examination
Radiographic evaluation
Surgical plan
Pain and anxiety control
Patient and surgeons preparations

Chair and Surgeons

Position
Comfortable for both the patient and
surgeon
Stand during extraction
Mx: Maxillary occlusal plane 60 to
the floor
Mn: Mandibular occlusal plane
parallel to the floor

Note patient
and surgeon
positions

Extraction Technique
A pharyngeal
partition is
used for the
duration of
all
procedures

A mouth prop is
used to
stabilize the
mandible for
mandibular
procedures

Daily Scrub Routine for Aseptic

Procedures

Closed technique (simple,

forcep)
Open technique (surgical, flaps)

> Only one 2 minute scrub with pre-op sponge needed

prior to clinic start

> Hand wash each time thereafter

Procedure for Closed

Extraction
Loosening of soft tissue
Woodson elevator
#9 periosteal elevator

Luxation of the tooth with small

straight elevator (301)

Handle of small straight

elevator, turned so that
occlusal side of elevator
blade is turned toward
tooth.

Handle of elevator, which may be

turned in opposite direction to displace
tooth further from socket. This can be
accomplished only if there is no tooth
adjacent posteriorly.

Excerpted from Contemporary Oral & Maxillofacial Surgery, Third Edition, 1998

Principle of Forcep Use

Periapical pressure (bony expansion)
Buccal movement (except mandibular
molars)
Lingual movement (mandibular molars)
Rotational pressure (conic roots)
Tractional force (delivering)

Procedure for Closed

Extraction continued

Procedure for Closed

Extraction continued

Procedure for Closed

Extraction continued

Adaptation of the forceps

Lingual first then buccal (beneath the soft
tissue)
Grasp end of forcep
Parallel to the long axis of the tooth
Grasp the root of the tooth as apically as
possible
Standing straight feet comfortably apart

Luxation of the tooth with the

forceps
Force to the thinnest therefore
weakest bone
Slow, steady force
No jerky wiggle motion

Removal of the tooth from the

socket
Slight traction force
Develop a sense for the direction
the tooth wants to move

Beaks of forceps act as

wedge to expand
alveolar bone and
displace tooth in
occlusal direction

1 Forcep

The forcep is seated

as far apically as
possble.

Luxation is
begun
with labial force.

Slight lingual force is used. The tooth is removed

to the labial-incisional.

Excerpted from Contemporary Oral & Maxillofacial Surgery, Third Edition, 1998

REMEMBER:

Handles of forceps are

squeezed forcibly
together, which
causes
beaks of forceps to be
forced into bifurcation
and exerts tractional
forces on tooth.

Strong buccal Strong lingual

forces are
forces are
used to
used to
expand
luxate tooth
socket.
further.

Extraction of tooth does not require a

large amount of brute force but rather
can be accomplished with finesse and
controlled force in such a manner that
the tooth is not pulled from the bone but
instead is lifted gently from the alveolar
process.

Tooth is delivered in
bucco-occlusal
direction with buccal
and tractional forces.

Larry J. Petersons book

Post-Extraction Care of
Tooth Socket
Curetted or not curetted
Compressed back
Periodontal disease case
Bony projections

Principles of Complicated
Exodontia continued
Envelope flap: 2 teeth anterior and 1
tooth posterior / Relaxing incision: 1
tooth anterior and posterior
Full thickness mucoperiosteal flap
(surface mucosa, submucosa,
periosteum)
Avoid injury to local vital structure
(lingual nerve, mental nerve)

Principles of Complicated
Exodontia

Surgical Extractions

Principles of Flap Design

Base must be broader than free
margin (blood supply)
Adequate size (surgical access)
Can be maintained with suture (6
8mm away from the bony defect)

Types of Mucoperiosteal Flap

Envelope flap
Envelope flap with vertical
releasing incision (1 or 2)
Semilunar incision
Y flap
Pedicle flap

Why anterior release?

Types (Flap)
Envelope flap
Advantage
Disadvantage

Flap with V.C.

Advantage
Disadvantage

Indications for Surgical

Extraction
Failed forcep extraction
Heavy and dense bone, older patient
vs. young patient
Severe attrition (bruxism)
Hypercementosis
Large bulbous root
Widely divergent roots (maxillary 1st molar)
Hook, dilaceration

Indications for Surgical

Extraction continued
Maxillary sinus has expanded to
include the roots of the
maxillary molars
Crown with extensive caries or
retained roots

Root Breakage
Application (beaks)
To cementum
Parallel

Wrong forceps
Extensive caries

Root Breakage
continued
Non-vital tooth
Root form
Curved
Hypercementosis
Supernumerary roots

Excessive density

Removal of Small Root

Fragments and Root Tips
Fx of apical 1/3 (3 4mm)
Closed technique vs. open
technique
Open window technique

Technique for Open Extraction

of Single-Rooted Tooth
Adequate visualization
Reflect flap
Forceps
Grasp a bit of buccal bone
Straight elevator
Remove buccal bone (Width: tooth
width / Length: root or 2/3)
Purchase point: craine pick

Small, straight elevator,

used as wedge to displace
tooth root from its socket.

Technique for Surgical

Removal of Multirooted Teeth
Convert multirooted tooth into singlerooted tooth
Mandibular 1st molar (crown present
vs. no crown)
Maxillary 1st molar (crown intact vs. no
crown)

Careful! Lots of
force generated

Purchase Point

Principles of Suturing

CRANE PICK

Flap to its original position

Hemostasis
Hold a soft tissue flap over bone
No suture across the empty tooth
socket
Mobile tissue first
Passing the tissue: right angle
Amount of tissue: 3mm
Not to be tightened too much
Not fall over incision line

Policy for Leaving Root

Fragments
Excessively traumatic (risk /
benefit)
Smaller than 4 5mm
Deeply embedded
No infection, no radiolucency on
apex

MULTIPLE
EXTRACTION

Multiple
Extractions
Preextracttion planing
1)Immediate denture or not
Full or removal partial denture
Single or multiple implants
2)Tuberosity reduction
Removal of undercuts
Graft the extraction sockets

Extraction
Sequencing

Maxillary teeth first

Ad:
- Anesthesia (Rapid onset,
disappear)
- Debris (Amalgams, bone chips)
- More room for mand. ext.
Disad:
- Hemorrhage to the mandible

Miscellaneous
Posterior First
1st Molar, Canine
Firm pressure
Alveoloplasty
Sutured (papillae)

Thank You

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