#EXODONTIA #OMFS #JOJI #PETER #SURGERY #PPT

1. DR JOJI PETER
MDS,FIBCSOMS

3. “ Exodontia 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”
~ Geffory L. Howe

4. “7 Minimum Essentials”
• Radiograph
• Anesthetic
• Forceps & elevators
• Flap tray
• Light
• Efficient assistance
• Suction apparatus
Raffles founded modern Singapore
Sir Thomas Stamford Raffles
(1781 – 1826)

5. Pre-Surgical Evaluation :-

6. Clinical Evaluation of teeth for removal
• assess difficulty of extraction.
• Access to tooth: if mouth opening of PT is
compromised-surgical extraction.
• Mobility of tooth: teeth with less than
normal mobility should be assessed for
hypercementosis and ankylosis----surgical
removal
6

7. • Condition of crown
• calculus present on tooth
7

8. • If adjacent tooth has amalgam
restoration or undergone endodontic
therapy, care must be taken while using
elevators.
8

9. Radiographic Examination of tooth for removal
• If it is a I° tooth, its relationship with a
succedaneous tooth should be visible
• Configuration of roots- If excess curvature
surgical extraction
• Length of roots
• Hypercementosis
9

10. • Relationship of associated vital structures
– For Max. teeth relation with max. sinus.
– For Mand. Molars inferior alveolar canal
– For Mand premolars relation with mental
foramen 10

11. Patient & surgeon Preparation
• All patients should be considered as having
blood born disease.
• Surgeon should wear surgical gloves, mask,
eyewear with side shield, long sleaving gowns.
• If surgeon has long hair it should be covered
with surgical CAP. 11

12. Order of extraction
Lower teeth are removed before the upper &
posteriors are removed before anteriors to
prevent bleeding from socket obscuring field
of operation (prof.J.Moore)
12

13. Indications : -

14. •Over retained deciduous teeth
•Teeth involved in significant infection
•Patients inability to afford more optimal treatment
because of limited finances or time.
•teeth in the line of #

15. • Supernumerary teeth
• Preprosthetic extractions
• Teeth associated with pathologic lesions
• Esthetics
• Economics

16. Contraindications
Local :
 H/o radiation therapy in the area
 Acute pericoronal infection
 Teeth involved with central hemangioma/vascular
malformation
 Teeth associated with a tumor

17. Contraindic atr io n s : -
Systemic : -
 Uncontrolled metabolic diseases
 Malignant diseases
 Uncontrolled Cardiac conditions
 Pregnancy
 Sever blood dyscrasias

18. CHOICE OF ANESTHESIA

20. • Pain and anxiety control
•Position of the patient
•Position of the operator
•Clear access to and vision of the surgical field
•Use of controlled force- elevators & forceps
•Unimpeded path of removal
PRINCIPLES OF EXODONTIA

21.  Wedge Principle
 Lever Principle
 Wheel and axle Principle

22. PRINCIPLES OF ELEVATION
1. Lever principle:
Fulcrum is between the load & the effort arm. For mechanical
advantage the effort arm must be longer than the load or
resistance arm.

23. 2. Wedge principle:
Elevator forced between the root & the bone along the long axis of
the tooth

24. 3. Wheel & axle principle:.
Can be used with lever or wedge principle. Cross bars work in this
principles.

25. Mechanical Principles:-
 Expansion of the bony socket
 Use of a lever and fulcrum
 Insertion of wedge(s) b/w root and bony socket wall

26. SOCKET EXPANSION
WEDGE

27. POSITION OF THE OPERATOR

28. Ch a i r a n d o p e r a t o r p o s i t i o n :

29. ROLE OF DENTIST’S LEFT HAND

30. Hand Support During Extraction of
Maxillary Central Incisor

31. Hand Support During Extraction of
Maxillary Premolar

32. Hand Support During Extraction of
Maxillary Molar

33. Hand Support During Extraction of
Mandibular Central Incisor

34. Hand Support During Extraction of
Mandibular Premolar

35. Hand Support During Extraction of
Mandibular Molar

36. FORCEP EXTRACTION OF DECIDUOUS
TEETH
• Upper & lower anteriors & canines-Extracted similar to the
permanent tooth
• Care should b taken with the extraction of the primary molars due
to the developing permanent premolars underneath them
• Broken primary molar teeth can be elevated using the right angled
Warwick James elevator.

38. INTRA ALVEOLAR EXTRACTION
• It means direct access is gained on the tooth to be extracted.
• It is carried out with the help of dental forceps and elevators.

39. Forceps Technique
Indications
• Fairly mobile teeth,
• Extraction of single tooth,
• Extraction of multiple teeth which are scattered.
Contraindications
• In complicated extractions,
• Deformed roots,
• Hard tissue pathology of roots like hyper-cementosis etc.
• Badly destroyed teeth.

40. Advantages –
• It causes the least amount of trauma.
• Promotes retention of a satisfactory blood clot.
• Favours rapid healing.

41. Various movement for extraction of individual
tooth
Upper central, lateral,
canine, first pre-molar,
second pre-molar
First apical slight labial/buccal
slight palatal rotation with
traction
Upper molars First apical buccal palatal
deliver the tooth buccaly
Lower central, lateral,
canine, first pre-molar,
second pre-molar
First apical slight labial/buccal
slight lingual rotation with
traction
Lower molars First apical buccal lingual
deliver the tooth buccaly

42. Elevator technique
Indications
• To luxate teeth which cannot be engaged by beaks
of forceps
eg: impacted, malposed or grossly destructed teeth.
• To remove roots

43. DISADV
• Fracture of maxilla or mandible.
• Fracture of the alveolar process.
• Injuring the soft tissue if proper care is not taken.
• Penetrating into the maxillary sinus, during extraction of
maxillary posterior teeth.
• Forcing a maxillary root into the maxillary sinus or forcing the
apical third of the root of the lower third molar into the
mandibular canal or into submaxillary or pterygomandibular
space depending upon the position of the impacted third
molar.

44. Rules to be followed when using an Elevator –
• Never use an adjacent tooth as a fulcrum unless
that tooth is also to be removed.
• Never use the buccal plate at the gingival line as
fulcrum except in third molars.
• Always use finger guards to protect the patient in
case the elevator slips.
• Use interseptal bone as fulcrum.
• Avoid using an elevator to luxate a tooth which has
a tooth distal to it.

45. APPLICATION OF FORCEP BLADES

46. Maxillary
forceps

47. Maxillary
forceps

48. Mand ib ular
forceps

52. Elevators

53. Elevators

55. Transal veo l ar
method

56. OPEN METHOD/
TRANS-ALVEOLAR EXTRACTION
Consists of dissecting the tooth or root from bony
attachments by removal of some bone investing the
tooth/roots, which are then delivered by use of elevators
and/or forceps

57. Ind ications : -
 Root # during forcep extraction
 Need for excessive force that may lead to # root, bone
or both
 Dilacerated roots
 Ankylosed tooth
 Impacted/submerged tooth
 Endanger to anatomical structures

58. Advantages:
• Removal of teeth lying in difficult position without damaging the
neuro-vascular bundle.
• Fracture of bone avoided.
• Less danger of creating an oro-antral fistula.
• Less chance of tearing of soft tissues & fracture of large pieces
of alveolar bone.

59. Steps in Trans-alveolar extraction:
• Local anesthesia.
• Incision and reflection of mucoperiosteal flap.
• Removal of bone/ bone cutting.
• Sectioning of tooth, if required.
• Elevation of the tooth.

60. • Smoothening of sharp edges of bone.
• Control of bleeding.
• Debridement of the socket.
• Suturing the flap.
• Suture removal & post-operative follow up.

61. Incision:-

62. Firm, continuous stroke, deep to the bone
 Avoid vital adjacent structures
 Base should be wider than the apex of the flap
 Flap should either include or exclude a papila
 Relieving incisions should cross the mucogingival junction
so that flap can be reflected well
 healing takes place across and not on the incision line
(so length does not affect the healing time)

63. Bone removal:
• Either with a dental bur or by the use of a chisel. (hand or mallet pressure).
Using Chisel & mallet
is usually used for removal of bone in maxilla because the bone is soft.
• Adv: - post operative edema will be less
- less time consuming.
• Disadv: - in conscious patient, the sensation produced by chisel &
mallet is objectionable.
- problem to TMJ.
- chances of slippage of instrument.
- chances of fracture of jaw.
• Contraindications: -if the bone surrounding the tooth is very hard & sclerotic
- if the mandible is thin.
- if the root is brittle.

64. Using bur:
• Bone may be removed with bur either by simply cutting it using a No.8 or 10
round bur or flat fissure pattern or by using the ‘postage stamp method.’
• The bur must never be allowed to over-heat during bone removal. Constant
irrigation should be done with sterile normal saline.
Postage stamp method
• In this technique, rows of small holes is made with a small round bur & then
they are joined together with either bur or chisel cuts.
• This simple procedure will minimize the risk of damage to the surrounding
tissues & limits the cutting.
• Disadv: - post operative pain & edema
- delayed wound healing

65. Chisel vs Bur technique
Criteria Chisel & mallet Bur
Technique Difficult Easy
Patient
acceptance
Not tolerated Well tolerated
Chance of # bone High Less
Healing of bone Good Delayed
Post op edema Less More
Dry socket Less More
Post op infection Less More

66. B o n e r e m o v a l : -

67. T o o t h S e c t i o n i n g : -

71. Stobie technique – extraction of
multiple mandibular anteriors by
using elevators b/w teeth

72. Policy for leaving root fragments
• 3 conditions must exist for a tooth to be left in
the alveolar process
• Root fragment must be small
• Root deeply embedded in bone
• Root must not be infected

73. POST OPERATIVE CARE
• Care of the empty socket
• Post operative instructions
• Prescription of antibiotics and analgesics

74. REFEREENCES
• THE EXTRAACTION OF TEETH, SECOND EDITION
-GEOFFREY L. HOWE
• PRINCIPLES OF ORAL SURGERY, FOURTH EDITION
-J.R. MOORE
• ORAL & MAXILLOFACIAL SURGERY, VOL-2
-DANIEL M. LASKIN
• TEXTBOOK OF ORALMAXILLOFACIAL SURGERY
-NEELIMA MALIK
• TEXTBOOK OF ORAL SURGERY
-F. D. Fragiskos