‫بسم هللا الرحمن الرحيم‬

Assighment Of Dental Surgery

/Principle of routine exodontia

: Supervised

Dr . Emad Majdalawy

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 ‫بسم هللا الرحمن الرحيم‬

‫عبد الرحمن خالد فهمي الزميلي‬/ ‫اسم الطالب‬ ‫جامعة األزهر غزة‬
20170475 /‫الرقم الجامعي‬ ‫كلية طب االسنان‬

; Assighment Of Dental Surgery

Principle of routine exodontia

Dental Extraction is defined as :

“The removal of a tooth from oral cavity by means of elevators
and forceps”.

Also referred as “Exodontia”.

• Tooth extraction :the ideal tooth extraction is the painless

removal of the whole tooth or roots from its socket with
minimal trauma to the investing tissues , so that the wound
heals normally with no post operative prosthetic problem .

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There are two techniques involved in the extraction:
1. Simple extraction (also called closed method, forceps technique,
intra-alveolar technique): which involve using forceps and/or
elevator to luxate the tooth and extract it.

Complicated extraction (also called open method, surgical technique,

trans-alveolar technique): which involve surgical intervention to open the
bone and remove the tooth

Indications Of Extraction:
advocated for dental extraction:

1-Unrestorable carious tooth.

2 -Pulp necrosis and irreversible pulpitis;untreatable by

endodontic therapy,due to calcified root canal,or patient refusal.

3 -Severe periodontal Indications disease; Bone loss,grade 3

mobility,furaction involvement.

4- -Im5 -Orthodontic treatment ; Crowding,Space

creation.Maxillary and Mandibular 1st Pre-molar.

6 -Mal-alligned teeth ; Tissue trauma,mal-positioning,esthetics.

pacted teeth ,resorption of roots of adjacent teeth.

7 -Esthetics ; Stained teeth, excessively protruded teeth,mal-

alligned.

8 -Cracked and fractured tooth ;Tooth in fracture

line,pain,Dialceration,, infection.

9 -Pre-prosthetic extraction ; Unsuitable abutments,interference

with appliance

10 -Supre-numerary teeth ; Impacted,resorption,

displacement,failure for eruption

11-Pre-radiation therapy ; to prevent Osteoradionecrosis.

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12 -Economical reason ; Unaffording patient.

13 -Lack of time ; Unavailability of time for other

options.

14- peri apical lesion or other pathology.

Contraindications Of Extraction:

Contraindications for Dental Extraction

Systemic Local

1-Local contraindications
1- Irradiated jaw which may lead to osteoradionerosis due to
endarteritis obliterans

2-Tooth located within the area of tumor.

Cause: metastasis.

3-Acute pericoronitis around a partially erupted lower third molar

Cause: trismus preoperatively & dry socket post operatively.

4-Acute cellulites

5- Acute alveolar abcess

6- Acute infectious stomatitis

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2-Systemic contraindications
1. Uncontrolled diabetes mellitus

Reason: infection & delayed healing

2. End stage renal disease &uremia

3. Uncontrolled bleeding problems like hemophilia and

thrombocytopenia.

4. Uncontrolled hyper tensive patient.

5. Uncontrolled cardiac disease .No surgery is performed within

1st 6 months due to high incidence of cardiac instability &
arrhythmias

6. Addison’s disease

7. Fever of unexplained origin

Suspected bacterial endocarditis

8.Pregnancy: 1st and 3rd trimesters . Relative contra

indication

9- uncontrolled thyroid disease.

10. Uncontrolled liver disease (bleeding)

11. Patient taking specific drugs : corticosteroids

,immunosuppressive ,

chemotherapeutic agents).

12. Senility: poor physiological response to injury.

13. Psychosis & neurosis , epileptic patients.

14. Uncontrolled pulmonary disease e.g. Asthma .

15 – uncontrolled epileptic patient

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PRE OPERATIVE ASSESSMENT
A. History Taking

1. Medical History :

(i) H/O Hypertension

(ii) H/O Jaundice

(iii) H/O Kidney diseases

(iv) H/O Rheumatoid arthritis

(v) H/O Cardiac diseases

(vi) H/O Asthma

(vii) H/O Bleeding disorder

2. Dental History

(i) H/O Extraction

(ii) H/O Uncontrolled bleeding

B: . Clinical Examination
(i)Accessibility (mouth opening)

(ii) Tooth mobility

(iii) Crown Condition of the tooth (G. Caries, large restoration,

facture, cervical caries)

(iv) Oral hygiene status

(v) Presence of infection at the site of injection

C. Radio logical Examination :

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 Relation To Vital Structure (Maxillary Sinus, Inferior Dental
Nerve)

 Root Configuration (Divergent, Convergent, Dilacerations,

Ankyloses, Hypercementosis, Periapical radiolucency

 Condition of the bone of the jaw

 Panoramic radiograph are used frequently but their
greatest usefullness is for impacted teeth.

 The relationship of teeth to be extracted to adjacent

erupted and unerupted teeth should be noticed

 When performing extractions of maxillary molars,its roots

 relation with the floor of the maxillary sinus should be
noted.

 A peri apical radiograph taken before the removal of

mandibular premolar teeth should include mental
foramen.

SURGEON PREPARATION
1. Wear of Hand gloves

2. Mask 3.

Eye Wear with sidesheild

4. Surgical Gown

5. Sterilization of above mentioned materials

PATIENTS PREPARATION
1. Prophylactic Antibiotics

2. Prophylactic Mouth cleansing

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 (i) Scaling

(ii) Polishing

(iii) Brushing

(iV) Rinsing with antiseptic mouth wash

(v) Placement of a towel on the patients chest

(vi) Eye wea

POSTIONING OF THE PATIENTS

 For a maxillary extraction the chair should be tipped
backward and maxillary occlusal plane is at 60 degrees to
the floor. The height of the dental chair should be 8cm below
the shoulder level of the operator.
 For a maxillary extraction of mandibular teeth, the patient
should be positioned the occlusal plane is parallel to the
floor. The chair should be 16cm below the level of operators
elbow.

Surgeon Positon

 For all maxillary teeth , anterior mandibular teeth & teeth of the 3rd
quadrant : Right front position.
 For teeth of the 4th quadrant : Right back position

illumination
Good illumination of the operator field is an absolute essential for
successful extraction of teeth.

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 Requirements of Ideal Extraction
1. Satisfactory access and visualization of the field of surgery.

2. An un-obstructed pathway for the removal of the tooth.

3. The use of controlled force to luxate and remove the tooth

Mechanical Principles for Tooth Extractions

1. Expansion of the bony socket.

2. The use of fulcrum or lever.

3. Insertion of wedge or wedges.

4. Wheel and axel.

Expansion of the bony socket

• Expansion of the bony socket by use of the
wedge-shaped beaks of the forceps .
• The forceps should be seated with strong
apical pressure to expand crestal bones and to
displace center of rotation as apically as
possible .

• If center of rotation is not far enough apicaliy, it

is too far occlusally, which results in excess
movement of tooth apex.

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• Excess motion of root apex caused by high
center of rotation results in fracture of root
apex.
• Buccal or labial pressure applied to tooth will
expand the buccal cortical plate toward the
crestal bone with some lingual expansion at
apical end of the root.
• Lingual or palatal pressure will expand lingual
cortical plate at crestal area and slightly expand
buccal bone at apical area.
• The initial linguo-buccal movement for
extraction of lower second mandibular molar.
• Initial rotational forces It is useful for removal of
teeth with conical roots; such as maxillary
central.
• Tractional forces are useful for final removal of
tooth from socket. They should always be small
forces, because teeth are not "pulled."
• The Final withdrawal movement for Most of the
upper and lower teeth is an outward- occlusal
direction. Except the lower third molar which
should be in a lingual- occlusal way and
maxillary 3rd molar should be disto-buccal.

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 The proper use of forceps
in luxation and removal of teeth
1. The extraction movements are essentially three movements
which are outward, inward, and rotatory movements.

2. The movement should be steady and with a reasonable

force.

3. Outward (buccal or labial) movement is the initial movement of

all teeth except the lower second and third molar where the
buccal plate of bone reinforced by the external oblique ridge .
4. Inward (lingual or palatal) movement is the initial movement during the
extraction of the lower second
and third molars.

5. Primary Rotatory movement is the initial movement used in upper central

incisor and lower second premolar.

6. If a resistance is felt in primary rotation, a bucco-lingual movement should

be started.

7. If rotatory movement continued, a spiral fractured of the tooth root may

occur.

7. The force should be held for several seconds to allow the bone time to
expand.

8. Once the alveolar bone has expanded sufficiently and the tooth has been
luxated, a slight traction force, usually directed buccally, can be used.

9. Final movement is the movement by which the tooth is removed from its
bony socket. It should be always directed outward and occlusally to avoid
traumatizing the opposing tooth,

10. The extraction forceps blade should be applied to the carious side first,
and the first movement made toward the caries.

The use of fulcrum or lever

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 • A lever is a mechanism for transmitting a modest force with the
mechanical advantages of a long lever arm and a short resistance arm
into a small movement against great resistance.

• When an elevator is used for tooth extraction, an acquired contact point

can be made on the root surface and a liter can be applied by the handle
of the elevator to elevate the tooth or a tooth root from the socket.

Insertion of wedge
• The wedge principle is useful for the extraction of
teeth in several different ways.
1. By using the beaks of the extraction forceps as a
wedge.
2. When a straight elevator is used to luxate a tooth
from its socket.

Wheel and axel

• When one root of a multiple-rooted tooth is let in

the alveolar process, the pennant-shaped
elevator is positioned in the socket and turned
• The handle then serves as the axle and the tip of
the triangular elevator acts as a wheel and
engages and elevates the tooth root from the
socket

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 Procedure for closed extraction:
 Requirements for extraction
• Adequate access and visibility
• Unimpeded pathway of removal
• Use of controlled force.

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
 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

 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.
 Sterile drape should be put across Pt's chest
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 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
 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

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.

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

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 Maxillary Incisor Teeth:

 Extracted with no:150 forceps.

 Left hand grasp on alveolar process.

 Forceps seated as far as apicaly possible.

 Luxation begins with labial force.

 Slight lingual force is used

 . Left index finger reflects the soft tissue & thumb rests on
alveolar process.

Maxillary Canine
• Longests tooth in the mouth.
• Bone over labial part is quite thin.

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 • Universal no:150 forceps is used.
• Initial movement is buccaly.
• Small amount of lingual force is applied.

Maxillary 1st Premolar:

 Common root fracture occurs with this case.

 No:150 forceps are used.

 Should be luxated as much as possible with straight

elevator.

 Has 2 thin roots.

 Firm apical pressure is applied to lower centre of

rotation as far as possible and to expand crestal
bone.

 Buccal pressure is applied initially to expand

buccocortical plate.Apices of the roots are pushed
lingually and are therefore subjected to fracture

 Tooth is delivered in buccolingual direction with

combination of buccal and tractional forces

Maxillary Molars:
• It has 3 large and relatively strong roots.
• Paired forceps no.53R and 53L are used.
• Luxation begins with a strong buccal force.

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• Lingual pressure are used moderately.
• Teeth is delivered in buccolingual direction.

Maxillary Second Molar:

Anatomy of the teeth is similiar to maxillary
1st molar & extraction procedure is similar

Maxillary 3rd molar:

Has conical roots and is usually extracted with no:210 s
forceps which is universal
forceps used for both right and left molars.

Mandibular Incisors and Canine:

• Both the teeth are similiar in shape with incisor being
shorter and slightly thinner and canine root being longer.
• Alveolar bone is quite thin in labial and lingual side.
• Lower universal no:151 forceps are used.
• Moderate labial force followed by lingual force is used to
expand the bone.

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• Tooth is delivered in labial incisal direction.

Mandibular Premolars:
• They are easiest teeth to remove.
• The overlying bone is thin on the buccal aspect and
somewhat heavier on lingual side.
• Lower universal no 151 forceps is used.
• Buccal force followed by slight lingual pressure is used for
luxation.  Mandibular Molars:
• No 17 forceps is used.
• If tooth roots are closely bi furcated no:23 or cow horn
forceps can be used.
• No 17 forceps is seated as far apically as possible.Luxation
of molar begin with a strong buccal movement.Strong lingual
pressure is used to continue luxation.

AFTER CARE

1. Irrigation of the socket with normal saline or

the other anticeptic solution .
2. Curettage of the socket to remove bony
fragment and granulation tissues .
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 3. Break down of the bony sharp edge at the
socket world and inter radicular bone.
4. Squeezing of the socket
5. Mouth rinsing with antiseptic solution once .
6. Suturing (if required)
7. Moist gauze pack to prevent hemorrhage

POST OPERATIVE INSTRUCTION

1. Remove the cotton/ gauze pack at least 1
hour later.
2. Take cool and soft diet for at least 24 hours.
3. Avoid hot and hard diet for at least 24 hours.
4. Do not rinse forcefully and do not brush of
the site of extraction for at least 24 hours .
5. Maintain the oral hygenie
6. If stitch is given ,come one week later to cut
it.

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‫‪TANK YOU‬‬

‫الصفحة ‪ 20‬من ‪20‬‬