The horrifying experience associated with the tooth extraction in the past is still to overcome

by the layman. Even today the removal of a tooth is still dreaded by the patient almost more
than any other surgical procedure. Many patients have extraction phobia, despite modern
methods of anesthesia. Today dentists often consider tooth extraction a minor and
unimportant procedure and without proper training, attempt difficult cases and land up in a
mess. Before undertaking the extraction of a tooth, one should thoroughly evaluate the care
involved. Further, consideration should be given to type of anesthesia used and a good
radiograph should be secured to rule out any abnormalities that may make extraction difficult.
So in this way we can avoid the hasty use of forceps and the type of procedure can be
selected that is most likely to yield the best results. The ideal tooth extraction is the
procedure of painless removal of whole tooth, or root with minimum trauma to soft tissue and
hard tissue so that the wound heals uneventfully and with no postoperative problem.
INDICATION FOR EXTRACTION OF TEETH
The value of a tooth should not be underestimated as they are important not only from an
esthetic point of view but also help in proper digestion of food. There are many reasons why
both deciduous and permanent teeth have to be extracted. Sometimes, normal teeth
occasionally must be sacrificed to improve mastication and prevent malocclusion. In most of
the instances, teeth are extracted because they are affected by disease or can cause ill health
due to spread of the infection.
Following are the main indications:
• Teeth affected by advanced caries and its sequelae
• Teeth affected by periodontal disease
• Extraction of healthy teeth to correct malocclusion
• Over-retained teeth
• Trauma to the teeth or jaws may cause dislocation of a tooth from its socket (avulsion)
• Extraction of teeth for esthetic reasons
• Extraction of teeth for prosthodontic reasons
• Impacted and supernumerary teeth
• Extraction of decayed 1st or 2nd molars to prevent impaction of 3rd molars
• Teeth involved in fracture line
• Teeth involved in tumors or cysts
• Tooth as foci of infection
• Teeth affected by crown, abrasion, attrition or hypoplasia
• Teeth affected by pulpal lesions e.g. pulpitis, pink spot or pulp polyp
• Teeth in the area of direct therapeutic irradiation.
CONTRAINDICATIONS FOR EXTRACTION
It is necessary for the well being of the patient to delay extraction until certain local or
systemic conditions can be corrected or modified. Analgesics and antibiotics can be used to
keep the patient comfortable. It is sometimes best to treat the infection first and extract the
tooth when the acute symptoms subside. There are few absolute contraindications to the
removal of teeth when it is necessary for the well being of the patient.
• Presence of acute oral infections such as, necrotising ulcerative gingivitis or herpetic
gingival stomatitis.
• Pericornitis (difficult surgical procedure involving bone removal is anticipated).
• Extraction of teeth in previously irradiated areas (at least 1 year should be allowed for
maximal recovery of circulation to the bone).
• There are number of relative systemic contraindications to the tooth extraction, e.g.
– Uncontrolled diabetes
– Acute blood dyscrasias
– Untreated coagulopathies
– Adrenal insufficiency
– General debilitation for any reason
– Myocardial infarction (wait for 6 months period).

Before extraction of deciduous teeth, a thorough examination should be performed to

minimize complications.
• As tooth crown and root structure differ from those of adult teeth, the use of specially
designed pediatric instrument is recommended.
• The main consideration in the removal of deciduous teeth is to avoid injury to the
developing permanent dentition.
• The most critical step in extraction of deciduous teeth is the administration of local
anesthesia. If the child allows this step then he will be definitely co-operative for the next
step, the extraction. This is because most anxiety and fear is generated during this phase.
Studies by most authors explain the rise of pulse rate and blood pressure during this time. So
it is critical to alleviate the fear of the child rather than increase it. It is most recommended to
perform some behavior shaping of children prior to extraction and local anesthesia. Some
methods are:
 – The first step: This is to make the patient comfortable. It is imperative that we do not
proceed with the extraction immediately. It is best if we first engage in some friendly talk
with the child and explain him the merits of taking out his carious teeth in a language that he
can comprehend according to the developmental status of the child.
– Tell–show–feel–do: This modification involves describing the procedure from the
application of topical anesthetic to postoperative reward. The patient is then showed an empty
syringe without needle and made to feel it to dispel any fears of injections that he may have.
However, during the actual procedure it is best not to load anesthetic or bring the needle or
syringe in front of child so as to avoid anxiety. It is best to cover the child’s eye with one
hand and perform the task with other.
– Use of euphemisms: Like comparing the pinch of needle to mosquito bite or comparing LA
solution to water to flush out bacteria from teeth have proven to be useful.
-Audiovisual distraction: It is also a vital technique as it allows multisensory distraction.
– Use of bite blocks: These are recommended for difficult patients who have a tendency to
close their mouth while the procedure as they are helpful in opening the mouth so as to avoid
any injury during procedure. – Modeling: This is especially useful in case of a close friend or
a sibling who can be observed performing the desired behavior.
– Physical restraints: This is the last and least preferred option with the dentist and is used in
highly uncooperative or special children.
• The technique of extraction is the same as that used in the removal of permanent teeth. But
it is important to ensure before application of forceps that the blades are fine enough to pass
down the periodontal membranes and applied to the roots.
• A firm lingual movement usually causes the tooth to rise in its socket and it can be
delivered by moving buccally and rotated forwards.
• The roots of the extracted deciduous teeth should be examined to ensure that they are
complete. Fracture root surfaces are flat and shiny with sharp margins, resorbed roots are
with irregular margins.
• In case of fracture of a root fragment the best option is to radiographically visualize it
before attempting any kind of retrieval. In case it is located superficially away from
underlying tooth bud it can be safely removed by reinstrumentation. However, if it is close to
the underlying tooth bud it is advisable to let it remain there as it may undergo resorption or
may appear with the erupting tooth.
OPERATIVE COMPLICATIONS
The most frequent operative complication that encounter during the extraction of teeth are:
• Fracture of the tooth
• Injuries to adjacent teeth
• Fracture of the alveolar bone
• Fracture of the tuberosity
• Extraction of the wrong tooth
• Root displaced in the sinus
• Maxillary sinus perforation
• Root displaced in the submandibular space
• Gingival and mucosal lacerations
• Injury to the inferior alveolar nerve
• Hemorrhage and hematoma
• TMJ trauma
• Damage to permanent successor.
POSTOPERATIVE CARE
After care when the tooth has been extracted the socket should be inspected and any loose
fragment of bone is removed or necessary socket irrigation is performed. The alveolar
process then should be pressed together with the thumb and forefinger in order to reduce any
distortion of the supporting tissues; suturing should always be done after multiple extractions
and if the gingival flaps are loose enough to be approximated. After extraction, a gauze pack
is placed over the socket and patient is directed to bite on the pack for ½ hour, exerting firm
even pressure. This will prevent bleeding while the patient returns home and it allows a blood
clot to form. Some postoperative instructions are:
• The patient should be warned that sucking the wound, investigating the socket with tongue
and rinsing during the first day disturbs the blood clot and may cause dry socket.
• Patient should be directed to remain quiet for several hours, preferably sitting in a chair or if
lying down, keeping the head elevated.
• Only liquids and soft solids should be advice on the first day. They may be warm or cold
but not extremely hot.
• The teeth should be brushed as usual and on the day after surgery rinsing of the mouth
should begin. A warm saline solution is best for this purpose.
• Some degree of postoperative pain accompanies many exodontia procedures and begins
after the effects of the anesthetic have left. So, it is better to take some analgesic before the
effect of anesthetic wears off.
• Prevention of swelling after extensive or difficult operation adds to the comfort of the
patient. The degree of swelling that occurs postoperatively is generally in direct proportion to
the degree of surgical trauma. The application of cold to the operated site is beneficial in
reducing the amount of postoperative swelling. Pressure dressings are also beneficial in
limiting the postoperative swelling.
• Smoking should be avoided after tooth extraction as it increases the incidence of alveolar
osteitis and should be discontinued for five days.

PREPARATION FOR EXTRACTION Preoperative Assessment • A history of general

disease, nervousness, or previous difficulty with extractions, will govern both the choice of
anesthesia and procedure of tooth extraction. • The general cleanliness of the patient’s mouth
and oral hygiene are observed. • Pre-extraction scaling should be performed, especially in
neglected mouths, at least one week prior to surgery. • Sick or fatigued should rest before
operative procedures. • Highly apprehensive patient should receive some form of sedation
before the operation. • Patient undergoing general anesthesia should be instructed to omit the
previous meal and to take nothing by mouth for at least 6 hours before extraction. • Patient
with inflamed or infected gingival should use an antiseptic mouth rinse before the extraction.
• Removable prostheses must be taken out of the patient’s mouth. • The administration of
antibiotics is recommended as a prophylactic measure in all medical compromised patients.
Pre-extraction Radiograph The purpose of pre-extraction radiograph is to show the whole
root structure and the alveolar bone investing the tooth with IOPA, lateral oblique view,
OPG. The following are the main indication for preoperative radiographs: • History of
difficult or attempted extractions • A tooth which is resistant to forceps extraction If a tooth
is to be removed by dissection • Close relationship of tooth or root with – Maxillary sinus –
Inferior alveolar canal – Mental nerves • All mandibular and maxillary 3rd molars, in
standing premolars or misplaced canines • Pulp less teeth with resorbed roots • Teeth
affected by periodontal disease • Traumatic teeth • An isolated tooth • Any partially erupted
or unerupted tooth or retained root • Retained deciduous tooth • Submerged tooth •
Conditions which predisposes to dental or alveolar abnormality, e.g. – Cleidocrania
ldysostolia — for pseudo-anodontia – Osteitisdeformans — for hypercementosed root –
Patient with therapeutic irradiation – Osteopetrosia. Choice of Anesthesia • Teeth may be
extracted under either local anesthesia or general anesthesia and one should assess the
indication and contraindications of both before deciding which to use in a particular case.
Most extraction of tooth can be done with local anesthesia alone. • To decrease the
nervousness, relieve tension and control psychic behavior sedation can be used in conjunction
with the local anesthesia. In young children, general anesthesia rather than local anesthesia
may be indicated to facilitate patient management. • All patients with general anesthesia or
local anesthesia should be observed in a recovery area until they are able to go home unaided
or should be accompanied by adult and not permitted to drive. PRINCIPLE OF
EXTRACTION In routine practice, the following three time mechanical principles of
extraction should be followed for the well being of the patients by doing atraumatic
extraction. Expansion of the Socket The extraction of a tooth requires the separation of its
attachment to the alveolar bone via the crestal and principal fibers of the PDL which involves
a process of expansion of alveolar socket. This is achieved by using the tooth as the dilating
instrument with the help forceps, to permit the removal of the tooth. Use of a Lever and
Fulcrum This basic principle is used with elevators that force a tooth or root out of the
socket along the path of least resistance. The Insertion of a Wedge This is done between
the tooth root surface and the bony socket wall to help the tooth to rise in its socket.
EXODONTIA TECHNIQUES The following techniques may be used for tooth removal: •
The forceps technique — closed method • The elevator technique — open • Transalveolar
technique — open method • Odontotomy. Forceps Technique It is the most commonly
used method for the extraction of teeth. But, it should not be used in difficult cases, e.g. tooth
with hypercementoid root or tooth with deformity of the roots. This forcep technique gives
least amount of trauma to soft tissues and hard tissue of judiciously used. In multiple
extractions the marginal gingival may have to be reflected to permit rounding and smoothing
of the sharp prominences of the alveolar process. Care should be taken to preserves the height
and breadth of the ridge for stability of a future denture. Proper use of this technique involves
the application of several basic principles. • The beaks of the selected forcep should be
sealed as far apically as possible without compression of the soft tissues after reflecting the
cervical gingival. • The placement of the beaks of the forceps should be as parallel as
possible to the long axis of the tooth. • The application of excessive force should be avoided
so that the fracture of the alveolar process or tooth itself does not occur. Elevator
Techniques This technique is used in two ways: 1. Elevator as a lever: In this case, the
alveolar crest serves as the fulcrum. The area of the compressed bone should be removed
with a file or rongeur to reduce the postoperative pain and infection. With elevators, one
should avoid traumatizing the gingival and loosening of adjacent teeth. This method is used
for the removal of whole or nearly whole roots. 2. Elevator as a wedge: This principle is
used for the removal of small root tips by way of displacement. If the root tip cannot be
dislodged from the socket easily, an open view method should be used. Transalveolar
Method (Open View Technique) This method is used where roots are inaccessible to
routine removal by forceps or by an elevator, when they cannot be luxated with simple
forces, or when the roots are covered by bone. This method is far less traumatic than when
there is prolonged use of forceps or elevator attempted root removal. Odontotomy In this
method, the extraction procedure may be simplified by cutting a tooth apart, e.g. in
multirooted deciduous or permanent teeth with divergent roots, where crown is decayed.
PROCEDURE FOR EXTRACTION Instrumentation and Positioning • Instruments are
selected and arranged according to the need and according to the surgeon’s preference. •
Position of the operator: – When extracting any tooth except the right mandibular quadrant
the operator stands on the right hand side of the patient. – For the removal of the teeth in
right mandibular quadrant, the operator stands behind the patient. – For maxillary teeth, the
chair should be adjusted so that the site of operation is about 8 cm below the shoulder level of
the operator. – During the extraction of mandibular tooth the chair height should be about 16
cm below the level of the operator’s elbow. – When the operator is standing behind the
patient the chair should be adjusted to enable him to have a clear view of the field of
extraction. • All these aspects combined with good illumination of the operative field is an
essential condition for the successful extraction of the teeth.