rinciples, techniques & complication

Science the earliest period of history of the extraction of the tooth
has been considered a very formidable procedure by the
layman, & it is because of the horrifying experiences associated
with the tooth extraction in the past that even today the removal
of a tooth is dreaded by a patient almost more than any other
surgical procedure.
Many patients suffer from extractionfobia & are often difficult to
care for, despite modern methods of anesthesia.
Many dentists still believe that speed is essential when extracting
the teeth.

• 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.
(Geoffray L Howe)


The 1st dentist was an EGYPTIAN
– HESI RE (31002181BC)

The history of dental extraction forceps is
very old and goes back to the time of
Aristotle (384 to 322 BC) where Aristotle
described the mechanics of oral surgery
forceps . This was over 100 years before
Archimedes studied and discussed the
principles of the lever.

Dental history arabic dentist
cauterizing dental pulp

Curing a Toothache with
FireThe fumes from

The Martyrdom of St. Apollonia,
shows the torturous extraction of

German Traveling Dentist

The Italian "Oral Surgeon" That
Traveling Dentist in a Dutch VillageEffortlessly Removes Jawbones

. which was invented in the 14th century by Guy de Chauliac and used until the late 18th century. until the 16th century. Dental Pelican.  A number of tools were invented for performing this procedure. dedicated dentists did not exist and dentistry was practiced by general physicians and barbers.


the key was replaced by the forceps. which .The instrument is a combination of the attributes of the an extracting forceps and a toothkey 1843 to 1863 In the 20th century.


Allen 1994 – caries in 48. 2. 6.8% cases – abscess Periodontal diseases – in 40. 12.1. 7. 8. 5. 3. 4. 11. 9. 10.7% cases – to prevent alveolar ridge resorption Tooth with necrosed pulp & periapical lesion – not responding to endodontic treatment Over retained deciduous tooth – but take radiograph first Orthodontic purpose Prosthetic purpose Unrestorable tooth Impacted tooth Supernumerary tooth Grossly decayed 1M / 2M – make room for 3rd molar HOTZ & SMITH Tooth in fracture line Teeth directly involved by cyst & tumor .

13. Teeth acting as foci of infection – ex. Teeth in the area of therapeutic irradiation 14.rheumatic fever RICHARDS (1932) – bacteremia after infected tooth extraction OKELL & ELLIOTT (1935) – STREPTOCOCCUS VIRIDANS in blood stream (75% of 40 patient) Use of local anesthetic solution (vasoconstrictor) infection rate of spread of . – bacterial endocarditis .


 Previously irradiated area (within 1 year) – less trauma + pre & post-op antibiotic prophylaxis .  NUG / HERPETIC GINGIVOSTOMATITIS – spread of infection & greater degree of systemic reaction.  In the era of antibiotics acute infection of odontogenic origin are not considered as absolute contraindication of immediate extraction. It may be judicious to delay the extraction until certain local or systemic condition corrected or modified.

   Untreated coagulopathies – congenital or acquired Adrenal insufficiencies Within 6 months of myocardial infarction . agranulocytosis.Other relative systemic contraindications –  Acute blood dyscrasias – acute leukemia .

B. Systemic Uncontrolled Diabetes Mellitus. Patients on long-term steroid therapy. Local Acute cellulitis. Hypertension. ANUG. Teeth that have undergone radiation [6 . Liver disorders. Bleeding disorders. A-V malformation. Cardiovascular diseases. Absolute : Central Haemangioma. 2. May cause uncontrolled bleeding. 1.CONTRAINDICATIONS : A. Relative : When some precautions have to be taken.


THE MECHANICAL PRINCIPLES Expansion of bony socket specially for forcep extraction sufficient tooth structure elastic bone (children) multiple small fractures of buccal cortical bone 1. Use of a lever & fulcrum remove the tooth/root along the path of least resistance basic factor governing the use of elevators .

The insertion of wedge or wedges between tooth-root & bony socket wall .THE MECHANICAL PRINCIPLES 2.

3. Wheel & axle principle .

Forces applied during extraction of tooth .



PREOPERATIVE ASSESSMENT  Take history of – 1. 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.any prosthesis . nervousness 3. general disease 2. resistance to inhalational anesthesia 4.

roots & alveolar bone viii. Planning to remove the tooth by dissection iv. Condition indicating dental or dentoalveolar deformities – osteitis deformans .hooked root therapeutic irradiation osteopetrosis . Trauma to tooth – fracture of tooth. Delayed erupting or having abnormal crown xi.hypercementosis cleido-cranial dysosteosis . Tooth having periodontal problem & some sclerosis – hypercementosis vii. PREOPERATIVE RADIOGRAPHS – Indications i. Abnormal root pattern – third molars. Close approximation with important anatomical structures v. Partially erupted. in standing premolars. misplaced canine vi. H/O difficult & attempted extractions ii. unerupted tooth & retained roots x. Isolated & Unopposed maxillary molars ix. Resistance to forcep extraction iii.

CHOICE OF ANESTHESIA General factors LOCAL ANESTHESIA GENERAL ANESTHESIA • • 5-10 min. uncooperative patients • • • • 30-45 min. No pre-op preparation Respiratory tract disease Cardiovascular diseases .

Local factors   Acute infection at the site of injection Hemangioma .

lights & chairs are inevitably sources of crossinfection. . Use the sterile gauze /cloth – to change the position of light.      Hands of operator Instruments Operation area Engines.STERILIZATION  Is defined as – removal of all micro-organisms from a given object.

Position of the operator – .Stand erect .application of force without stress to shoulders & back .Force delivery – with arm & shoulder not with hand .generally on right hand side .GENERAL ARRANGEMENT 1.operating box .for Right posteriors – back side . equal distribution of weight on both feet .

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 . Position of the patient – make the patient comfortable on dental chair 3.GENERAL ARRANGEMENT 2.

Light – good illumination . Angulation of the chair – maxillary teeth – 45-60 degree mandibular teeth – parallel or 10 degree 5.GENERAL ARRANGEMENT 4.

6. Role of opposite hand . . dislodged filling . . . root. Reflection of soft tissue Protection of other teeth Stablization of patient’s head Supporting & stablizing the mandible Supports alveolar bone Tactile information Compress socket Deliver the whole tooth. . . . .

7. . offhand comments – increase patient’s anxiety . . . . 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 Avoid casual .decrease patient’s cooperation . . .

 Use of controlled force  Unimpeded path of removal .PRINCIPLES OF TOOTH REMOVAL  Clear access to & vision of the surgical field.


 Alveolar expansion  Bleeding is arrested by pressure pack.What we do in extraction of a tooth ????  Separation of tooth from alveolar bone with crestal & principal periodontal fibers. .

Separation of Tooth from Soft Tissues  Severing Soft Tissue Attachment The straight and curved desmotomes .

and b curved . a straight.Reflecting Soft Tissues Chompret elevators.

Transalveolar extraction (open method) .Techniques of exodontia A. Intra-alveolar extraction (closed technique) B.

intra-alveolar extraction 1. forcep Technique 2. elevator Technique .

root deformities .least trauma .brittle root  Advantages .grossly decayed root .grossly decayed crown .1.gingival fibers reduces the size of extraction orifice so promotes healing . Forcep Technique  Commonly used  Not used in – hypercementosis .

Basic principles for forcep technique 1. 3. HOW TO HOLD THE FORCEP Thumb – just below the joint Handle in palm Little finger – inside the handle . Beaks should seated as far apically as possible Beaks should be parallel to the long axis of tooth Excess force should be avoided. 2.


Adaptation of blade

Buccally & lingual parallel to long axis of tooth.
Forced through periodontal membrane, towards apex.
Firm pressure.
1st apply on less accessible side of tooth under direct
2ndly on other side
Cervical caries - 1st movement towards carious part

IT IS SAID THAT Time spent in careful application of
forcep blades to the radicular
portion of tooth is never wasted.

Displacement of tooth from

Pressure applied by the operator by moving his
trunk from hips not from elbow.

Movements – linguobuccal & buccolingual
- firm, smooth & controlled


rotatory / figure
of 8

Maxillary buccal bone is thinner – buccally removal of

Mandibular buccal bone till molar is thinner - buccally
removal of teeth

Mandibular buccal bone in molar region is thicker lingually removal of teeth

Socket compression

Avoid soft tissue laceration

Maxillary incisors .

as prior extraction of incisors weakens the labial cortex.Maxillary canine  In multiple extraction cases canine should be extracted prior to extraction of incisors. .

Maxillary premolars .

Maxillary molars .


.MANDIBULAR CANINE  Heavy bladed forceps are used.




So use fine blades Permanent successors Warwick james elevators can be Limited access used Extraction of deciduous molar with forceps. 2. Forceps are positioned mesially or distally on the crown and .Extraction of deciduous teeth Factors – 1.

Elevator technique  Works on lever & fulcrum principle  It forces the tooth / root along the line of withdrawal R/G  Fulcrum – bone or adjacent tooth  Elevator grasping .2.

Application – in periodontal space 450 to long axis of tooth  Placement of gauze between finger and lingual side. for protection from injury in case the elevator slips .

Point of application Application of elevator – Buccally Mesially distally .

Movement – rotate the elevator along its long axis .

a During luxation of a tooth. with a risk of injury to tissues surrounding the . the alveolar ridge is used as a fulcrum. not the adjacent tooth. c Photoelastic model showing extraction of the third mandibular molar using a straight elevator. Using the adjacent tooth (second molar) as a fulcrum creates great tension around the tooth. b Incorrect placement of the instrument.

or at an angle to the root .Extraction of Single-Rooted Teeth with Destroyed Crown Positioning of straight elevator on the distal surface of the root. either perpendicular to.


Removal of the root of mandibular premolar with the special instrument (endodontic filebased action) for root extraction .

Extraction of multi-rooted Teeth with Destroyed Crown Separation of roots of the mandibular first molar with fissure bur .

Extraction is accomplished by sectioning roots using a straight elevator .Extraction of Multi-Rooted Teeth with Destroyed Crown Roots of mandibular first molar.

Positioning of the elevator and the fingers of the left hand for separation of molar roots .

Using an elevator with T-shaped handles to remove intraradicular bone .

using double-angled elevators .Extraction of Root Tips Diagrammatic illustrations showing luxation of the root tip of the mandibular second premolar.

MESIAL ROOT OF A MANDIBULAR MOLAR Technique for removing the tip of a mesial root of a mandibular molar. Removal of intraradicular bone and luxation of the root tip using a doubleangled elevator .

Removal of the tip of the distal root of a maxillary molar .

the root tip is drawn upwards by hand (a). or with a needle holder (b) . After the endodontic file enters the root canal.REMOVAL OF ROOT TIP Removal of the root tip using an endodontic file.

AFTER CARE        Irrigation of the socket Squeezing of the socket Mouth rinsing with warm bland water for once Suturing if require Moist gauze pack Medication Post extraction instructions – verbal & written .

Transalveolar extraction (open method) .

4.INDICATIONS 1. Intra-alveolar attempt is failed Retained roots in proximity with maxillary sinus & not accessible to forcep History of difficult or attempted extraction Heavily restored tooth Geminated / dilacerated tooth . 5. 3. 2.

Radiograph showing abnormal root pattern .

Hypercementosed / ankylosed tooth .

Fusion of teeth Dens in dente of maxillary left canin .


Deciduous mandibular molar. whose roots embrace the crown of the succedaneous premolar. . Risk of concurrent luxation with the simple extraction technique.

Method to be used to deliver the tooth / root from socket 3.Main components of transalveolar extraction – 1. Bone removal used to facilitate tooth / root removal . Design of mucoperiosteal flap 2.

Design of mucoperiosteal flap Base – broad Raise to render the operative site clearly visible & accessible Suture should not be placed over blood clot Obliteration of buccal sulcus should be avoided .

INCISION      Sharp scalpel Firm pressure Mucousa + periosteum Avoid Button hole formation in case of sinus Incision of sufficient length at once .


REFLECTION OF FLAP Austin’s retractor Minnesota retractors for retraction of the cheek and tongue .

Bone removal      To expose root/tooth Facilitated by large flaps Provides point of application After tooth/root removal – remove all sharp edges & bone prominences Instruments used - .

dental burs       Round / rose head provides – less clogging. It doesn't cut the tooth that easily Should not contact soft tissue Avoid overheating Postage stemp method then join with chisel . better control.

TOOTH DIVISION     Different line of removal for different roots Divide the root from furcation area Make space for application of forcep / elevator Osteotome / burs .

.REMOVAL OF TOOTH OR ROOT   Engage the elevator in a notch on side of root If notch is not present then create it with round bur directed at 450 angle to the long axis of root.

AFTER CARE       Irrigation of the socket Suturing Moist gauze pack Medication Post extraction instructions – verbal & written Recall after 48 hours SUTURE REMOVAL   Normally 7 days Within 2 days – if it was for control of hemorrhage  OAC repair – 10 days .

and then finally removal of the mesial and distal roots (b) .Removal of maxillary molar Steps in the surgical extraction of an intact maxillary first molar. sectioning of two buccal roots from the crown (a). removal of the crown together with the palatal root. Reflection of the envelope flap.

The buccal plate covering the surface of the root is removed.hypercementosis at the root tip An L-shaped incision is made and the flap is reflected. and the tooth is extracted using forceps .

Surgical extraction of a mandibular molar with hypercementosis at the distal root tip. part of the buccal plate is removed. b. and the tooth is sectioned buccolingually at the crown as far as the intraradicular bone .Hypercementosis at the distal root tip a. The envelope flap is reflected.

Extraction of the mesial portion of the tooth. so that removal of the root is possible without fracturing the bulbous root tip . which includes the crown and root Widening of the alveolus with a round bur.


Root of a maxillary first premolar. The surgical technique is indicated for its removal .



Radiograph of roots of the mandibular first molar.
The surgical technique is indicated for their removal

Root of a maxillary first

RUBBER BAND EXTRACTION INDICATIONS – 1. Note extrusion of mesial root. Patient Under Coverage of BISPHOSPHONATE 2. . Hemophilic patients PROCEDURE – Root canal treated and split mandibular molar during exfoliation process. Dentin bulge (arrows) preventing elastics from sliding apically.

† Maxillofacial Surgeons and RizanJNashef. 2008 0278-2391/08/6606-0011$34. DMD‡ Oral Maxillofac Surg 66:1157-1161.00/0 doi:10.Atraumatic Teeth Extraction in Bisphosphonate-Treated Patients © 2008 American Association of Oral and Eran Regev.1016/j.059 . DMD. DMD.2008.01.joms. MD.* Joshua Lustmann.

Sockets immediately after exfoliation of .

support of mandible & position of patient’s head The dental surgeon should never act as both operator & anesthetist.Specific consideration for extraction under general anesthesia  Take careful history  Take care of – airway. .

11. 8. 6. 4. 9. 5. 2. Accompanying person No driving 6 hrs of NPO Emptying the bladder Loose the tight clothing Patient Comfortable in dental chair Head slightly extended Mandible should be parallel to floor Arm & leg position of patient Waterproof apron Hearing of patient’s each breath .PREPARATION FOR ANESTHESIA 1. 3. 7. 10.

4.Preoperative consideration 1. Identify the tooth All prosthesis are removed All instruments should be keep ready Larger the anesthesia – increase risk of anoxia & aspiration Ideal time – 5-10 min. 3. 5. . 2.

Mouth gauge 3. Mouth pack 4. Dental prop 2.Special arrangements – 1. Efficient suction apparatus 5. Tracheostomy kit .

5. Tooth priorities Avoid excess force to mandible Soft tissue injury should be avoided Postpone – remove pulp if it is exposed Fractured root v/s resorbed root .Modification of extraction technique 1. 3. 4. 2.

Co-operation between dentist & anesthetist .


Reconstruction of alveolar process & replacement of immature bone by mature bone tissue . Replacement of granulation tissue by connective tissue & epithilialization of wound – 4-35 days 4. Organization of clot by granulation tissue – 3-7 days 3. Replacement of connective tissue by coarse fibrillar bone – 6-8 weeks 5. Hemorrhage & clot formation – 1-2 days 2.5 Stages 1.

4.Factors influencing the healing 1. 2. Infection Size of wound Blood supply Resting of part Foreign bodies General condition of the patient . 6. 5. 3.


DDS*. Harry KEYWORDS Powered periotome Polyurethane foam Piezosurgery Immediate implants Orthodontic extrusion Bone grafting Physics forceps Dent Clin N Am 55 (2011) 501–513 doi:10. Brooklyn.008 0011-8532/11/$ – see front matter 2011 Elsevier Inc. The Brooklyn Hospital Center. E-mail address: aweissdds@gmail.2011. .Technological Advances in Extraction Techniques and Outpatient Oral Surgery Adam Weiss. USA * Corresponding author. Avichai Stern.02. DDS Department of Dentistry and Oral and Maxillofacial Surgery. All rights reserved.1016/j. DDS. NY 11201. 121 Dekalb Avenue.

3.1. 4. 6. 2. Powered periotome Piezosurgery Lasers Coronectomy Orthodontic extrusion Physics forceps . 5.

No. Nicholas Toscano September 2009 Volume 1. 6 .Powered periotome Powertome® Assisted Atraumatic Tooth Extraction The Journal of Implant & Advanced Clinical Dentistry Jason White. Dan Holtzclaw.

.Powered periotome       Precise extraction of tooth Preserves bone & gingival architecture Option for immediate implant placement Mechanism of “WEDGINNG” & “SEVERING” Severs the periodontal ligament Multirooted teeth requires sectioning.

Presurgical radiograph of Case 1. Atraumatic removal of the tooth . Rotational movement of root with forceps Powertome® blade advanced in a ”sweeping” fashion.

Presurgical clinical presentation Powertome® blade advanced down PDL Extracted segments of maxillary canine .

Presurgical clinical presentation Presurgical radiograph .

Motorized periotome _Powertome_ for atraumatic extractions .YouTube.flv .

Piezosurgery  Piezosurgery is an innovative bone surgery technique that produces a modulated ultrasonic frequency of 24 to 29 kHz.  It works selectively. and a microvibration amplitude between 60 and 200 mm/s.  The surgical control of the device is effortless compared with rotational burs or oscillating saws because there is no need for an additional force to oppose rotation or oscillation of the instrument. without harming soft tissues such as nerves and blood vessels even with accidental contact with the cutting tip.  The amplitude of the vibrations created allows a very clean and precise surgical cut. .

 Uses of piezosurgery device to cut and elevate a precisely defined bone lid on the lateral cortex of the mandible to provide access to the teeth needing extraction or even a lesion that needs to be excised. the investigators also noted that the piezoelectric osteotomy reduced postoperative facial swelling and trismus. the bone lid is placed back into its original position and fixated with absorbable miniplates. .  After the visual confirmation of an undamaged IAN and adjacent tissues. Despite the longer time of the procedure. The bone window is then elevated with the help of a curved osteotome.

piezosurgery flaples extraction of lower first molar in severe ankylosis with kaps microscope .flv .YouTube.


 The benefits of laser therapy include the creation of a bloodless surgical field and thus improved visualization during surgery. decreased postoperative pain. creating a narrow gap with minimal bone loss. laser the fiber is closely guided around the teeth. and limited scarring and contraction. using the Er:YAG laser.  Time consuming. significantly inhibition the laser cutting because of the overall volume of irrigation and blood covering the bone surface. . layer by layer. the covering bone was first ablated.  In the case of the fiber-optic Er:YAG [erbium:yttrium-aluminum garnet ].LASERS FOR EXTRACTION OF IMPACTED TEETH  For the surgical extraction of the teeth. sound and smell.

 The advantage of this technique is that the risk of direct trauma to the nerve is eliminated.Orthodontic extrusion  Third molars in close proximity to the IAN have a significant negative impact on recovery for pain and oral function. . due to both the increased distance between the roots and the mandibular canal and the decreased need for surgical manipulation during the extraction.

working in this area of the mouth presents great difficulty. . being certainly difficult.  This technique should be used only in carefully selected cases in conjunction with an orthodontist. and not always successful.  In addition.  This technique will be of no value for a tooth that cannot move because of ankylosis. and the action of the masseter muscle leads to cheek compression against the orthodontic appliances. A potential problem with this technique is soft tissue damage from impingement on the mucosa of the cheek and the gingiva. time consuming.

DDS. DDS © 2010 American Association of Oral and Maxillofacial Surgeons 0278-2391/10/6802-0032$36.STAGED REMOVAL OF HORIZONTALLY IMPACTED THIRD MOLARS TO REDUCE RISK OF INFERIOR ALVEOLAR NERVE INJURY J Oral Maxillofac Surg 68:442446.038 . DDS. DDS. DDS.* Paolo Francesco Manicone.† Stefano Piccinelli.‡ Alessandro Raia.2009.joms.00/0 doi:10.1016/j.§ and Roberto Raia.07. PhD. 2010 Staged Removal of Horizontally Impacted Third Molars to Reduce Risk of Inferior Alveolar Nerve Injury Luca Landi.

Panoramic radiograph at initial consultation. . The mandibular third molars are mesially impacted with the roots close to the alveolar canal.

Postoperative radiograph after the right mandibular third molar was surgically sectioned. More space was created distal to the right mandibular second molar to allow further migration . The space distal to the second molar would allow mesial migration of the impacted tooth. Postoperative radiograph after second sectioning of the right mandibular third molar. A pulpotomy has been performed.

Periapical radiograph obtained 2 months after second sectioning.3 months after odontectomy. the roots were away from the alveolar canal. However. The third molar moved mesially. the mesial root was still in contact with the alveolar canal. A second sectioning was required. and a riskless extraction could be scheduled. . At that time.

 Once the tooth is loosened. it may be removed with traditional instruments such as a conventional forceps .Physics forceps  The Physics Forceps uses first-class level mechanics to atraumatically extract a tooth from its socket. the handles are actually rotated as one unit using a steady yet gentle rotational force with wrist movement only.  Together the “beak and bumper” design acts as a simple first-class lever. By contrast.  One handle of the device is connected to a “bumper.” which acts as a fulcrum during the extraction.  A squeezing motion should not used with these forceps.

Upper Anterior .Extracts Teeth 2 to 5 GMX-100L .Upper Left Extracts Teeth 12 to 15 .Extracts Teeth 6 to 11 GMX-200 Lower Universal Extracts Teeth 18 to 31 GMX-100R .Upper Right .GMX-100A .

Physics Forceps Price .flv .Dental Extraction Forceps .Forceps Dental Extraction.Extraction Forceps .

209: 111–114 • Coronectomy is a technique 1*. . Guys Hospital. SE1 9RT third molars *Correspondence to: Dr Vinod Patel Email: vinod. 3 AUG 14 2010 Accepted 29 April 2010 DOI: 10. London. London. Floor 23.2010.1038/sj.3Oral and Maxillofacial Surgery. Guys when it is felt there is an increased risk of injury to the inferior dental nerve. Oral and Maxillofacial that should Department. SE1 9RT. be considered for mandibular Floor 26. Patel. Great Maze Pond.673 ©British Dental Journal 2010. 2Restorative Dentistry. S.patel@hotmail. Moore and C. Great Maze Pond. Sproat BRITISH DENTAL JOURNAL VOLUME Refereed Paper 209 NO.Coronectomy – oral surgery’s answer to modern day conservative dentistry V.bdj.

In this study there were 3 cases of transient IDNI which showed resolution one week post operatively.06%) in the Coronectomy group. where as in the Coronectomy group one patient (1%) complained of altered sensation postoperatively which resolved within one month. .reported no IDNI in 58 successful Coronectomy patients and a 19% IDNI rate in those having traditional extractions. compared with one (0. of which 3 patients were diagnosed with permanent injury.  The retrospective analysis of O’Riordan consisted of 52 patients that underwent Coronectomy. One patient developed permanent IDNI. reported that in the extraction group six patients (5%) suffered IDNI.  Leung et al. showed nine (5%) patients in the control group presented with IDNI.  Renton et al. which was thought to be as a result of perforation of the canal due to operator error rather than the Coronectomy technique itself.  Hantano et al. Coronectomy can be beneficial but success requires both good patient selection and operator technique.

narrowing of the canal 4. 6. deviation of the canal 3.1. curving of root 7. narrowing of root. loss of lamina dura of canal . periapical radiolucent area 5.darkening of roots 2.

Radiographic imaging showing pre and post coronectomy of the right mandibular third molar (48) . trimming cutting surface to less than 3 to 4 mm below alveolar crest. B.Coronectomy: A. cutting crown below cement-enamel junction (arrow).

IMPLANT DRILLS FOR EXTRACTIONS PRIOR TO IMMEDIATE IMPLANT PLACEMENT  To avoid traumatizing the surrounding bone during elevation. . thereby decreasing the chance of traumatizing the thin buccal bone. implant drills were placed in the root canals to thin the root walls giving way to extraction with the application of much less force.



alveolar procedure.FAILURE TO ACHIEVE ANESTHESIA / TOOTH REMOVAL     Faulty technique Inadequate solution Test the efficacy of anesthesia Tooth could not be removed with intra-alveolar or trans. .

FRACTURE OF TOOTH Crown / root – Grossly carious  Tooth with Endodontic treatment  Improper application of forcep  One point contact  Slip off of forcep  Excessive force  Hurry  Tooth with divergent roots /hypercementosis Then trans-alveolar method is indicated  .

Remove all the root fragments except – 1. (Simpson 1958) 2. Apical 1/3 rd of palatal root of maxillary molars & requires excessive bone removal If removal is indicated – inform the patient radiograph If root is left in place – pulpectomy should be performed. 5 mm & requires excessive bone removal – well tolerated. .

FRACTURE OF ALVEOLAR BONE Causes –  Excessive inclusion of bone within the forcep beaks  Extraction of incisors before canine  Intact versus torn periosteum FRACTURE OF MAXILLARY TUBEROSITY    Generally during extraction of maxillary 3rd molars Pneumatization of maxillary air cells Gemination .

Management –       i. ii. . Preoperative radiograph is essential Raise the mucoperiosteal flap Separate the tooth & bone from gingiva Mattress Suture 10 days If tuberosity is excessively mobile – Splint the tooth for 6-8 weeks Sectioning the crown & pulpectomy.

FRACTURE OF ADJACENT TEETH    Heavily restored adjacent teeth –in the line of withdrawal Abutment teeth When used as fulcrum FRACTURE OF OPPOSITE TEETH    Uncontrolled force Under general anesthesia – gauge & props intubation .

FRACTURE OF MANDIBLE Causes –  Excessive / incorrectly applied force  Pathologic fracture  Senile osteoporosis Precautions –  Peroperative radiograph  Splint febrication  Exraoral support management –  Inform the patient  Reduce the fractured segment .

DISLOCATION OF ADJACENT TOOTH     When used as fulcrum Improper use of elevators Give support to adjacent tooth from other hand Don’t apply the elevator mesial to 1st molar Management –  Place the tooth in socket & splint it .

DISLOCATION OF TEMPOROMANDIBULAR JOINT Causes –  Excessive / incorrectly applied force  Improper use of mouth gauge Management –  Senile osteoporosis   Reduce it immediately Reduction technique Instructions to patient Precautions –   Take history  Exraoral support beneath the angle of mandible .

DISPLACEMENT OF ROOT INTO MAXILLARY SINUS Causes –  Abnormal root curvature  Carious root  Roots of premolars & molars involved by sinus  Excessive / incorrectly applied force  Inadequate grasping of tooth Precautions –  Take past dental history  Apply the forcep on sufficient tooth structure  Leave uninfected apical 1/3 rd of root  Never force the root towards sinus  Transalveolar method .

OROANTRAL COMMUNICATION Causes   Maxillary posterior teeth Involvement of sinus lining by – Periapical pathology Diagnosis –  Increased intra nasal pressure – air coming out from mouth can be heard  Amount of blood will be doubled  Wisp of cotton wool will be deflected .

impression material  Give incision in sinus membrane Precautions –  Mouth rinsing with antiseptic solution before closure of oroantral communication  Passage of instruments from mouth to sinus should be avoided. denture base. .Management –  Mucoperiosteal flap rising  Decrease alveolar height  Interrupted horizontal suture  Protect the clot with – acrylic.

Diagnosis –  Air bubbles from socket  Cotton wool deflection  Fluid taken from oral cavity nose Management –  Take radiograph .  Blow the air through nose  Under general anesthesia – stop the general anesthesia wait till regaining the cough reflex     Suction + irrigation ½ inch wide iodoform gauze Sometimes incision in sinus membrane Caldwell-Luc approach .

DISPLACEMENT OF ROOT INTO INFRATEMPORAL FOSSA  Mostly maxillary third molars Management –  Extend the incision posteriorly  Blunt dissection  Grasp the tooth carefully  Or wait for several weeks until it becomes somewhat encapsulated. .

DISPLACEMENT OF ROOT INTO SUBMANDIBULAR SPACE Reflect the soft tissue flap on lingual aspect of mandible as forward to the premolars gently dissect the mucoperiosteum Detach the mylohyoid muscle. .

chest pain occurs.fever. Radiograph of alveolar socket/ sinus/ chest Re-examine the patient after 3 days Patient is asked to report immediately.DISPLACEMENT OF ROOT INTO PHARYNGEAL SPACE If the root is not appearing in the oral cavity/pressure pack      Ask the patient to cough & spit Turn the patient towards the operator & position with the mouth towards the floor. . cough.

EXCESSIVE HEMORRHAGE Perioperative hemorrhage –  Oozing of blood during operation Management –  Wipe  Sucker  Hot 50 degree celcius for 2 min.  Hemostate  Local anesthetic solution having vasoconstrictor  Gelatine sponge  oxidized cellulose  After tooth removal – moist pressure pack for 10min. horizontal mattress suture .

Psychological approach Determine site & amount of hemorrhage Remove excess blood clot Provide firm gauze pack with tannic acid . No staneous exercise . 3. . . Less talk for 2-3 hrs. .Postoperative hemorrhage –  Instructions to the patients – 1. Tea bag 4. Pressure pack 2. No smoking for 12 hours 5.

Horizontal mattress suture into mucoperiosteum Wait for 5 minutes after placing gauze pressure on suture Gelatin / fibrin foam & All post extraction instructions and avoid frequent aggressive mouth rinsing .

DAMAGE TO SOFT TISSUES Gingiva Lower lip – mechanical & thermal injury Tongue & floor of mouth .

Injury to the inferior alveolar nerve Causes –  Compression with clot or bone debris  Partially or completely torn Precautions –  Preoperative radiograph  Elevator should not be forced below tooth  Resect 1 root before tooth elevation Management –  Reposition the ends at close approximation  Decompression  Microsurgical reanastomosis  Nerve grafting .

Injury to the mental nerve Causes –  Transalveolar extraction of premolars Precautions –  More Bone reduction mesial to 1st premolar & distal to 2nd premolar  Retraction of nerve with mental retractor .

.Injury due to breakage of instrument   Burs Management – drilling the groove around it .

Eccymosis  Submucosally & subcutaneously  Older patients – increased capillary fragility decreased tissue tone weaker inter cellular attachments  Onset 2-4 days Resolve within 7 – 10 days  .

.WOUND DEHISCENCE Cause –  Suture without adequate bony foundation  Suturing the wound under tension  Mostly in the region of mandibular 2nd & 3rd molar (internal oblique ridge) Management –  Leave the projection – slough out within 2-4 weeks  Smooth it with bone file under local anesthesia.

. . . Too small flap – much traumatic retraction Injury from bur. .POSTOPRATIVE PAIN 1. Due to traumatized hard tissue – Bruising from bone during intrumentation Excessive heating from bur Sharp bony edges Avoidance of tissue toileting Due to traumatized soft tissue – Incision only through mucous membrane ragged flap .heals slowly . . . . 2.

 alveolitis sicca dolorosa.  postoperative alveolitis.  localized osteitis.  necrotic socket.  fibrinolytic alveolitis .  localized osteomyelitis.DRY SOCKET Synonyms :  alveolar osteitis (AO).  septic socket.  alveolalgia.

Definition Postoperative pain in and around the extraction site. Surg. which increases in severity at any time between 1 and 3 days after the extraction accompanied by a partially or totally disintegrated blood clot within the alveolar socket with or without halitosis. I. 31: 309–317. 2002. R. etiopathogenesis and management: a critical review. Int. J. Oral Maxillofac. Blum: Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization. 2002 International Association of Oral and Maxillofacial Surgeons .

 Unlikely .ONSET AND DURATION  Mostly 1–3 days after tooth extraction . depending on the severity of the disease. .  Within a week . but it usually ranges from 5–10 days.In 95% and 100% of all cases. because the blood clot contains anti-plasmin that must be consumed by plasmin before clot disintegration can take place.  The duration of alveolar osteitis varies to some degree.before the first postoperative day.

tissue Some patients may also complain of intense continuous pain irradiating to the ipsilateral ear. 3. 4. Trismus is a rare occurrence in mandibular third molar extractions probably due to lengthy and traumatic surgery. Regional lymphadenopathy (occasionally). 5. temporal region or the eye. grayish yellow bony socket bare of granulation 2. unpleasant taste (occasionally). .SIGN & SYMPTOMS The denuded alveolar bare bone may be painful and tender. Initially blood clot appears dirty gray disintegrates 1.

Treponema denticola Difficulty and trauma during surgery Roots or bone fragments remaining in the wound Excessive irrigation or curettage of the alveolus after extraction Physical dislodgement of the clot Local blood perfusion & anesthesia Oral contraceptives . aggravating and precipitating factors: Oral micro-organisms . 4. 7. 3. Smoking . 8. Multifactorial origin Following have been implicated most commonly as etiological. like pyrogens will activate the fibrinolytic system indirectly. 2.ETIOLOGY   1. 6. 5.estrogens.

Use of oral contraceptives . Immunocompromised individuals . 7. 3. 2. Deeply impacted mandibular third molar (risk factor is directly proportional to increasing severity of impaction) . 5. Poor oral hygiene of patient . Active or recent history of acute ulcerative gingivitis or pericoronitis . 4. Smoking (especially >20 cigarettes per day) . Associated with the tooth to be extracted . 6. 8. .RISK FACTORS 1. Previous experience.

 BIRN : (BIRN H.) . Int J Oral Surg 1973: 2: 215–263. Etiology and pathogenesis of fibrinolytic alveolitis (‘dry socket’).

.CONTACT This conversion is accomplished in the presence of tissue or plasma pro-activators and activators.

streptokinas e 2. Indirec t 1.Plasminogen Activators Direc t Intrins ic 1. Endothelial plasminogen activators . Factor XII dependent activator 2. Tissue 2. staphylokin ase activato r comple x plasminoge n Extrinsi c plasminogen activators 1. urokinase.

endothelium) Plasmino gen C3 Plasm in C3a Fibri n Fibrin split products . XIIa.Fibrinolytic system Plasminogen activator (kallikrein. leukocytes.

Non-pharmacological and 2. . Pharmacological preventive measures.PROPHYLACTIC MANAGEMENT References in the literature correlating to the prevention of alveolar osteitis can be divided into 1.

Use of good surgical principles 4.Non-pharmacological measures 1. Extractions should be performed with minimum amount of trauma and maximum amount of care 5. Careful planning of the surgery 3. Use of good quality current preoperative radiographs 2. Confirm presence of blood clot subsequent to extraction (if absent. scrape alveolar walls gently) .

Comprehensive pre. 9. Advise patient to avoid vigorous mouth rinsing for the first 24 h post extraction and to use gentle toothbrushing in the immediate postoperative period .and postoperative verbal instructions should be supplemented with written advice to ensure maximum compliance .6. 8. 10. Encourage the patient (again) to stop or limit smoking in the immediate postoperative period . For patients taking oral contraceptives extractions should ideally be performed during days 23 through 28 of the menstrual cycle . Wherever possible preoperative oral hygiene measures to reduce plaque levels to a minimum should be instituted 7. .

4.polylactic acid (PLA) 5. Obtundent dressings 6. Clot supporting agents . Steroid anti-inflammatory agents . Antiseptic agents and lavage Chlorhexidine (CHX) 3. Antifibrinolytic agents .PHARMACOLOGICAL MEASURES 1.para-hydroxybenzoic acid (PHBA). Antibacterial agents 2.

The patient is given a plastic syringe with a curved tip for home irrigation with chlorhexidine solution or saline and instructed to keep the socket clean. Do not attempt to curette the socket. Prescription of potent oral analgesics. as this will increase the level of pain. 2. which is followed by careful suctioning of all excess irrigation solution.NON-DRESSING INTERVENTIONS TO MANAGE ALVEOLAR OSTEITIS 1. As the socket may be exquisitely tender local anaesthesia may be required. Irrigate the socket gently with war sterile isotonic saline or local anaesthetic solution. 5. 4. Remove any sutures to allow adequate exposure of the extraction site. home irrigation can be discontinued. Once the socket no longer collects any debris. 6. . 3.

Any foreign bodies if present were thouroghly removed. Anand. Verma. The detached gingival margins were also scraped. . rounded. The desired medications as well as precautions . M. 2006 Volume 4 Number 1. The Internet Journal of Dental Science. but was also comfortable both physically as well as psychologically from the very next day. B.5580/e31        Under block anesthesia The clot devoided socket is thoroughly curetted. DOI: 10. The sharp margins were trimmed. Singh.SURGICAL MANAGEMENT OF “DRY SOCKET” S. V. Rai: Dry Socket An Apriasal And Surgical Management. both from the floor of the socket as well as from the bony walls.C. Goel. Patient was not only without pain. A.

POSTOPERATIVE SWELLING Normal oedema After multiple teeth extraction surgical tooth extraction  Management –  Ice pack application  Heat application Traumatic oedema Blunt instrumentation Excessive extraction of badly designed flap Too tight suture  .

 Crackles can be felt under finger  Resolves within 1-2 days Due to infection of wound –  Preoperative antibiotic  Prevention of entry of micro-organism into wound  Mild infection – intraoral hot saline mouth wash .Subcutaneous emphysema –  Air into connective tissue of intramuscular & fascial spaces  Swelling is of sudden onset.

TRISMUS  It is defined as inability to open the mouth due to muscle spasm. Causes –  Post operative oedema  Hematoma formation  Inflammation of soft tissue  After mandibular block  Traumatic arthritis of TMJ  Multiple injections .

Management – Treat underlying cause  Intraoral heat application  Antibiotics & specialist treatment.  .

Sign & symptoms – dizziness. .SYNCOPE  Transient loss of consciousness and postural tone characterized by rapid onset. short duration. and spontaneous recovery due to global cerebral hypoperfusion that most often results from hypotension. Management –  Position  Oxygen administration  Blood pressure & pulse measurement  250 mg aminophylline is given slowly. weakness. pale & sweating. nausea skin is cold.

 Brook airway can be inserted over tongue  Check carotid pulse & apex beats at regular intervals .RESPIRATORY ARREST   Skeletal muscle become flaccid pupil dilate widely management –  Patient flat on the floor  Clean the airway  Pull the mandible forward  Extend the neck fully  Pulmonary resuscitation so that chest is seen to rise every 3-4 sec.

CARDIAC ARREST Sign & symptoms –     Deathly pallor & grayness of skin Cold sweat Pulse & apex beat can be felt Heart sounds can not be audible Children  Beginning of heartbeat if the sternum is tapped sharply Adult – Patient flat on the floor Cardiac compression at 1 second interval .

Oxygen vii. Management – i. respiratory arrest & cardiac arrest complicate the general anesthesia. Pull the mandible forward iv. Extend the neck v. Remove all the packs. Tracheostomy  . iii. debris & apparatus from mouth.ANESTHETIC EMERGENCIES  Syncope. Clear the airway ii. Head – downward /forward in dental chair .upward if lying on the floor vi. Larygotomy viii.

The extraction of teeth by – GEOFFREY L HOWE 2. . Contemporary Oral & maxillofacial surgery by. TUCKER 5. by – DANIEL M.RESOURCES Text books 1. ELLIS. FRAGISKOS 4. LASKIN 3. Oral Surgery by . Oral & maxillofacial surgery volume 2 .HUPP. Text book of Oral & maxillofacial surgery by – S M BALAJI.FRAGISKOS D.

DDS*. No.theclinics.1038/sj. The Journal of Implant & Advanced Clinical Dentistry. J Oral Maxillofac Surg 68:442-446.02. 3 AUG 14 2010 . Patel.‡ Alessandro Raia. DDS.1016/j. Avichai Stern. Horowitz. DDS.RESOURCES 1.2010. DDS Dent Clin N Am 55 (2011) 501–513 doi:10. 6 5.673 ©British Dental Journal 2010. Moore and C.† Stefano Piccinelli. Rohrer. September 2009 Volume 1. 6 3. S. Jason White.§ and Roberto Raia. Michael D. Jason White. No. Nicholas Toscano. 209: 111–114. DDS. Dan Holtzclaw. DDS. Ziv Mazor. Harry Dym.cden. Dan Holtzclaw. 2010 0011-8532/11/$ – see front matter 2011 Elsevier Inc. 2. DDS. Refereed Paper Accepted 29 April 2010 DOI: 10. DDS.008 dental.bdj. September 2009 Volume 1. Prasad. PhD. Hari S.* Paolo Francesco Manicone. Coronectomy – oral surgery’s answer to modern day conservative dentistry V. Staged Removal of Horizontally Impacted Third Molars to Reduce Risk of Inferior Alveolar Nerve Injury Luca Landi.2011. Technological Advances in Extraction Techniques and Outpatient Oral Surgery Adam Weiss. Enhancing Extraction Socket Therapy Robert A. The Journal of Implant & Advanced Clinical Dentistry. Nicholas Toscano. BRITISH DENTAL JOURNAL VOLUME 209 NO. Powertome® Assisted Atraumatic Tooth Extraction. Sproat.

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