LECTURE

OUTLINE
• 1. DEFINITION  
 

• 2. METHODS OF EXTRACTION
 

• 3. INDICATIONS FOR TOOTH REMOVAL

 
• 4. CONTRA INDICATIONS FOR TOOTH    
 REMOVAL
 

• 5. PRE OPERATIVE PREPARATION

 

• 6. INSTRUMENTATION
 

• 7. SPECIFIC TECHNIQUE FOR REMOVAL

OF  
      EACH TOOTH
 Direction of tooth movement for Maxillary teeth

         
       Tooth Movement
Central incisor Rotation
Lateral incisor Rotation
Canine Rotation and Buccal traction
First premolar Buccal traction

Second premolar Rotation and Buccal traction

First molar Buccal Traction- predominately
Disto- Buccal twist to deliver
Second molar Buccal , Disto-buccal twist to deliver
Third molar Buccal , Disto-buccal twist to deliver
Direction of tooth movement for Mandibular teeth

         
       Tooth Movement

Central+ lateral incisor Bucco-lingual

Canine Rotation

First and second Rotation

premolars
First molar Bucco-lingual or Figure of  8

Second molar Bucco-lingual  or  Figure of 8

Third molar Bucco-lingual  or Figure of 8

 LECTURE
OUTLINE
Principles of Extraction

Elevators & Principles of elevators

Transalveolar extraction
Indications
Procedure
i) Mucoperiosteal flap
ii) Guttering of bone
iii) Splitting of tooth
iv) Debridement of socket
v) Suturing
 Principles of extraction
• Adequate access & visibility

• Secure, two point grip

• Controlled force in a pre-determined direction

• Expansion of the cortical plates

• Safe delivery of the tooth

twq point grip
 tooth extracted
directors
peaked
in

✓ 1st
fore
is
apical
direction
to
get
Cork cat
-

deeper
bone
grip
expansion
①
Apical
direction

②
Expansion
of cortical

bone
③ Tooth
come out

oscdusally
 ELEVATORS
&
PRINCIPLES OF ELEVATORS
 -
Should use
forceps
Indications for use of Elevators first
1
more complication
Impacted teeth than
forceps
Malposed teeth
- when
forceps cannot
gap
Firm & Decayed teeth

Removal of roots
 Principles of Instrumentation/Elevators

• Wedge principle -
between I
surfaces
'

taxation → Coupland can laxafe

• Lever & Fulcrum principle anywhere
'

elevation distal
→
only most

• Wheel & Axle principle tooth in arch

,

not in other

tooth can
,

cause lobation
of adjacent tooth
 Wedge Principle
In this principle the elevator is forced between the root of the tooth and
the Investing Bony tissue parallel to the long axis of the root.

While the wedge principle can be and is used as a sole principle in

removing teeth, it is most frequently used in conjunction with lever
principle.

As the tip of the beak are advanced still further the bony sockets is
expanded so the tooth is displaced out of the socket.

The sharper the angle of the wedge, the less effort required to make it
overcome a given resistance.
/
lead to
root
displacement of
 Lever and Fulcrum Principle
• Elevators work on first order lever

• In a lever of the first class the position of the fulcrum

(F) is in between the effort (E) and the resistance (R)

• In order to gain a mechanical advantage in the lever

of the first class, the effort arm on one side of the
fulcrum must be longer than the resistance arm, on
the other side of the fulcrum
 Lever and Fulcrum Principle

R Effor
SA LA
t
Resistance E

Long Arm= 3/4th of the total length

Short Arm= 1/4th of the total length
 Lever and Fulcrum Principle
10lbs

30lb
F

Downward force of 10lbs acting at the end of the effort arm causes
an output force of 30lbs at the end of resistance arm

Mechanical advantage= output force 30lbs

----------------- = --------- = 3
Input Force 10lbs

Formula for Levers= R x SA = LA x E

Wheel & Axle principle
 I
hold
further
beak to
from
make radius The triangular part of the
beaks engage the furcation
of wheel bigger
, On the buccal and lingual
sides
more mechanical
advantages

Application of forceps on
lower right molar with two point
grip
 Couplands Elevator

Lindo Levin pattern

Handle
Blade Shank

→ For 3rd molar

No -
I → No 2 →
No 3
Charenton
of
. .

tooth )
fruityremoval of tooth )
 Couplands Elevator
if rest here,
laxate 1
-

can

fracture adjacent
tooth

I
rest Shank at
interdental
bone

Wedge and Lever & fulcrum principles

 upper
Cryer`s elevators -
third molars /
second molars
Cryer’s elevator applied on the
mesial side of the maxillary third molar

The concavity should

always engage on the
mesial aspect of the tooth

- Level &
fucoum
Wheel & Axle
-

Used for the removal of distal most tooth in the maxilla

 Warwick James Elevators
-
better than
Cryer's

loan enter and tooth when interdental

too
engage
small
mesial
of
space
Warwick James Elevators
Used when the interdental space is less

Warwick James elevator applied on the

mesial side of the maxillary third molar

Used for the removal of distal most

tooth in the maxilla
Apex elevators -

wedge pad.pk
apical portion
-

remove

Buccal / lingual
-
Apex elevators
Winters Crossbar elevators ( ✗ common )

can lead to
Blade
mandible
fracture of
Blade
/
maxilla

S
S
h
h
a
The handle and shank are perpendicular a
n to each other n
k The blade or the working end is almost parallel k
to the
handle

Handle Handle
Winters Crossbar elevators
Winters Cross bar elevators

Can be used in the furcation of the lower molars

To luxate the tooth out of the socket
 Molt’s Periosteal Elevator
sqoarate gingiva from lingual /
-

buccal site

* Prevent
crash forceps causing soft tissue

Broad end
sharp end
I 1
Elevation
Refraction Mo .
9 *
Firm
manner
&
gentle
to
prevent trauma
 Dangers in using Elevators

Damage to the neighboring teeth

ttoaeture)
# of Maxilla and Mandibular alveolar processes

Slipping of tooth or root into the surrounding soft tissues

Damage to the blood vessels and nerves

Penetrating into the maxillary antrum or the lingual pouch,

pterygomandibular or pterygomaxillary spaces
 TRANS – ALVEOLAR EXTRACTION
(access is made through side of alveolus)
INDICATIONS

• Tooth – resists intra-alveolar extraction

• Retained roots that cannot be grasped with forceps or elevator

• Impacted teeth

• Hypercementosed or ankylosed teeth

• Teeth with abnormal shape or size

• Any tooth that is close to the maxillary antrum that cannot be readily
extracted with forceps
STEPS INVOLVED IN TRANSALVEOLAR EXTRACTION

Incision & Flap design

Flap elevation (Reflection & Retraction of the flap)

Bone removal

Tooth removal (with or without tooth division)

Debridement of socket & Hemostasis

Suturing
 Incision :
• Should be placed on the sound bone
• A firm continuous stroke no
-

repeated
stroke
• No sharp angles
• Avoid injury to the vital structures
Flap Design
• Adequate access
• Base of the flap should be wider than the free end
• Margins of the flap should rest on sound bone
• Maintaining integrity of interdental papilla
 rest
on
sound \
bone
 MUCOPERIOSTEAL FLAPS
Classification of flaps

One sided flap (envelope flap)

Two sided flap (Triangular flap)

Three sided flap ( Trapezoidal flap)

Semilunar flap
One sided flap (Envelope Flap)

Made by extended horizontal incision in the gingival sulcus along the

cervical lines of teeth.
Advantages

Avoidance of vertical incision.

Easy approximation to original position.

Disadvantages

Restricted access (especially palatal side)

Limited visualization
Two sided flap

Made by placing an additional L-shaped

(2nd incision) on the side of envelope flap
preferably divergent towards vestibular sulcus.

This design is adequate for most transalveolar extractions,

surgical removal of root tips, cysts and apicoectomies
Advantages

Ensures good blood supply

Good visualization

Good stability

Disadvantages

Limited access to long roots

Defects can be caused in attached gingiva

Tension is created when flap is held against retractor.

 Three sided flap

. With triangular flap an additional 2nd relieving incision is

given on the distal end of the flap.
. This pattern allows extra mobilization of soft tissues and
greater exposure of underlying tissues.

Advantages

Provides excellent access

Provides no tension on tissues
Allows easy reapproximation of flap to its original position
Disadvantages

Defect can be produced in attached gingiva.

Can cause gingival recession.

wider
+
than

free and
flap
Semilunar flap
Flap is made by curved incision beginning from vestibular fold and has a bow
shaped course.

Lowest point of flap should be atleast 0.5 mm from the gingival margin.

Done when periapical exposure is required, apicoectomies, removal of cysts

and apical root tips.
Advantages

Small recession and easy reflection

No recession of gingiva, no intervention at periodontium.

Easier oral hygiene

Disadvantages

Difficult to reapporximate and suture

Tendency to tear
BONE REMOVAL -

create
space
between teeth
& bone

Occlusal surface

Buccodistally
 BONE REMOVAL
Bone removal should achieve specific objectives:

1.To expose the tooth and clear its path of exit

2.To provide suitable points of application -
elevator can rest
INSTRUMENTS FOR BONE REMOVAL

3
Chisel and Mallet
Bone burs Not common

Bone curette
-> Remove debris &

-
canses more granulation
tissue

Surgical burs: a swelling

Used with straight hand piece
Bur speeds of 10000 – 300000 revolutions per minute
Tungsten carbide straight fissure burs (medium sized) is preferentially used
Needs a lot of cooling with plenty of saline (coolant).

Blunt burs produce only excessive heat. (should not be used)

 SPLITING AND REMOVAL OF TOOTH

Suitable point of application should be made by removing bone around the root for tooth
removal.

Elevator is engaged in the root by drilling a small notch in its side.

TOOTH DIVISION (done only when needed)

When path of exit of impacted third molar is obstructed by position second

molar.

The roots are dilacerated ,widely divergent.

When the tooth in concern is very near of involving the anatomical structures (nerves ,sinus,
artery)
 DEBRIDEMENT OF THE SOCKET
After removal of tooth :

Socket should be cleaned and checked for pieces of debris.

Check for loose pieces of bone, tooth or filling material.

Larger fragments are best retrieved with curved artery forceps.

Irrigate with sterile saline for clear view.

Gentle curettage of bony socket walls with spoon end of Mitchell s trimmer for removal
of infected granulation tissue.

After extraction bone might need to be

trimmed around the socket if it does not feel
smooth. This can be done with a “bone file”

Extraction socket is now ready for closure.

SUTURING
 PURPOSE OF SUTURING

• Provide an adequate tension of wound closure without dead

space but loose enough to obviate tissue ischemia and
necrosis.

• Maintain Hemostasis

• Permit proper flap position and primary healing

• Provide support for tissue margins

• Reduce post operative pain

• Prevent bone exposure resulting in delayed healing and

unnecessary resorption.
END
 I wound
/
Retract
'

gingiva cheek

-
Retract cheek
combined cheek & Wound retractor
AAus.tn retractor

Bowdler Henry retractor

Tongue retractor

Sean Mueller retractor Bone

rongeur
Trimming
→

Bone
file
& bona
→
Filing CI direction) Toothed Non -
toothed

polishing forceps pomp

 -
has
depression
Artery
forego
Needle Into depression

Foroop

Mosquito
forceps
Towel
dip

Mouth Metal suction

prop

Mandibular Coco
Anterior Premolar Molar Third Horn
molar

foray

* E- ¥-11 '¥a4ZFbi¥FBk
slanted
1st )
→

Premolar Capper toot

 anterior
Maxillary Maxillary Premolar Maxillary molar

forceps forceps forceps

Cowhorn third
cowhom Maxillary
troop Foraep
molar
forceps
 Coupland
elevator

Not No :L No -3

Bayonet

Apex Warwick Cryer 's

James elevator
elevator
elevator
 Mott's Root Bowdler Mouth
parietal tip Prop
elevator elevator Henry
Retractor

Cheek & Wound Austin

Tongue
cat
paws / retractor retractor retractor
Jenn Malheur

htteadle Artery Mosquito

Toothed
Yagyu, Bigge Bone
forceps Forceps forceps
Forceps tongeur
 Magill forceps
Small Towel Intubation
Large
surgical clip
from
Take out
foreign substance
→
scissors

pharynx