It is a procedure that incorporates
principles of surgery, physics and
Painless removal of the tooth or root
with minimal injury to the
surrounding soft tissue & bone
Removal of tooth does not require
large amount of force, but fine and
controlled forced in such a manner
that tooth is not pulled from bone but
lifted gently from alveolar process
Pain and Anxiety control
Profound local anesthesia results in loss
of pain, temperature and touch but not
When the tooth has pulpitis or
surrounding soft & hard tissues inflamed
or infected, periodontal injection is
given, that gives anesthesia for 15-
20min. If it fails intra osseous injection
can be given.
Sensory innervation of jaws
Inferior alveolar nerve all mandibular
teeth, buccal soft tissues of PM,
canine & incisors.
Lingual nerve; Lingual soft tissues of
Long buccal nerve: Buccal- soft
tissues of molars.
Anterior superior alveolar nerve;
maxillary incisors and canine, buccal
soft tissues of incisors and canines.
Middle superior alveolar nerve: Max.
PM & MB root of 1st molar, Buccal
soft tissue of PM.
Post sup. Alveolar nerve: Max.
molars except a portion of 1st molar,
buccal soft tissues of molars.
Greater palatine palatine nerve;
Lingual soft tissues molars &
Nasopalatine nerve: Lingual soft
tissues of incisors and canines.
Mandibular PM region buccal soft
tissue innervated primarily by mental
branch of IAN and also by terminal
branches of long buccal nerve.
Duration of Anesthesia
1. Local anesthesia with out
Mand. teeth- 40-60min.
Soft tissue- 2-3 HR
2. Local anesthesia with
Max. teeth 50-60 min
Mand. teeth 90-100min
Soft tissue 3-4 HR
3. Long acting local anesthesia with
Max. teeth 60-90 min.
Mand teeth - 3HR
Soft tissue 4-9 HR
In case of mild anxiety- proper
explanation of procedure; assurance
that there will not be sharp pain,
expression of concern caring,
empathy will reduce anxiety.
In moderate anxiety: Preoperative
oral diazepam provide rest at night
before surgery and relieve anxiety in
Sedation by inhalation of nitrous
oxide or IV sedation with diazepam
can be given in severe anxiety.
Presurgical Medical Assessment
A proper medical history
Indications for removal of teeth
Severe caries: that can not be
Pulpal necrosis: if endodontic Rx can
not be performed becoz Pt declines,
or root canal that is tortuous, calcified
or endodontic failure.
Severe periodontal disease: excessive
bone loss and irreversible tooth
Mal - opposed teeth; if they
traumatize the soft tissue or can not
be repositioned by orthodontic Rx
(Max. III M. in severe buccal version
and causes ulceration & trauma
on cheek or teeth that are hyper
erupted becoz of loss of teeth in
Orthodontic reasons: Max. & Mand
PMs Mand. incisors are commonly
Cracked teeth: or with fractured root
Preprosthetic extraction: teeth
interfering with design and
placement of full dentures, partial
Impacted teeth: that is unable to
erupt to functional occlusion.
Supernumerary teeth: Impacted,
interfering with eruption of
succedaneous teeth or causing
resorption and displacement of
adjacent teeth should be extracted.
Teeth associated with pathologic
lesions: If maintaining the tooth
compromises, complete surgical
removal of lesion.
Pre - radiation therapy: remove
teeth in line of radiation therapy.
Severe attrition, abrasion or erosion
Teeth involved in jaw #: If tooth is
severely luxated, tooth in # line
should be removed.
Esthetics: Severely stained,
malopposed or protruding teeth are
Economics: inability of PT to pay or to
take time from work may require the
tooth to be extracted
Contraindications for removal of
End stage renal disease with severe
Uncontrolled cardiac disease
Unstable angina pectoris
Severely uncontrolled hypertension
Pregnancy 1st and last trimester
Bleeding disorders like hemophilia
Patients on anticoagulants
H/o therapeutic radiation- causes
Tooth in area of tumour: disseminate
cells and cause metastasis
Clinical Evaluation of teeth for
Tooth to be extracted is examined to
assess difficulty of extraction.
Access to tooth: if mouth opening of
PT is compromised-surgical
Mobility of tooth: teeth with less than
normal mobility should be assessed
for hypercementosis and ankylosis-
Condition of crown: if large portion
of crown is decayed by caries or
tooth with large amalgam
restoration, forceps is placed as far
apical as possible.
If large amount of calculus is
present on tooth, it should be
removed before extraction
otherwise it will interfere with
application of forceps or
contaminate socket after
If adjacent tooth has amalgam
restoration or undergone endodontic
therapy, care must be taken while
Radiographic Examination of tooth
IOPA shows portion of crown and root
of tooth under consideration
If it is a I° tooth its relationship with
a succedaneous tooth should be
Relationship of associated vital
For Max. teeth relation with max. sinus.
For Mand. Molars inferior alveolar canal
For Mand premolars relation with mental
Configuration of roots- If excess
curvature surgical extraction
Length of roots
Root # more liable to #
Root resorption liable to #
H/o endodontic Rx -tooth is brittle or
ankylosed -so surgical extraction.
Condition of surrounding bone
If more radio opaque- condensing
osteitis or sclerosis- so difficult to
Periapical pathologies- should be
removed after extraction.
Patient & surgeon Preparation
All patients should be considered as
having blood born disease.
Surgeon should wear surgical gloves,
mask, eyewear with side shield, long
If surgeon has long hair it should be
covered with surgical CAP.
Order of extraction
Lower teeth are removed before the
upper & posteriors are removed
before anteriors to prevent bleeding
from socket obscuring field of
Methods of extraction
Closed or intra-alveolar
Open or transalveolar or surgical
Stobie technique – extraction of
multiple mandibular anteriors by
using elevators b/w teeth
Chair position for forceps
Best position is one that is most
comfortable to PT & to surgeon.
Correct position allows surgeon to
deliver force with arm and shoulder
and not with hand.
For Max. extraction,
Position of chair
Height of chair is such that height of
patient's mouth is at or slightly below
Chair is tipped backward that
Max.occlusal plane is 60° to floor
Position of patient
During procedures of Max. Right + left
quadrant PT's head is turned towards
For Max. Ant. Teeth, PT should be
looking straight ahead.
Position of operator
Front & right side of the patient for right
handed operator & reverse in left handed
Position of left arm
Left upper teeth, thumb supports the
palatal alveolar bone & index finger
retract the buccal tissues
Right upper teeth – thumb retracts the
buccal tissues & index finger supports
the palatal alveolar bone
In left handed operator the reverse
Position of chair
Chair is positioned in such a way that,
Mand. occlusal plane is parallel to floor.
Surgeon's arms are inclined downward at
an angle of 120° at elbow.
Position of patient
In Mand. right post teeth-PT is turned
Position of operator
Mand. right post teeth, operator is
behind the pt &
In Mand. left post region, surgeon is in
front of PT.
Left handed operator the position is
If surgeon chooses to sit, the PT is at a
more lower level than standing and other
position are similar
Position of left arm
Lower left teeth – thumb supports the
mandible &index finger retracts the
buccal soft tissues ,middle finger controls
Lower right teeth – index finger retract
the buccal tissues, thumb controls the
tongue & other fingers supports the
Reverse for left handed operator
Mechanical Principles Involved
in tooth extraction:
Elevators I°rly works on lever
principle E.g straight elevator
Wedge principle is also used when
elevator is used to luxate tooth.
Wheel and axle principle is used by
triangular shaped elevators
E.g Cryer's elevator
Principles of forceps use
Use of forceps:
To expand bony socket
To remove tooth
Forceps should be placed below CEJ
Traction towards least resistance
For removal of anterior teeth or roots
After detaching the labial gingiva the
labial beak is placed under the tissues in
alveolar bone &apply pressure
Major Motions of forceps
1.Apical pressure: Tooth socket is
expanded by insertion of beaks down
into periodontal ligament.
2. Buccal pressure: produces
expansion of buccal plate and lingual
Lingual pressure: Expands lingual
cortical plate and buccal apical
Rotational pressure: Teeth with
single conical roots e.g. Max. incisors
Mand. PM, But the roots should not
Tractional force: For delivering tooth
out of socket.
Procedure for closed extraction:
Requirements for extraction
Adequate access and visibility
Unimpeded pathway of removal
Use of controlled force.
General steps for closed
Loosening of soft tissue attachment
Done by a Periosteal elevator
Helps to assess anesthesia
Allows extraction forceps to be placed
Luxation of tooth with a dental
A straight elevator is inserted to the
tooth into interdental space.
Strong, slow, forceful, turning of
handle moves tooth in posterior
direction causing expansion of bone
Tearing of periodontal ligament
Excess force can damage or displace
adjacent tooth especially if it has a
large restoration or caries
Adaptation of forceps to tooth:
Tips of forceps beaks should grasp root
Lingual beak is seated first.
Beaks must be parallel to long axis of
Force should be applied with shoulder &
upper arm & not with wrist.
Sterile drape should be put across
Before Extraction, PT should
vigorously rinse mouth with antiseptic
4X4 inch gauze can be placed in to
back of mouth to prevent teeth or
fragments falling into mouth
Luxation of tooth with forceps:
Major force should be directed towards
thinnest portion of bone.
Slow steady force is used.
Removal of tooth from socket:
Done by tractional force usually given
Role of opposite hand
Reflect soft tissues of cheek, lips and
tongue, give visibility.
Protect other teeth from forceps.
Stabilize PT's head
Supporting and stabilizing mand. during
Supports alveolar process and provide
tactile information about expansion of
Role of assistant
Helps to visualize and gain access, by
reflecting soft tissues and tongue
Suction away blood, saliva, irrigating
Specific Technique for removal
of Each tooth
Maxillary incisor teeth:
They have conical roots.
LI may have a distal curvature for root.
Alveolar bone is thin over buccal side
and thick over palatal side.
After apical Pre. the force is given
buccally, less palatal force followed by
rotational force, no rotational force if
there is curvature.
Tooth is delivered in labial direction
Longest tooth in mouth
Root is oblong in C.S.
Bone on labial aspect is thin. So a
fragment of bone usually fractures from
buccal aspect when tooth is removed.
Buccal, palatal and a small amount of
rotational movement and removed in
labio - incisal direction.
If Bone is detached from periosteum, it
should be removed.
If buccal bone is attached to periosteum,
it can be left, normal healing will occur.
Maxillary I PM
Single rooted with bifurcation to bucco-
lingual roots at apical 1/3
Most common root #
Buccal bone is thinner
Tooth should be luxated as much as
Apical, buccal, palatal movements,
palatal should be less
Maxillary II PM
Thin bone buccally and thick palatally
Buccal, palatal, bucco - occlusal
3 roots,2 buccal roots are relatively
closer and palatal is divergent towards
Buccal cortical plate is thinner than
Forceps have projection on buccal beak
to fit buccal bifurcation.
Upper cowhorn forceps is used in teeth
with large caries or restoration.
More buccal force, less palatal force
removed with bucco occlusal tractional
II M similar anatomy except less
divergence for roots and removed in
Erupted III M. conical roots
Easily extracted by elevators alone
Mand. ANT. Teeth
Incisor roots are thinner and shorter and
canine roots are longer and heavler.
Bone on labial aspect of canine is
Equal movements labially, lingually &
tooth is luxated by a rotational force &
extracted by labio-incisal tractional force
Roots are straight & conical
Bone thinner on buccal & thicker on
Buccal, less lingual, rotational and
occluso - buccal tractional force.
If any root curvature rotation is avoided
2 roots and widely divergent for IM
Roots may converge at apical 1/3
Most difficult of all teeth to extract.
Apical, buccal, lingual and bucco occlusal
Lingual bone is thinner than buccal so
more lingual pressure
Lower cowhorn forceps is used by
squeezing the bifurcation, buccolingual
movements can also be used.
Erupted mand. III M. Conical roots
lingual plate is thinner, so more
movements are given lingually and
delivered in lingo occlusal direction.
Modification for extraction of I°
Similar buccolingual movements
Rotational movement is avoided for
Tooth is delivered in least resistant
If the roots embrace PMT crown,
sectioning of roots should be done
Post extraction care
If any periapical pathology in
radiograph, and no granuloma
removed with extracted tooth,
periapical area is carefully curetted.
If any debris, calculus, amalgam, tooth
fragment, in socket it is removed with
Remnants of periodontal ligament &
bleeding bony walls improves healing.
Vigorous curettage delay healing by
causing additional injury
Finger pressure is applied to buccal &
lingual cortical plates to compress the
socket, to prevent bony undercuts
If there is excess granulation tissue
around gingival cuff, it should be
removed with curette or hemostat.
Sharp bony projections should be
smoothed with bone file.
Moistened 2x2 inch gauze is placed
over extraction socket and it should fit
into the space that was previously
occupied by tooth. So that biting force
will give pressure, will cause
Larger gauze is placed if multiple teeth
extracted of opposing tooth is missing.
Failure to remove tooth by closed
Unfavourable root pattern
Fracture or caries extending to root
Steps in open extraction
Raising mucoperiosteal flap
Removal of bone around the tooth or
Establishment of point of application
Removal of tooth from socket
Trimming the bone
Toileting the wound
Control of bleeding
Repositioning & suturing
Planning of an incision
Def.of incision-a cut or wound
deliberately made by an operator in
skin or mucosa using a sharp
instrument, so that the underlying
structures can be exposed for surgical
Incision is placed parallel to
structures without causing damage to
Extraoral incisions are planned along
the Langers lines of normal skin
tension or creases, so that min. scar
Incision should be placed on sound
Pen grasp (intraoral) or table knife
(extra oral) grasp is used
Skin or mucosa to be incised to be
stabilized with finger pressure to
guide the passage of blade.
A firm continuous stroke should be
Change in direction is accomplished
by a gradual curve.
Incisions in oral cavity
Incise through attached gingiva over
a healthy bone.
Incisions placed near teeth for
extractions should be made in
Integrity of interdental papilla should
Incisions involving reflection of
mucoperiosteal flap are direct,
straight-line or curvilinear taking the
shortest distance vertically through
Blood supply to the incision should be
Contraindications for placement
Over canine prominence
Vertical incision in mental nerve
Near greater palatine vessels in
Through incisive papillae.
Over bony lesions
Vertical incision on lingual side of
Types of incisions
Horizontal:-given along the gingival
margin either mesially or distally. e.g.
Internal bevel incision & crevicular
Vertical:-also called releasing incision
Single vertical incision-triangular flap
Double vertical incisions-trapezoidal flap
Incision should extend beyond
mucogingival line to alveolar mucosa.
Vertical incisions should be placed at
obtuse angle to horizontal incision &
should leave interdental papillae intact
Used to maintain attached gingiva intact
& for endodontic surgery.
Horizontal component rest on bone.
5mm gap is present from base of
gingival sulcus to incision.
Complications of flap surgery
Flap tearing:-to prevent this
Incision should be clean,sharp&should
penetrate entire mucoperiosteum.
Flap should be reflected as one unit.
Length of flap should not be more than
twice the width of base.
Flap necrosis:-to prevent this
Base of flap should be wider.
Margins of flap should be either parallel
to each other or converge from base to
Axial blood supply should be included in
flap e.g.palatal flap based on greater
Flap dehiscence=separation of flap
margins or gaping of wound.
Poor tissue handling
Too tight suturing
Sutures are placed over healthy bone.
Most common type
Sulcular incision is made around the
tooth on buccal or lingual aspect
including interdental papillae.
Entire mucoperiosteal flap is
Mainly used in surgical extraction of
A vertical releasing incision is made
on one side of envelope flap diverging
towards buccal vestibule.
Vertical incision is made in the
interproximal area not on the facial
aspect of tooth to avoid periodontal
Flap is reflected towards the base of
2 vertical releasing incisions are
made on either side of envelope flap.
Base of flap should be wider.
Used in periapical surgery.
Suture line should not be on bony
Toileting the wound
Debridement of necrotic, foreign
bodies, severely injured tissues.
Use of medicated mouthwashes after
every food intake.
Hemostasis should be achieved
To minimize blood loss.
Reduces operating time
Minimizes postsurgical trauma.
it can be achieved by
Intermittent pressure:-with cotton
or gauze sponges. pressure is applied
for 20-30sec for smaller vessels&5-10
min. for larger vessels.
Electrocautery:-for this area around
the vessel is dried thoroughly.Avoid
Suture ligation:-when large vessel
is severed it is grasped with
hemostat. Nonabsorbable suture is
used to ligate the vessel.
thrombin or collagen gel foam
Compression dressing over the
wound:-if there is oozing over a
large area a cotton pad or ribbon
gauze is stabilized over the wound
&secured in position with sutures &
kept for 2-3 days.
Dry socket or alveolar osteitis
Undue trauma during extraction
Pre existing infection
Disturbance of clot due to vigorous
mouth wash or curettage
Increased fibrinolytic activity
Localized impaired vascular supply
Use of OCP
Continuous throbbing & excruciating pain
h/o extraction 48-72 hrs
Alveolar socket is covered with grayish
Denuded alveolar bone
Irrigate with warm saline or
chlorhexidine for removal of dead
bone or infected tissues
Do not curette
Obtundant dressing (ZOE with cotton
to cover the denuded bone or
Control bleeding prior to closure
Apply ice extraorally
Antibiotics to prevent infection
Anti inflammatory drugs