P r i n c i p l e s of E x o d o n t i a
William Stuart McKenzie, DMD, MD
KEYWORDS
 Exodontia  Elevators  Dental forceps  Dental extractions
KEY POINTS
 Exodontia services comprise the largest portion of clinical practice for most oral and maxillofacial
surgeons in the United States.
 This article is an overview of the principles of exodontia including the physics principles underlying
the appropriate use of dental elevators and forceps.
 New instruments including periotomes, piezosurgery, Physics Forceps, and vertical extraction sys-
tems are also introduced and reviewed.
The most common procedure performed by most
oral and maxillofacial surgeons is extraction of
decayed or impacted teeth. According to the Na-
tional Institute of Dental and Craniofacial
Research, 92% of US citizens age 20 to 64 have
had dental caries in their permanent dentition,
with 26% of adults in this age range with current
untreated caries.1 Many patients require one or
more extractions throughout their lifetime because
of impaction, caries, periodontal disease, fracture
of teeth from mastication or previous dental pro-
cedures, and failed root canal therapy. The ideal
principles of exodontia should allow the efficient,
effective, and safe removal of teeth with a primary
focus on minimizing complications and maxi-
mizing comfort for the patient and provider. Failure
to understand the instrumentation and the physics
principles being used can cause prolonged opera-
tive time, iatrogenic injury to the patient, and un-
necessary fatigue and/or injury to the provider.
This article reviews the principles, techniques,
and instrumentation of exodontia, and presents
new instruments being currently marketed for
exodontia.
PREOPERATIVE ASSESSMENT
Before any surgical procedure, a thorough history
and physical examination must be completed.
Although most patients can safely undergo basic
exodontia procedures, medical history and current
medications can allow the surgeon to anticipate
Mid-State Oral Surgery and Implant Center, 445 Henslee Drive, Dickson, TN 37055, USA
E-mail address: mckenzieomfs@gmail.com
Oral Maxillofacial Surg Clin N Am 32 (2020) 511–517
https://doi.org/10.1016/j.coms.2020.06.001
1042-3699/20/Ó 2020 Elsevier Inc. All rights reserved.
and avoid intraoperative and postoperative com-
plications including bleeding issues, bone and/or
soft tissue healing issues, and the best pain man-
agement strategy for the individual patient. This
assessment also includes forecasting the specific
instrumentation that may be needed for the pro-
cedure. Communication of the need for special
instrumentation or hemostatic agents to the surgi-
cal team maximizes procedural efficiency. The ex-
amination process also includes diagnostic
radiographs of the teeth requiring removal to
confirm necessity of removal and to assess for
possible complications. The radiograph also al-
lows the patient to visualize the teeth that are to
be removed, and to participate in the informed
consent process by seeing the structures that
may be at risk, such as the maxillary sinus cavity,
the inferior alveolar nerve canal, or adjacent
restorations.
The use of cone beam computed tomography
(CBCT) scan by oral and maxillofacial surgeons
has become increasingly popular in the United
States. Although most patients having routine
exodontia do not require CBCT, CBCT may be
indicated when impacted mandibular wisdom
teeth are in close proximity to the inferior alveolar
canal. Matzen and Wenzel2 performed a compre-
oralmaxsurgery.theclinics.com
hensive and well-designed review of the efficacy
of CBCT before mandibular wisdom tooth extrac-
tion. They found a paucity of randomized
controlled trials in their review of more than 300 ar-
ticles, and ultimately concluded that periapical