EXODONTIA

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Definition
• The ideal tooth extraction is: The painless removal of the whole tooth, or root,
with minimal trauma to the investing tissues, so that the wound heals uneventfully
& no post-operative prosthetic problem is created
Basically, we have two methods of extraction: -
1- Intra-alveolar extraction (forceps extraction).
2- Trans-alveolar extraction (surgical extraction).
In forceps extraction which is enough for extraction in most of cases consist of
removing the tooth or root by the use of forceps or elevators or both. While in
trans-alveolar extraction we dissect the tooth or root form its bony attachment by
rising a flap and removal of some of the bone surrounding the roots, which are then
removed by the use of elevators and/or forceps.

Indication for extraction:

1.badly carious teeth.
2. sever periodontal diseases
3. Tooth with necrosed pulp & periapical lesion – not responding to endodontic
treatment
4. Over retained deciduous tooth.
5. Orthodontic purpose.
6. Prosthetic purpose.
7. Unrestorable tooth.
8. Impacted tooth.
 9. Supernumerary tooth.
10. Grossly decayed 1st molar and 2nd molar – make room for 3rd molar
11. Tooth in mandibular fracture line
12. Teeth directly involved by cyst & tumor
13 prior to irradiation:-(before radiotherapy)
Irradiation is one of the methods of treating oral carcinomas and teeth which
cannot be kept in a sound condition should be removed before irradiation, trauma
(extraction) with superadded infection will lead to development of
osteoradionecrosis of the jaw bone which is unpleasant complication and difficult
to be treated.
14. Teeth acting as foci of infection –ex. – bacterial endocarditis, rheumatic fever
15. Retained roots.

Contraindications:
I. Local contraindications:
1- Acute and uncontrolled infection ?.
Extraction in the presence of acute and uncontrolled infection may lead to spread
of infection locally or systemically leading to many complications some of them
are dangerous and life threatening
2-Previous radiotherapy:
Previous therapeutic radiation in oral and maxillofacial region for treatment of
cancer lead to fibrosis and decreased vascularity of the tissue or area of extraction
and end with a condition in the bone called osteoradionecrosis
3- Teeth located within area of tumor:-
Especially in vascular lesion or malignant tumor should not be extracted because
extraction may lead to dissemination of the tumor, unhealed socket and
postoperative complications, for example, bleeding postoperatively and
intraoperative.
II. Systemic contraindications:

Systemic contra-indications preclude extraction because the patient's systemic

health is such that the ability to withstand the surgical work may be compromised.
So extraction should be postponed until the severity of the problem has been
resolved and maybe arranged after consultation with the physician to perform
extraction safely without complications so caution is advised in the following
conditions:-
1- Severe uncontrolled metabolic disease, e.g. uncontrolled diabetes, end-
stage renal disease.
2- Uncontrolled leukaemia and lymphomas.
3- Sever uncontrolled cardiac disease, e.g. myocardial infarction, unstable angina
pectoris, dysrhythmias.
4-Sever uncontrolled hypertension.
5-Pregnancy.
6- Bleeding disorder e.g. haemophilia, platelet disorder, patient on anticoagulants.
7- Patients who take a variety of medications e.g. patient on steroid and
immunosuppressive drugs, cancer and chemotherapy.
8-Uncontrolled epilepsy.
Mechanical principles of tooth extraction:
1.Expansion of bony socket specially for forceps extraction.

2. Use of a lever & fulcrum remove the tooth/root along the path of least resistance
basic factor governing the use of elevators
3.The insertion of wedge or wedges between tooth-root & bony socket wall

4.Wheel & axle principle:

Preoperative assessment:
• Take history of –
1. general disease
2. nervousness
3. resistance to inhalational anesthesia
4. previous difficulty with extraction
• Oral hygiene status of the patient
oral prophylaxis
antiseptic mouth rinse
• Clinical examination of the tooth
• Clinical examination of the oral cavity- if there is any prosthesis

PREOPERATIVE RADIOGRAPHS (x-ray)

Indications:
1. History of difficult & attempted extractions
2. Resistance to forceps extraction
3. Planning to remove the tooth by dissection
4. Close approximation with important anatomical structures
5. Abnormal root pattern – third molars, in standing premolars, misplaced
canine
6. Tooth having periodontal problem & some sclerosis – hypercementosis
7. Trauma to tooth – fracture of tooth, roots & alveolar bone
8. Isolated & Unopposed maxillary molars
9. Partially erupted, unerupted tooth & retained roots
10. Delayed erupting or having abnormal crown
11. Condition indicating dental or dentoalveolar deformities – osteitis
deformans – hypercementosis ,cleido-cranial dysosteosis , hooked root
therapeutic irradiation osteopetrosis
 General arrangement:

1. Position of the dentist:

• the position of dentist for extraction of all upper and lower teeth (except
right posterior mandibular teeth) is in front and right side of patient,
• for right posterior mandibular teeth the dentist positioned behind patient.
• In case of the left-handed dentist follow all above instructions except (in
case of the lower left posterior teeth (molars and premolars) dentist
positioned behind patient).

the position of dentist for extraction of all upper and position for right posterior mandibular teeth
lower teeth (except right posterior mandibular teeth)

2. Position of the patient:

make the patient comfortable on dental chair

3. Height of Dental Chair

maxillary teeth – 8 cm / 3 inch below the shoulder level of operator
mandibular teeth – 16 cm / 6 inch below the elbow of operator
4. Angulation of the occlusal plane and chair;
• For maxillary teeth _the angle between occlusal plane and floor is 45-60
degree.
• For mandibular teeth_ the angle between occlusal plane and floor is
parallel or 10 degree.
• while the angulation of chair is as following picture:
5. Light –
good illumination
6. Role of opposite hand
1. Reflection of soft tissue
2. Protection of other teeth
3. Stabilization of patient’s head
4. Supporting & stabilizing the mandible
5. Supports alveolar bone
6. Tactile information
7. Compress socket
8. Deliver the whole tooth, root, dislodged filling

7. Role of assistant
• Helps the surgeon to gain access & visualize the field
• Suction
• Protect the teeth of opposite arch
• Support the head
• Support the mandible
• Psychological & emotional support

Principles of tooth removal:

• Clear access to & vision of the surgical field.
• Use of controlled force
• Unimpeded path of removal