Exodontia Copyright by Department of Oral & Maxillofacial Surgery, University of Dental Medicine, Yangon

1. Department of Oral & Maxillofacial Surgery
University of Dental Medicine

2. What is ideal exodontia?
 Painless removal of the whole tooth or tooth root with
minimal trauma to the investing tissue, so that, the
wound heals uneventfully and no post-operative
prosthetic problem is created.
 Exo out, dontia tooth
 Extraction of tooth

3. Indications for removal of teeth
 Variety of reasons
 In modern dentistry, all possible measures should be
taken to preserve and maintain the teeth in oral cavity.
 Indications are just recommendation. There is no
absolute rule.

4. 1. Severe caries
 most common and widely accepted reason
 that is, severely carious, which is beyond the
available conservative management, which is a
judgment between the dentist and patient
2. Pulp necrosis
 presence of pulp necrosis and irreversible pulpitis
 not possible to do endodontic management ( may be,
patient declining endodontic treatment, tortuous or
calcified root which is untreatable by standard
endodontic management
 endodontic failure

5. 3 Severe periodontal diseases
 severe periodontitis excessive bone loss
and irreversible tooth mobility beyond the
periodontal management
4 Orthodontic reasons
 orthodintic correction
 extruded dentition to provide space for
tooth alignment

6. 5 Mal-opposed teeth
 mal-opposed teeth or mal-positioned teeth may be
indicated for removal in severe situation
 some these tooth could traumatized the soft tissue
leading to ulceration, and which can not be
repositioned by orthodontic management ( example
: severe buccally erupted maxillary third molar )
 loss of teeth especially in lower arch leading to
hyper-erupted tooth of upper arch which interfere
prosthetic management

7. 6 Cracked tooth
 clear but uncommon
 that is cracked or has a fractured root
 painful unmanageable by a simple
conservative technique
 even complex restorative procedure can not
relieve pain of the cracked tooth

8. 7 Pre-prosthetic extraction
 occasionally, some teeth interfere with the design
and proper placement of prosthetic appliances
8 Impacted teeth
 should be considered for removal
 partially impacted tooth is unable to erupt into
functional occlusion because of inadequate space or
interfere from adjacent teeth
 contraindicated in patient’s age is more then 35,
which is fully bony impacted without any symptoms
medically compromised

9. 9 Supernumerary teeth
 usually impacted
 which interfere with eruption of permanent teeth (
has the potential for causing resorption and
displacement of permanent tooth )
10 Teeth associated with pathologic lesion
 may be required
 some of the tooth can be retained by complex
endodontic therapy ( example : small radicular cyst)
 maintaining the tooth compromises the complete
surgical removal of the lesion, the tooth should be
removed

10. 11 Pre-radiation therapy
 to be considered for removal of bad or diseased
tooth or teeth in the line of radiation therapy
12 Teeth involved in fractured jaw
 teeth involved in line of fracture can be maintained,
except, the tooth is severely luxated or may be
necessary to prevent infection
13 Teeth /Tooth with apical pathology
14 Root fragments and retained deciduous tooth/teeth

11. 15 Esthetics
 severely stained (tetra; stained, fluorosis, severely
protruded which too beyond the orthodontic
management)
 also depend on the patient decision ( after the
explanation of detailed treatment plan )
16 Economic
 unwilling or unable financial support to maintain the
tooth teeth

12. Contraindications for removal of teeth
SYSTEMIC CONTRAINDICATION
LOCAL CONTRAINDICATION

13. Systemic contraindication
 The patient’s systemic health is inability to withstand the
surgical stresses
a) Uncontrolled metabolic disease – such as D/M
mild D/M and well controlled severe D/M can be treated
b) Uncontrolled leukaemias and lymphoma –
 should not have removal of teeth until under
controlled
 infection because of abnormal WBC
 Bleeding disorder bleeding tendency with excessive
bleeding , such as, in the case of platelet disorder

14. c) Uncontrolled cardiac diseases
such as – IHD, valvular heart diseases, heart failure……
d) Uncontrolled hypertension
persistent bleeding can be occurred
CVA as a result of stress
e) Pregnancy
especially first and last trimester
later part of first trimester and first month of last
trimester as safe as middle or 2nd trimester
if possible, deferred until the child has been delivered

15. f) Severe bleeding diathesis
- haemophilia, platelet disorders, cogulopathy
g) Medications
- such as corticosteroids, immunosuppressive, cancer
chemotherapeutic agents, long term use of low dose
asprin ….
h) Organ failure
such as liver failure, renal failure
some renal and liver diseses

16. Local contraindication
a) History of therapeutic radiation for head and neck
cancer
b) Tooth or teeth located within tumour especially
malignant tumour.(hasten the metastatic process
and disseminate cells)
c) Severe pericoronitis
d) Acute dentoalveolar abscess
e) Acute infection especially with an uncontrolled
cellulitis

17. ASA – American Society of Anesthesiologists
established in 1940 , modified in 1961
 System of classifying patients according to their physical status and guiding
judgement decisions
 ASA I – Normal healthy patient
 ASA II – A patient with mild systemic disease that does not interfere with day to
day activity or that has a significant health risk factor
 ASA III- A patient with moderate to severe systemic disease that is not
incapacitating but that may alter day-to-day activity; may have significant drug
concerns; may require special patient care; would generally require dental
management alterations
 ASA IV- A patient with severe systemic disease that is a constant threat to life;
definitely requires dental management alterations; best treated in special facility
 ASA V – Moribund , not expected to live 24hrs regardless of operation
 e – emergency operation

18.  ASA II , III , IV – consultation , specialist opinion
 Fit to do extraction /surgery - justification

19. Evaluation of teeth for removal
I. Clinical evaluation
a. Access to the tooth
b. Mobility of the tooth
c. Condition of the crown
d. Condition of the adjacent teeth
e. General condition of patient
II. Radiological evaluation
a. Associated vital structure
b. Configuration of the root/roots
c. Conditions of the surrounding bone and structure

20. Clinical Evaluation
Access to the tooth
 Mouth opening(any limitation-?)
 -trismus – limitation of the opening of the mouth due
to the spasm of muscle of mastication (most likely
causes are – infection, TMJ dysfunction, muscle
fibrosis)
 Location and position of tooth
 -normal or crowded dentation, ant. or post.
 Partially erupted or unerupted

21.  Mobility of the tooth
 -usually greater than normal mobility is frequently
seen in severe periodontal disease
 -less than normal mobility –presence of
hypercementosis or ankylosis of root (retain root,
endodontically treated tooth )

22. Condition of crown
 -large caries or heavy restoration- crushing the crown
 -forceps be applied as far apically as possible- so as to
grasp the root portion of the tooth, in stead of the
crown.
 -condition of adjacent tooth- any heavy restoration?

23. Radiographic evaluation of tooth
for removal
 -The most accurate and detailed information
concerning the tooth , it’ s root and surrounding
tissue.
 -Radiographs that are taken but not available
during surgery are not valuable.
(1)Relationship of associated vital structure
 Aware of the proximity of the maxillary molar ‘ s
root to the floor of the maxillary sinus

24.  Inferior alveolar canal - injury to nerve
 Mandibular premolar – mental foramen- especially
surgical flap
(2) Configuration of root
 Number of root
 Curvature of root and degree of divergence
 Size and shape of root

25.  Eg. Short and conical shape root – easy flat root -
quite difficult
 Condition of root - hypercementosis , internal
resorption , ankylosis
(4) Condition of surrounding bone
 Periapical radiograph indicates density of
surrounding bone

26.  Radiographically more opaque indicate more
density of bone
 Periapical radioluency ?

27. Steps to remember
 Surgical plan
 Anaesthesia
 Asepsis
 Proper instrument
 Surgical assistance
 Light
 Atraumatic surgery
 Haemostasis
 Wound care
 Postoperative regimen

28. Position of the patient
 Upper teeth- occlusal plane - about the shoulder level
of the operator.
 Lower teeth- occlusal plane – about the elbow level of
the opertor.
Position of the operator
All upper teeth-right anterior
For lower teeth, left posterior and all anterior right
anterior

29.  Right posterior right posterior
Position of the Hand
 For upper teeth, first finger and thumb should be
placed on either side of the tooth
 -Left posterior ----thumb (P), first (B)
 -Anterior -----------thumb(P), first (B)
 -Right posterior --- thumb(B), first (P)

30.  For lower teeth
 -Left posterior and right anterior ---first finger—(B),
Second finger (L), thumb (support the jaw extraorally)
 -Right posterior – (operator’s position) ---right
posterior--- thumb (L), first finger (B), others---
support jaw extraorally.

31.  Order of Extraction
 Anaesthesia---- more earlier in the maxilla
 Usually maxillary teeth are extracted first (debris and
any fragments cannot be lost in open mandibular
socket)
 Posterior teeth should be removed first for better
vision --- blood can collect in posterior region

32.  First molar and canine are extracted after the adjacent
teeth are removed for better purchase and earlier plate
expansion.
 (more difficult and long root)
 so as usual--- 8,7,5,6,4,2,3,1

33. What is Dental/Extraction forceps?
 Components
 ---Handle
 ---Hinge
 ---Beak
 2 Goals
 (I) Expansion of bony socket by use of wedge shape
books of forceps and movement of tooth itself with the
forceps.
 (II) Removal of tooth from the socket.

34. Dental forceps
 Five major motions
 (I)Apical pressure
 (a) minimal movement of tooth in apical direction.
 (b) the center of tooth rotation is displaced apically.
 (II) Buccal force
 (III) Lingual force
 (IV) Rotational pressure
 (V) Tractional force

35. Dental Elevators
 Used to luxate teeth from the surrounding bone.
 Loosening teeth make a difficult extraction  easier
 Minimize the incidence of broken roots and teeth.
 Even fractured occurred after luxation  fractured
root/teeth can be removed easily
 To expand the alveolar bone.

36.  Three major components
 -blade, handle, shank
 Sometime ‘T’ bar handle are used Caution can
generate a very large amount of force.
 Three basic types
 Straight (or) gauge type.
 Triangle (or) pennant-type pick type.
 Wedge action (√√√)
 Wheel and Axle action (√√)
 Lever action(√)

37. Extraction techniques ;
 Closed
 Open

38. Techniques
 Closed type of exodontia; Simple or forceps
technique, Intra alveolar extraction
 Open type of exodontia; Surgical or flap technique ,
Complicated exodontia, Trans alveolar extraction

39. Closed type of exodontia;
 Simple or forceps technique
 Primary consideration for almost every extraction.
Intra- alveolar extraction which require either forceps
or elevator without surgical flap
 Alveolar purchase is when the crest of the alveolar
bone is purchased by the forceps along with the
coronal portion of the root and remove.

40. Consent
 Procedures under LA is commonly obtained verbally
 Consent to the procedure and full explaination of the
options and consequences
 Recognises a patient's right of autonomy

41. Procedure of closed extraction ;
 loosening of soft tissue attachment from cervical portion of
the tooth
 gently first ,increasing force
 check for profound anaesthesia
 luxation of the tooth with elevator
 adaption of the forceps
 beaks of the forceps must be held parallel to the long axis of
the tooth
 forceps must be seated apically as far as possible , below CEJ

42.  luxation of the tooth with forceps by the adaptation of forcep
to the tooth
 expansion of the alveolar bone and tearing of the periodontal
ligament
 bone direction towards the thinnest and therefore the
weakest bone
 bucco-lingually not jerky wiggles , bone time to expand
 removal of tooth from the socket – slight traction force
usually directed buccally

43. Post extraction instructions
 The swab over the socket must be bit firmly for one hour
 Avoid rinsing and spitting for 24hs after extraction
 Avoid taking hot food and drink for 24 hrs
 Do not explore the wound with tongue ,fingers , lips and cheeks
 Avoid smoking , alcohol drinking and also excessive physical exercise for 24
hrs
 If bleeding occur , place sterile swab over the socket and bite firmly without
releasing the pressure for another one hour
 If the problem persists , come back or contact to the Dental surgeon
 Prescribed medicine should be taken as directed
 Brush other teeth , but avoid the wound or socket
 TCA according to the instruction

44. Postoperative Patient Management for Extraction
I. Control of Post-op bleeding
II. Control of Post-op pain and discomfort
III. Post-op follow up visit
IV. Operative note for records

45. I - Control of Post-op bleeding
 -placement of small damp gauze pack directly over the
empty socket has adequate size(if it is too large does not
pressure to the bleeding socket)
 (moisten/damp gauze oozing blood does not coagulate
in the gauze)
 -at least 30minutes, not chew, just to hold with firm
pressure.
 Slight oozing for 24hrs after extraction is usually normal.
 gives post-op instructions to prevent dislodgement of the
blood clot.

46. II- Control of post-op pain and discomfort
(A) pain  Analgesics
 -Even in the cases with low level of pain patient should
be told to take analgesics post-operatively to prevent initial
discomfort when L.A. action disappear.
 First dose of analgesics before the affect of L.A. subsides.
 Post-op pain much more difficult to overcome, if
administration is delayed.
 What about medical history?
 Choice of drugs.

47. (B)- Diet
 High-caloric, high-volume semisolid/liquid diet is best
for the 1st 12 to 24 hours.
 Feed- soft & cool.
(C) Oral Hygiene
 Keeping the teeth and mouth reasonably clean 
which result is more rapid healing of surgical wound.
 Antiseptic mouth wash.

48. (D) Oedema
 Simple extraction of single tooth will probably not
result.
 (Multiple extraction, large amount of bone removal,
trauma ↑↑↑)
 Ice bag kept on the local area for 20 minutes & left
off for 20 minutes (not more than 24 hours)
 2nd day  neither ice nor heat
 Swelling reaches its maximum within 24-72 hours,
after surgery.

49.  Moderate amount of swelling usually normal &
healthy reaction of tissue to the trauma of surgery.
 (E) Control of infection
 Especially in preexisting infection(+) & depressed
host-defense response.
 (F) Other
 Trismus
 Ecchymosis blood oozes submucosally &
subcutaneously.
 Especially  old age.

50. III- Post-op follow-up visit
 Check the patient’s progress after surgery & any
further management.
IV- Operative note for the record
 Critical factors must be entered into the record.

51. Surgical Complications of Exodontia
I- Complication during the operative procedures.
A. Soft tissue injuries
B. Injuries to osseous structures
C. Oral-antral ( Oro-antral Communication)
D. Fractures of the mandible
E. Injuries to adjacent teeth
F. Complication with the tooth being extracted
G. Injuries to adjacent structures.

52. II- Complications during the post-operative period
 A- Bleeding
 B- Delayed healing and infection
III- Prevention of Complications

53. Surgical Complications of Exodontia
 I- Complication occurring during the operative
procedure
(A) Soft tissues injuries
 All most always as a result of the surgeon’s lack of
adequate attention to the delicate nature of the
mucosa and , the use of excessive & uncontrolled force.
 Tearing of the mucosa flap during surgical extraction
of tooth.
 (Inadequate flap size create adequately sized flap &
use small amount of retraction)

54.  Not duly attentive use of elevators leads to puncturing of soft
tissues.
 Abrasions or burns of the lip & corners of the mouth.
(B) Injuries to osseous structures
 Usually, the surrounding bone can be expanded to allow an
unimpeded pathway for tooth removal.
 Sometimes, fracture can be occurred, instead of expanding of
alveolar bone.
 Use of excessive force (or) uncontrolled force.
 Usually occurred at buccal cortical plate over the maxillary
canine, & maxillary molar, portions of the floor of the maxillary
sinus (associated with maxillary molars), the maxillary
tuberosity , labial bone of mandibular incisors.

55.  Prevention care pre-op assessment.
 Elder patient move brittle, less elastic more likely to
fracture.
 Major therapeutic goal to maintain the fracture bone.
(C) Oro-antral Communication
 Removal of maxillary molars occasionally results in
communication between the oral cavity and the maxillary
sinus.
 Large sinus, no bone between teeth & sinus, roots are
widely divergent….

56.  Two common sequelae post-op maxillary sinusitis &
formation of chronic OAF.
 It’s related to size of OAC & management of the exposures.
 Careful pre-op assessment.
 Diagnosis can be made in several ways
 -bone adhering to the roots end
 -small bone (or) no bone?
 -nose-blowing test air passage, bubbling of blood.
 Treatment depend on approximate size of communication.

57.  <2mm  no additional surgical management, to
ensure high-quality blood clot and sinus precautions.
 Probing of communication is absolutely
contraindication is absolutely contraindicated(
Unnecessarily lacerate the membrane, introduce
foreign bodies & bacteria leading to further
complication.
 Sinus precaution avoid blowing the nose, violent
sneezing, sucking on straws & smoke  In order to
avoid pressure changes.

58.  Size 2-6mm figure of ‘8’ suture and sinus precaution and
medications penicillin or erythromycin for 7 days and
antihistamine and nasal decongestant nasal spray.
 >7mm  closing the OAC with flap procedures  buccal
flap, palatal rotation flap and sinus precautions and
medications.
(D) Fracture of mandible
 rare complication
 Application of a force exceeding that needed to remove a
tooth and often occurs during the use of dental elevators.

59.  Lower third molars deeply seated fracture
occurred, even with small amount of force.(Atrophic
mandible..)
(E) Injuries to adjacent teeth.
 The focus of attention is mostly on that particular
tooth.
 So, likelihood of injury to the adjacent teeth increases.
 Most common fracture of either a restoration or a
severely carious lesion of adjacent teeth, while the
surgeon is attempting the tooth to be removed with an
elevator. (Warning Before management)

60.  Inappropriate use of the extraction instruments
especially in crowded dentition.
 Teeth in the opposite arch may also be injuried as a result
of uncontrolled tractional forces.
 Extraction of wrong tooth especially mixed dentition
with abnormal shape and size.
(F) Complication with the tooth being extracted
 Root fracture
 especially long, curved, divergent roots that lie in dense
bone are most likely to be fracture with especially by using
 uncontrolled force.

61.  must be balanced risk and benefit
1) if removal of the tooth root will cause excessive
destruction of surrounding bone
2) if removal of the tooth root endangers vital structure
3) root tip can displaced into tissue spaces or
anatomical structure such as maxillary sinus

62.  the patient must be informed that, the surgeon’s
judgment, leaving the root in its position will do less
harm than surgery
 must be recorded in the patient chart with
radiographic documentation
 must be recalled
 contact the surgeon immediately , should any
problems develop

63.  Policy for leaving root fragments
Size less than 4 -5mm in length
Root must be deeply embedded in bone
Tooth must not be infected, no radiolucency around
root apex.
Please balance between “Benefit and Risk”
Root displacement
Most commonly displace into unfavourable anatomic
space is the maxillary molar rootwhich is the forced
into the maxillary sinus.

64.  1st Identify size of root/fragments
  any infection (tooth or sinus)
 (G) Injury to adjacent structures
 Most likely to be injured during extraction are the
branches of 5th cranial nerve.
 (Mental, Lingual( severe)
 , long buccal and nasopalatine  not severe
Reinnervation of affected area usually occur rapidly.

65.  Another major structure that can be traumatized  is
TMJ especially, when removal of mandibular molars
frequently requries a substantial amount of force.
 Why uncontrolled force and inadequate support.

66. II- Complications occuring during the Post-
operative period
 (A) Bleeding
 (B) Delayed wound healing and infection.

67. (A) Bleeding
a) Several reasons
b) Tissue of mouth and jaws are highly vascularized.
c) Extraction  open wound which allows additonal
oozing and bleeding
d) Impossible to apply dressing material
e) Salivary enzymes may lyse the blood clot before it has
organized.

68.  Prevention of bleeding Best management
 Any bleeding problems in the past.
 Any family history of bleeding.
 Any medication that may interfere with coagulation.
Eg- aspirin, anticoagulant, antibiotics, alcohol,
anticancer.
 Any systemic disease that interfere coagulation. Eg –
hypertension, non-alcoholic liver disease.
 Post-op instruction

69. Treatment Applied pressure
Patient bites down firmly for at least 30 minutes with 2” × 2”
damp sponge
 Surgeon should not dismiss the patient from the office
until haemostasis has been achieved.
 Others material for haemostasis
 -absorbable gelatin sponge ( Gel foam)
 -oxidized regenerated cellulose ( Surgical)
 Liquid preparation of topical thrombin can be saturated
onto a gelatin sponge.( convert fibrinogin  fibrin)

70.  Collagen  plug (platelets aggregation)
 tape
 Some bleeding patient does not follow the post-op
instruction.
 Post-op bleeding into adjacent soft tissue
Ecchymosis.

71. (B) Delayed wound healing and infection
 Prevention of infection Asepsis and thorough
wound debridement
 Wound dehiscence sutured under tension
  Unsupported soft tissues flap
 Dry socket (or) A A O.

72. Thanking you