This document provides an overview of exodontia (tooth extraction). It begins with definitions, noting that the ideal extraction removes the whole tooth with minimal trauma. It then covers the types of extractions, history of dentistry and forceps, indications, contraindications, preoperative assessment, armamentarium including different forceps and elevators, extraction procedures, postoperative care, complications, and advances in the field. Key points include that extractions aim to gently lift the tooth from the alveolar process using controlled force. Medical history, tooth condition, and radiographs must be evaluated preoperatively to plan the procedure.

2. EXODONTIA
Presented by
Mala. M
1st year Post graduate student
Dept. of oral and maxillofacial surgery
Guided by
Dr. Santosh Nandimath

3. CONTENTS
INTRODUCTION
DEFINITION
TYPES
HISTORY
INDICATIONS
CONTRAINDICATIONS
PRE OPERATIVE ASSESSMENT
ARMAMENTARIUM
GENERAL CONSIDERATIONS
EXTRACTION PROCEDURE
INTRALVEOLAR EXTRACTION
TRASALVEOLAR EXTRACTION
POST OPERATIVE CARE
COMPLICATIONS AND ITS MANAGEMENT
NEWER ADVANCES

4. INTRODUCTION
EXODONTIA- The term exodontia means
extraction/removal of teeth.
Extraction of tooth does not require large amount of
force, but a fine and controlled force, so that the
tooth is gently lifted from alveolar process and not
pulled out.

5. DEFINITION
The ideal tooth extraction is the painless removal of
the whole tooth, or tooth- root, with minimal trauma
to the investing tissues, so that the wound heals
uneventfully and no post operative prosthetic problem
is created.
- Geoffrey L Howe
Types
Intra-alveolar extraction
Trans-alveolar extraction

6. HISTORY
The first Dentist was an Egyptian
_Hesi re(3100-2181bc)
The History of Dental Extraction forceps was very old
and goes back to the time of Aristotle (384-322bc).
Aristotle described the mechanics of oral surgery
forceps and later Archimedes studied and discussed
principles of lever.

9. Dentistry was not a separate profession at that time and mainly
the barbers were extracting the tooth popularly known as ‘barber
surgeons’. They used to hang rows of rotten teeth outside their
shops to advertise their services as tooth pullers.
The operator used to hold the patient’s
head between his knees, the soft tissue was cut with a sharp
scalpel, and the tooth was pulled out in single direction.
Often the wound was cauterized with a red hot iron.

10. Evolution of dental forceps

11. INDICATIONS
SEVERE CARIES
PULP AND PERIAPICAL PATHOLOGY
SEVERE PERIODONTAL DISEASE
ORTHODONTIC CONSIDERARTION

12.  Impacted teeth
 Fractured teeth
 Prosthodontic
considerations

13.  Over retained deciduous teeth
 Cracked teeth
 Pre radiation
 Fractured tooth

14.  Teeth associated with pathological
lesions
 Supernumerary teeth
 Teeth in fracture line
 Aesthetic considerations
 Economics

15. CONTRAINDICATIONS
RELATIVE CONTRAINDICATIONS
LOCAL CONTAINDICATIONS
Acute infection
Acute pericoronitis
Acute oral infections

16. SYSTEMIC CONTRAINDICATIONS
Uncontrolled diabetes mellitus
Pulmonary disorders
 Bronchial Asthma
 COPD
 Pulmonary Effusion
CVS Disorders
 Hypertension
 Ischemic Heart Disease
 Angina Pectoris
 Myocardial infraction
 Congestive Cardiac failure
 Valvular heart disorders

17. Hepatic disorders
Acute liver infections
Liver disorders
Rental Disorders
Glomerulonephritis
Uremia
Chronic renal failure
Neurological disorders
Stroke
Epilepsy
 Endocrine disorders
 Hyperthyroidism
 Hypothyroidism
 Adernal insufficiency

18. Blood dyscrasias
Severe anaemia
Leukopenia
Thrombocytopenia
Pancytopenia
Leukaemia
Agranulocytosis
Bleeding and clotting
disorders
Immunocompromised patients

19. ABSOLUTE CONTRAINDICATIONS
Within 6 months of myocardial infraction
Teeth associated with vascular lesions
Teeth in the irradiated jaw
Teeth associated with malignant tumor

20. PHYSIOLOGICAL CONTRAINDICATIONS
Pregnancy (1st and 3rd trimester)
Menstruation period
Extreme old age

21. PREOPERATIVE ASSESSMENT
Medical assessment
Clinical evaluation of tooth
Radiographic evaluation of tooth
Treatment planning

22. MEDICAL ASSESSMENT
When evaluating a patient preoperatively, it is critical that the
surgeon examine the patient's medical status.
 Patients can have a variety of maladies that require treatment
modification or medical management before the surgery can be
performed safely.
 Special measures may be needed to control bleeding, lessen the
chance of infection, and prevent worsening of the patient's
preexisting disease state.

23. CLINICAL EVALUATION OF TEETH
FOR REMOVAL
Access to tooth
Mobility of tooth
Condition of crown
Condition of adjacent tooth and opposing tooth

24. RADIOLOGICAL EVALUATION OF TOOTH
FOR REMOVAL
Configuration of roots
Relationship of associated vital structures
Condition of surrounding bone

25. Indications for preoperative radiographs:
■ History of difficult or attempted, failed extraction
■ A tooth which is abnormally resistant to elevation or forceps extraction
(hypercementosis, ankylosis, dilacerated roots, extra long roots, curved
roots)
■ Any teeth or roots in close relationship to either the maxillary sinus or
inferior dental canal or mental nerve
■ Any teeth with history of trauma (fractured crown or roots or alveolar
bone)
■ Any partially erupted, unerupted tooth, missing tooth, supernumerary
tooth, retained root, lingually placed tooth, impacted tooth
■ Heavily restored tooth or pulpless tooth—brittle, possible presence of
periapical pathology
■ Any condition, which predisposes to dental or alveolar abnormalities,
like: osteitis deformans (hypercementosis of the roots), osteoradionecrosis,
osteopetrosis, etc.

26. Configuration of roots:
■ Number of roots
■ Width—greater below cementoenamel junction (CEJ) than at the CEJ
■ Size of roots
■ Curvature of roots, divergence of roots
■ Length—thin, tapered roots
■ Resorption of roots
■ Shape of the individual root
■ Hypercementosis, ankylosis, root caries/root resorption
■ Previous endodontic therapy.
.

27. Relationship with
associated vital
structures:
■ Maxillary sinus
■ Inferior alveolar canal
■ Mental nerve
■ Adjacent teeth roots.
Condition of
surrounding bone:
■ Density of bone
surrounding the tooth
■ Dense bone—condensing
osteitis, sclerosis will increase
the difficulty.

28.  As the proverb says ‘Failing to plan is planning to fail’.
 It is of paramount importance to device a proper treatment
plan before carrying out an extraction procedure.
 The degree of difficulty must be anticipated during the pre-
extraction period.
 A large amount of force during simple exodontia must be
avoided as it may injure local soft tissue and damage
surrounding bone and teeth.
 There are also chances of crown fracture which makes the
procedure more difficult.
 Also, the application of excessive force aggravates the
intraoperative and postoperative discomfort of the patient
Treatment Planning

29. ARMAMENTARIUM
Instruments used for the extraction of teeth :
• Elevators
• Forceps

30. Extraction forceps
Primary instrument used to remove a tooth from the
alveolar process is known as extraction forceps.
COMPONENTS OF FORCEPS
1. Handle
2. Hinge
3. Beaks

31. The forceps are of two types:
1. English Pattern:
These forceps have a hinge that is directed vertically to the handles of
the forceps.
2. American Pattern:
These forceps have a hinge that is directed in a horizontal direction
with the handles of the forceps.

32. MAXILLARY FORCEPS
1. MAXILLARY ANTERIOR FORCEPS(NO. 01)
Identical beaks, approximated with each other.
Use: Extraction of maxillary incisors and canines.

33. 2. Maxillary premolar forceps(no. 07)
Identical beaks, Beaks do not approximate
use: Extraction of maxillary premolars

34. 3. Maxillary molar forceps(no.17 and no. 18)
These are paired forceps having unidentical and broader
broader beaks. Beak is pointed on one side(known as
prong) which engages the buccal bifurcation of roots and
blunt on the other side engaging palatal root.
Use: extraction of maxillary molars.

35. 4. Maxillary cowhorn/ splitbeak forceps (no.89 and no.
90)
These are also paired forceps, pointed on one side engaging
engaging buccal bifurcation and notched/split on the other
engaging palatal root.
Use: Extraction of maxillary molars with extensive loss of coronal
structure.

36. 5. Maxillary third molar forceps(no.67)
Beaks are curved, identical and angulated, offset to engage the
crown of third molars. Handle is long for accessing the posterior
region.
Use: Extraction of maxillary third molars

37. 6. Bayonet forceps (no. 65)
Beaks of the forceps are narrow, Identical and approximating,
approximating, angulated to provide access to posterior areas as
well.
Use: To remove maxillary broken roots.

38. MANDIBULAR FORCEPS
1. Mandibular anterior forceps(no.75)
Beaks are perpendicular to handle, identical and
approximating each other.
use: Extraction of mandibular incisors and canines

39. 2. Mandibular premolar forceps(no.75)
Beaks do not approximate. Identical beaks, Handle is similar to the
of the anterior forceps .
Use: Extraction of mandibular premolars

40. 3. Mandibular molar forceps(no.22)
Beaks are broader with triangular projections(prongs) to engage
engage the buccal and lingual furcations
use: Extraction of mandibular molars

41. 4. Mandibular cowhorn forceps.(no.86)
Beaks are pointed and conical resembling the horns of cow. Beaks
engage the furcation.
Use: Extraction of mandibular molars with extensive loss of coronal
structure

42. 5. Mandibular root forceps
• Have identical, slender beaks that are closed
• Longer than premolar forceps which enables to get a firm grip
on the root stump.

43. 5. American pattern mandibular molar forceps.
Beaks are similar to that of mandibular molar forceps except that
they are facing forward toward each other at right angles
use: Extraction of mandibular molars.

44. Principles of forceps use
1. Selection of appropriate forceps
2. Grasp
3. Application
4. Movements/forces

45. (a) Maxillary forceps must be held in a ‘palm up’ position
(b) mandibular forceps must be held in a ‘palm down’ position.
Grasp

46. Application
1. Forceps must be placed as apically
as possible.
2. 2 Point contact
3. Parallel to the long axis of tooth
4. lingual beak is inserted first and
then the buccal beak
5. The handles are grasped at the
end to gain the maximum
mechanical advantage.
Center of rotation of tooth gets
displaced apically when the forceps is
inserted beyond cementoenamel
junction

47. The forceps can apply five major motions to luxate the
teeth and expand the bony socket:
1.Apical pressure
2.Buccal pressure.
3.Lingual pressure.
4.Rotational pressure.
5.Tractional forces

48. ELEVATORS
1.Elevators are the instruments used for luxating (loosening) the
teeth before application of forceps making extraction easier,
subsequently avoiding complications like fracture of crowns, roots,
and bone.
2. Elevators are single bladed instruments designed for specific
purposes delivering maximum mechanical advantage with
minimum efforts.

49. Elevators have three
components
• Handle: It is of generous size for
proper grip and delivering adequate
but controlled force. Handle can be a
continuation of the shank or at a right
angle to the shank.
• Shank: It connects the handle
with the working end or blade of the
elevator. It is strong enough to
transmit the force from the handle to
the blade.
• Blade: It is the working end of the
instrument and transmits the force to
the tooth, bone, or both to achieve
the desired action

50. Classification
1. According to the working tip shape
• Straight- Miller’s, Pott
• Triangular- Cryer
• Pick type- Crane, Root tip
2. According to the use designed
• To remove the entire tooth- Straight, Coupland
• To remove the roots broken at the gingival margin- Apexo, Coupland
• To remove the roots halfway to the apex- Cryer, Winter’s
• To remove the apical third of the root- Crane, Root pick
• To reflect the mucoperiosteum- periosteal elevators
3. According to the form- Straight- wedge type (straight, apexo)
Angular- right and left Cryer
Cross bar- (handle at right angle to shank)winter’s

54. 7. Crane pick elevator
• Used as a lever to elevate a broken root from the tooth socket
• A hole of 3 mm is drilled into the root at the bone crest and the tip of
the pick is inserted into the hole and with the buccal plate as the
fulcrum, the root is elevated.

55. 8. Apex/ root tip elevators
• Delicate instrument used to tease the small root tip
from the socket
9. Potts elevator

56. 10. Hockey stick/ London Hospital elevator
• Working blade is at an angulation to the shank but
blade is straight.
• It has a flat and convex surface where the flat surface
is the working surface and has transverse serrations
for better contact

57. OTHER INSTRUMENTS USED
1. No 9 MOLT’S PERIOSTEAL ELEVATOR
 It has 2 ends- a sharp pointed end and a broad, rounded end.
 The pointed end is used to release the interdental papillae,
separation of periosteal attachment from bone
 The broad end is used for elevation of the periosteum from the
bone and can be used to retract the soft tissues.
 The types of motions used-
 Prying- the pointed end used in pryring motion to elevate
the soft tissues, e.g. reflecting the interdental papillae.
 Push- broad end to reflect the periosteum

58. 2. MOON’S PROBE
 It is a thin, flat instrument with a narrow and
sharp tip at right angles to the handle
 It is used to elevate the attached gingiva
around the tooth prior to the extraction

59. Principles of Exodontia
Biological principles
1. Hold the elevator with palm grip.
2. Never use the adjacent tooth as the fulcrum, unless that the
adjacent tooth is also to be extracted.
3. Never use the buccal or lingual plate as the fulcrum.
4. Always use finger guards to protect the soft tissues if the
elevator slips.
5. Support the shank of the elevator with the index finger to
control the forces applied to the elevator.
6. Always elevate from the mesial side of the tooth.
7. The concave or flat surface of the elevator faces the tooth/root
to be elevated, following the root curvature.

60. HOLDING THE ELEVATOR
IN PALM GRASP

61. MECHANICAL PRINCIPLES
1. LEVER PRINCIPLE
2. WEDGE PRINCIPLE
3. WHEEL AND AXIAL PRINCIPLE

62. 1. Lever Principle:
 Most commonly used principle The elevator is the lever of first
class.
 To gain mechanical advantage in frst-class lever, the effort arm
must be longer (3/4th of the total length) than the resistance
arm.
 Mechanical advantage : 3
 Example: Coupland elevator.

64. 2.Wedge Principle:
 Introduction of the blade of an elevator between the bone
and tooth, parallel to the long axis of the tooth is wedging.
 A wedge is basically a movable inclined plane which
overcomes a larger resistance at right angle to the applied
effort.
 The resistance has its effect on the slant side when the effort
is applied at the base of the plane.
 Mechanical advantage: 2.5
 Example: straight elevator,
apexo elevator

66. 3. Wheel and Axle Principle:
 In this principle, the effort is applied to the
circumference of a wheel, which turns the axle
generating the force to raise a weight.
 Greater the diameter of the wheel, more is the
mechanical advantage.
 Mechanical advantage: 4.6
 Example: Cryer's elevator, crossbar

68. GENERAL CONSIDERATIONS
1. ADMINSTRATION OF LOCAL ANESTHESIA
2. SURGEON AND PATIENT PREPARATION
3. PATIENT AND CHAIR POSITION
4. OPERATOR POSITION
5. ROLE OF OPPOSITE HAND

69. ADMINSTRATION OF LOCAL ANESTHESIA
Extraction of the tooth can be effectively carried out under local
anesthesia. Hence, administration of local anesthesia must be carried out
with proper technique and appropriate agent. Once the nerve block
and/or local infiltration is administered, surgeon must wait for it to act
and confirm the same by subjective and objective tests

70. Surgeon and patient preparation
The principles of universal precautions must be followed.
To avoid transmission of diseases, a surgeon and the assistant must
wear surgical gloves, surgical mask, eye-wear with shields, surgical
cap, and a long-sleeved surgical gown.
Before the patient is subjected to the extraction procedure, a sterile
drape should be put over to the patient to decrease the risk of
contamination.
It is advisable to reduce the bacterial contamination in the patient’s
mouth by making him/ her rinse the mouth vigorously using an
antiseptic rinse like chlorhexidine prior to the procedure.

71. PATIENT AND CHAIR POSITION

72. OPERATOR POSITION

73. Maxillary teeth extraction, (a) Right posterior, (b) Anterior, and (c) Left posterior
Mandibular teeth extraction (a) Right posterior,(b) Anterior and (c) Left posterior

74. Role of opposite hand
1.For reflecting soft tissues, cheeks, lips, tongue
2. Supporting and stabilizing the jaw.
3. Provides the tactile information to the operator concerning the
expansion of alveolar process during luxation.
4. Stabilizes TMJ during mandibular teeth extraction.

75. INTRA ALVEOLAR EXTRACTION
◦ ALSO CALLED AS CLOSED
EXTRACTION/FORCEPS EXTRACTION
◦ CONSISTS OF REMOVING THE
TOOTH/TOOTH ROOT BY THE USE OF
FORCEPS OR ELEVATOR OR BOTH.

76. • Step 1: Loosening of soft tissue attachments
around the tooth.
• Step 2: Luxation of the tooth with a dental
elevator.
• Step 3: Adaptation of the forceps to the tooth.
• Step 4: Luxation of the tooth with the forceps
• Step 5: Removal of the tooth from the socket.
PROCEDURE OF INTRA ALVEOLAR EXTRACTION

77. 1. Step 1: Loosening the soft tissue attachments around the
tooth.
 It is carried out using periosteal elevator or moons probe.
 It also helps to asses the depth of anesthesia.
 It allows the forceps to be placed more apically without impingement
on gingiva.
 The pointed end of the instrument is used in prying motion to elevate
dental papilla and attached gingiva.

78. 2. Step 2: Luxation of the tooth with a dental elevator.
 Usually straight elevator is used, which is inserted perpendicular
to the tooth into the interdental space after reflection of
interdental papilla.
 Slow strong, forceful turning of the elevator is carried out with
inferior portion of the blade resting on alveolar bone and
superior portion of the blade is turned towards the tooth to be
extracted.
 This will result in some amount of alveolar expansion and
tearing of the periodontal ligament and tooth will move in the
posterior direction

79. 3. Step 3: Adaptation of the forceps to the tooth.
 Forceps must be placed as apically as possible.
 2 Point contact
 Parallel to the long axis of tooth
 Palatal/lingual beak is inserted first and then the buccal
beak
 The handles are grasped at the end to gain the
maximum mechanical advantage.
 The surgeon should be prepared to apply force with
the shoulder and upper arm without any wrist
pressure.

80. 4. Step 4: Luxation of the tooth with the forceps
 various motions are carried out to luxate the tooth Once the tooth is
luxated, apical force is applied again to shift the center of rotation
further apically.
 This is again followed by buccal and lingual movements of tooth.
 The forces applied in buccal and lingual direction must be slow
deliberate pressures with no jerky movements

81. 5. Step 5: Removal of the tooth from the socket.
 Once the alveolar bone has expanded sufficiently and the tooth has
been luxated, a slight tractional force, usually directed buccally, can
be used.
 Tractional forces should be minimized, because this is the last
motion that is used once the alveolar process is sufficiently
expanded and the periodontal ligament completely severed

82. Specific techniques for removal of each tooth
1. Incisors
A. Left hand grasps
alveolar process.
B. Forceps are seated
as far apically as
possible.
C. Luxation is begun
with labial force.
D. Slight lingual force is
used.
E. Tooth is delivered
with rotational,
tractional Movement
Maxillary teeth

83. 2.Canine
A, Hand and forceps
position for removal of
maxillary canine is similar
to that for incisors. Forceps
are seated as far apically as
possible.
B, Initial movement is
buccally.
C, Small amounts of lingual
force are applied.
D, Tooth is delivered in
labial-incisal direction with
slight rotational force.

84. 3.1st Premolars
A, Hand position is similar to
that used for anterior teeth.
B, Firm apical pressure is applied
first to lower center of rotation
as far as possible and to expand
crestal bone.
C, Buccal pressure is applied
initially to expand Bucco cortical
plate.
D, Palatal pressure is applied but
less vigorously than buccal
pressure.
E, Tooth is delivered in Bucco
occlusal direction with
combination of buccal and
tractional forces.

85. 4. 2nd Premolars
A, When extracting
maxillary second premolar,
forceps are seated as far
apically as possible.
B, Luxation is begun with
buccal pressure.
C, Very slight lingual
pressure is used.
D, Tooth is delivered in
Bucco occlusal direction.

86. 4. Molars
A, Extraction of maxillary
molars. Soft tissue of lips and
cheek is reflected, and
alveolar process is grasped
with opposite hand.
B, Forceps beaks are seated
apically as far as possible.
C, Luxation is begun with
strong buccal force.
D, Lingual pressures are used
only moderately.
E, Tooth is delivered in Bucco
occlusal direction.

87. A
MANDIBULAR TEETH
1. Anterior teeth
A, left hand supports the
mandible and the alveolar
process
B, Forceps are seated apically as
far as possible.
C, Moderate labial pressure is
used to initiate luxation process.
D, Lingual force is used to
continue expansion of bone. E,
Tooth is delivered in labial-incisal
direction.

88. A
B C D E
2. premolar.
A. Mandible is stabilized, soft
tissue is reflected, left hand
supports the mandible and
alveolar process ,
B, Forceps are seated apically as
far as possible to displace
center of rotation and to begin
expansion of crestal bone.
C, Buccal forceps are applied to
begin luxation process.
D, Slight lingual pressure is
used.
E, Tooth is delivered with
rotational, tractional force.

89. 3. Molars
A, Hand positions of
surgeon is similar to that
used for premolar teeth.
B, forceps are seated as far
apically as possible.
C, Luxation of molar is
begun with strong buccal
movement.
D, lingual pressure is used
to continue luxation.
E, Tooth is delivered in
Bucco occlusal direction.

90. EXTRACTION SEQUENCING
Maxillary teeth are extracted first as the
anesthesia acts early in maxilla. Followed by
mandibular teeth.
Posterior teeth are removed first followed by
anterior teeth.
First molar and canine are extracted after
their adjacent teeth are removed.
Order of extraction – 3rd molar, 2nd molar, 2nd
pre molar, 1st molar, 1st premolar, lateral
incisor, canine, central incisor.

91. TRANSALVEOLAR EXTRACTION
Commonly called the ‘surgical extraction’
This method involves removal of the bone
investing the roots, which are then delivered
by the use of elevators and/ or forceps.

92. INDICATIONS
Any tooth, which offers a lot of resistance for elevation technique.
 Retained roots, which cannot be grasped by the forceps or delivered
with an elevation technique
Previous history of difficult or attempted and failed extraction technique
Any large restoration with root canal therapy— brittle teeth
Hypercementosis/ankylosis of a tooth
Geminated/dilacerated tooth

93. Radiographic evidence of complicated/difficult root pattern or roots
with unfavorable or conflicting lines of withdrawal
Sclerosis of the bone
Teeth associated with pathology—periapical granuloma, cyst,
tumor, etc.
Impacted teeth, embedded teeth.
Roots close to maxillary sinus.
Fractured teeth

95. 1. FLAP DESIGN
The term flap Indicates a section of soft tissue that
(1) is outlined by a surgical incision,
(2) carries its own blood supply,
(3) allows surgical access to underlying tissues,
(4) can be replaced in the original position, and
(5) can be maintained with sutures and is expected to heal.

96. PRINCIPLES OF FLAP DESIGN
1. When the flap is outlined, the base of the flap must usually be broader than
the free margin .
2. The flap must be of adequate size
3. Sufficient soft tissue reflection is required to provide necessary visualization
of the area.
4. Adequate access also must exist for the insertion of instruments required to
perform the surgery.
5. the flap must be held out of the operative field by a retractor that must rest
on intact bone.
6. a long, straight incision with adequate flap reflection heals more rapidly
than a short, torn incision, which heals slowly by secondary intention.
7. If a relaxing incision is to be made, the incision should extend one tooth
anterior and one tooth posterior to the area of surgery
8. Flaps for tooth removal should be full-thickness mucoperiosteal flaps.

97. A, Flap must have base that is
broader than free gingival margin.
B, If flap is too narrow at its base,
the blood supply may be
inadequate, which can lead to flap
necrosis.
A, To have sufficient access to root
of second premolar, envelope flap
should extend anteriorly, mesial to
canine, and posteriorly, distal to first
molar.
B, If releasing incision (i.e. , three-
cornered flap) is used, flap extends
mesial to first premolar.

98. A, When designing flap, it is necessary to anticipate how much
bone will be removed so that after surgery is complete, the
incision rests over sound bone. In this situation, the vertical
release was one tooth anterior to bone removal and left an
adequate margin of sound bone. B, When releasing incision is
made too close to bone removal, delayed healing results.

99. A, Correct position for end of verticalreleasing incision is at line angle
(mesiobuccal angle in this figure) of tooth. Likewise, incision does not
cross .canine eminence. Crossing such bony prominences results in
increased chance for wound dehiscence. B, These two incisions are
made incorrectly: (1) incision crosses prominence over canine tooth,
which increases risk of delayed healing; incision through papilla
results in unnecessary damage; (2) incision crosses attached gingiva
directly over facial aspect of tooth, which is B likely to result in soft
tissue defect and periodontal and aesthetic deformities.

100. TYPES OF FLAPS
1. ENVELOP FLAP
2. 3 CORNERED FLAP
3. 4 CORNERD FLAP
4. SEMILUNAR FLAP

101. Developing a Mucoperiosteal Flap
Scalpel handle is held in pen grasp for
maximal control and tactile sensitivity.
No. 15 blade is used to
incise gingival sulcus.

102. A, Knife is angled slightly away from
tooth and incises soft tissue, including
periosteum, at crestal bone.
B, Incision is started posteriorly and is
carried anteriorly, with care taken to
incise completely through interdental
papilla.
Reflection of flap is begun
by using sharp end of
periosteal elevator to pry
away interdental papilla.

103. When three-cornered flap is
used, only anterior papilla is
reflected with sharp end of
elevator. Broad end is then
used with push stroke to
elevate posterio superiorly.
Periosteal elevator is used to
reflect mucoperiosteal flap.
Elevator placed perpendicular to
bone and held in place by
pushing firmly against bone, not
by pushing it apically against soft
tissue.

104. Removal of bone
Bone should be excised to provide a point of application for an
elevator or forceps.
It is removed by using dental bur or chisel and mallet
Round head burs cut more efficiently. No 8, No 10, or flat fissured
burs are used.
The bur must not be allowed to over heat and constant saline
irrigation should be provided which removes the debris and
prevents the bur from clogging
 The width of buccal bone that is removed is essentially the same
width as the tooth in a mesiodistal direction . In a vertical
dimension, bone should be removed approximately one half to two
thirds the length of the tooth root.
Postage stamp method can be employed.

105. When removing bone from buccal
surface of tooth or tooth root to
facilitate removal of that root,
mesiodistal width of bone removal
should be approximately same as
mesiodistal dimension of tooth root
itself. This allows unimpeded path for
removal of root in buccal direction.
Bone is removed with bone-
cutting bur after reflection of
standard envelope flap. Bone
should be removed
approximately one half to two
thirds the length of tooth root.

106. ODONTECTOMY/TOOTH DIVISION
Tooth sectioning is usually accomplished with a straight
handpiece with a straight bur, such as the no. 8 round bur, or
with a fissure bur, such as the no. 557 or no. 703 bur.
The tooth may be divided with a bur to convert a multirooted
tooth into two or three single-rooted teeth, when the path of
withdrawal of multirooted teeth is different.
Once the tooth is sectioned, the small straight elevator is used to
luxate and mobilize the sectioned roots

107. If lower molar is difficult to extract, it can be sectioned into single-rooted teeth.
A, Envelope incision is reflected, and small amount of crestal bone is removed
to expose bifurcation. Drill is then used to section the tooth into mesial and
distal halves.
B, Lower universal forceps are used to remove two crown and root portions
separately.

108. A, This primary second molar cannot be removed by
closed technique because of tipping of adjacent
teeth into occlusal path of withdrawal and of high
likelihood of ankylosis.
B, Envelope incision is made, extending two teeth
anteriorly and one tooth posteriorly.

109. C, Small amount of crestal bone is removed, and
tooth is sectioned into two portions with bur
D, Small straight elevator is used to luxate and
deliver mesial portion of crown and mesial root.

110. E, Distal portion is luxated with small
straight elevator.
F, forceps are used to deliver
remaining portion of tooth

111. SOCKET TOILET
 Unwanted bony prominences should be
removed with rongeur, chisel or burs
 Infected granulation tissue has to be
removed using a curette.
 Sharp edge should be smoothened with
bone files
 Wound should be irrigated with normal
saline so that the debris is removed from
the socket.

112. SUTURING OF THE FLAP
When an envelope flap is repositioned into its correct location, it is held
in place with sutures that are placed through the papillae only.
If a three-cornered flap is used, the vertical end of the incision must be
closed separately. Two sutures usually are required to close the vertical
end properly

113. A, To make the suturing of three-cornered flap easier, periosteal
elevator is used to elevate small amount of fixed tissue so that suture
can be passed through entire thickness of mucoperiosteum.
B, When three-cornered flap is repositioned, first suture is placed at
occlusal end of vertical-releasing incision (1). Papillae are then sutured
sequentially ( 2 , 3 ) , and finally, if necessary, superior aspect of
releasing incision is sutured (4).

114. Removal of root fragments
If fracture of the apical one third (3 to 4 mm) of the root occurs
during a closed extraction, an orderly procedure should be used
to remove the root tip from the socket
Retrieval can be done by two methods:
closed method
open method
The closed technique for root tip retrieval is defined as any
technique that does not require reflection of soft tissue flaps and
removal of bone.
If sufficient luxation occurred before the fracture, the root tip
often is mobile and can be removed with the closed technique.
 Irrigation-suction technique
 Tease the root apex from the socket with a root tip
pick

115. A, When small (2 to 4 mm) portion of root apex is
fractured from tooth, root tip pick can be used to
retrieve it.
B, Root tip pick is teased into periodontal ligament
space and used to luxate root tip gently from its
socket.

116. A, When larger portion of tooth
root is left behind after extraction
of tooth, small straight elevator
can sometimes be used as wedge
to displace tooth in occlusal
direction. One must remember
that pressure applied in such
fashion should be in gentle
wiggling motions; excessive
pressure should not be applied.
B, Excessive pressure in apical
direction results in displacement
of tooth root into undesirable
places, such as maxillary sinus.

117. If the closed technique is unsuccessful, the surgeon should
switch—without delay—to the open technique
A, If root cannot be
retrieved by closed
techniques, soft tissue
flap is reflected and
bone overlying root is
removed with bur.
B, Small straight
elevator is then used to
luxate root buccally by
wedging straight
elevator into palatal
periodontal ligament
space.

118. A, Open-window
approach for retrieving
root is indicated when
Bucco crestal bone must
be maintained. Three-
cornered flap is reflected
to expose area overlying
apex of root fragment
being recovered.
B, Bur is used to uncover
apex of root and allow
sufficient access for
insertion of straight
elevator.
C, Small straight elevator
is then used to displace
tooth out of tooth socket.

120. POST EXTRACTION CARE
Inspection of the socket: debris, tooth fragments, bone fragments
should be removed.
Curettage of granulation tissue, smoothening of sharp bony edges.
The expanded buccolingual plates should be compressed back to their
original configuration.
Finger pressure should be applied to the buccolingual cortical plate to
compress the plates gently but firmly to their original position(Bidigital
alveoloplasty)
Initial control of hemorrhage is achieved by use of a moistened 2 x 2-
inch gauze placed over the extraction socket.
A larger gauze sponge (4 x 4 inches) may be required if multiple teeth
have been extracted or if the opposing arch is edentulous.

121. Gauze pad (2 x 2-inch pad) is folded in half
twice and placed into space. When patient
bites on gauze, pressure is transmitted to
gingiva and socket.
If large gauze is used,
pressure goes on teeth,
not on gingiva or socket.

122. Instructions to the patient
Maintenance of pressure pack for 30 – 60 minutes (Initial clot is soft
and friable. Clot retraction takes 30-45 minutes)
 Swallow the saliva and not to spit or rinse till 24 hours post extraction
 Soft and cold diet for 24 hours so as not to disturb the clot and for
vasoconstriction
 Warm saline rinses after 24 hours to enhance healing of socket
 Avoid smoking as it may dislodge the clot and lead to bleeding
Avoid violent exercise, stimulants, very hot food or drinks to minimize
the risk of post extraction hemorrhage
Antibiotics and analgesics are prescribed.

123. COMPLICATIONS OF EXODONTIA
INTRAOPERATIVE COMPLICATIONS
1. Failure to secure anesthesia
2. Fracture of- crown
root
alveolar bone
maxillary tuberosity
adjacent or opposing tooth
mandible
3. Dislocation of – Adjacent tooth
TMJ
4. Displacement of the root- into soft tissues
into the maxillary antrum

124. 5. Hemorrhage- during tooth removal
On completion of the extraction
6. Damage to- gums
Lips
Inferior dental nerve or its branches
Lingual nerve
tongue and floor of mouth
7. Extraction of wrong tooth
8.Aspiration of tooth

125. Postoperative (delayed complications):
1. Haemorrhage: Reactionary, secondary
2. Pain
3. Dry socket: Alveolar osteitis
4. Postoperative oedema/swelling
5. Hematoma/ecchymosis
6. Infection
7. Trismus
8. Creation of Oro antral communication

126. Late complications:
■ Chronic
osteomyelitis/osteoradionecrosis
■ Nerve damage:
Anaesthesia/paresthesia
■ Chronic pain

127. 1. Failure to secure anesthesia
• Due to faulty technique or insufficient dosage of the anesthetic
agent
• After administration of anesthesia, a blunt probe is pushed firmly
into buccal and lingual gingival crevice to check for anesthetic
effect
2. Fracture of crown
• Caused by improper application of forceps
• One point contact of forceps.
• weakened tooth structure due to severe caries, large
restorations
• Hurry is usually the underlying cause of these errors.
• Exhibition of excessive force to overcome resistance.

128. 3. Fracture of roots
• Same factors that cause the fracture of crown cause fracture
of the root as well
• Although all the root fragments are advised to be retrieved
in all the circumstances, some have to be left behind in
certain situations
• Root fragments lesser than the apical third, or 5 mm, with a
vital pulp in a healthy patient can be left alone; while those
greater than 5 mm, with necrotic pulps and with periapical
radiolucent areas should be removed.

129. . 4. Fracture of alveolar bone
• Caused due to accidental inclusion of alveolar bone in the
forceps or due to pathological conditions of the bone
• Canine extractions can cause the fracture of labial plate
when the premolar and lateral incisor are not extracted first
• Advised to remove all the alveolar fragments which has lost
its periosteal attachment and sutures placed.

130. 5. Fracture of the maxillary tuberosity
• Caused by the invasion of the tuberosity by the
antrum commonly seen in the case of isolated
maxillary molars

131. 6. Fracture of adjacent or opposing tooth
• Careful examination will reveal whether the adjacent
or the opposing tooth is carious, heavily restored or in
the line of withdrawal.
• If the tooth to be extracted is an abutment tooth,
bridge should be divided with burs prior to extraction
• Care should be taken not to use the adjacent tooth as
the fulcrum
• Opposing tooth may get chipped or fractured if the
tooth being extracted yields suddenly to uncontrolled
force and the forceps strikes them. Therefore,
controlled forces have to be used.

132. 7. Fracture of the mandible
• Caused by excessive and incorrectly applied
force, weakened bone due to pathological
changes.
• Controlled forces have to be applied
• If a fracture occurs, then treatment of the
fracture has to be done by reduction and
stabilization of the fracture

133. Dislocation of the adjacent tooth
• Can occur during elevation
• One finger should be placed upon the adjacent
tooth to support the tooth
• Subluxation: Tooth is stabilized with wire or
acrylic splint
• Avulsion: Reimplanted immediately and
stabilized with splints Endodontic therapy is
planned

134. 9. Dislocation of the TMJ
• Complication of mandibular extraction
• Application of excessive force, failure to support the mandible,
more likely to occur under GA, when masticatory muscles are
relaxed

135. 10. Displacement of the tooth/root into tissue
space
• Tooth can get displaced into the in the lingual pouch, in
pterygopalatine fossa, through the lingual cortex of bone
in submandibular space.
• Causes are thin cortical plate, uncontrolled force, and
fenestration in cortical plates
• Use controlled force, and support the alveolus during
extraction and support of one finger over lingual cortical
plate.
• Radiographs may be required. Attempt should be made
for its retrieval. Manipulation or pushing the root piece
back into its socket should be tried.

136. 11.Displacement of the tooth/root into the
maxillary sinus
• Commonly involved root: Palatal root of maxillary first
molar
• Large antral cavity close to the apices of posterior teeth
• Use of controlled force with support to the alveolus
• Leave the apical third of maxillary molar palatal roots;
unless there is an indication for their removal

137. 12. Soft tissue injury
• Improper surgical technique: (Inadequate size of flap)
• Improper handling of instruments: (careless retraction)
• Use of excessive and uncontrolled forces
• Common areas: Upper—posterior palate Lower—tongue
and floor of the mouth
• Managed by : Proper surgical technique (Proper designing of flap)
Proper handling of instruments
Use of controlled force
Closure of tear after completion
of surgical procedure

138. 13. Extraction of a wrong tooth
• Caused due to carelessness
• Improper communication (Referred patients,
particularly by orthodontists)
• Careful extraction
• Replace tooth as soon as possible; and stabilize
with wire or splint/arch bar Plan for endodontic
treatment

139. 14. Haemorrhage
• Primary hemorrhage: Hemorrhage at the time of surgery
• Reactionary hemorrhage: Hemorrhage within few hours
surgery, when vasoconstriction of damaged blood vessels
ceased
• Secondary hemorrhage: Hemorrhage up to 14 days
postoperatively, as a result of infection
• causes
• Local: Bleeding from arteriole or vessel
Granulation tissue
Crush injury
General: (a) Natural: i. Haemophilia A
ii. Haemophilia B
(b) Acquired: Anaemia (Severe)
Hypertension (uncontrolled)
Vitamin K deficiency
Vitamin C deficiency
Anticoagulation therapy
Liver diseases,
Hemorrhagicdisorders
Idiopathic thrombocytopenia

140. Control the hemorrhage from soft tissues:
(a) Mechanical pressure in the form of finger/thumb pressure
(b) Electric cauterization
(c) Injection of local anesthetic containing a vasoconstrictor
(adrenaline), for relief of pain as well as for vasoconstriction
(d) Suturing; particularly, figure-of-eight type, across the
margins of the socket
(e) Clamping of bleeding vessel and ligation with 3/0 or 4/0
ligature, or coagulation with diathermy

141. f) Application of hemostatic substances: absorbable
sponges: gelatin foam (gelfoam), surgicel, liquid
preparation of topical thrombin, collagen
g) Smearing of bone wax into relevant spaces in bone
marrow with the help of an instruments such as burnisher
or Mitchell’s trimmer
h) A block of impression compound is moulded over the
area to offer compression

142. 15. Dry socket/ Fibrinolytic alveolitis/ alveolar
osteitis/ localized osteitis alveolalgia/ alveolar
osteomyelitis/ Alveolitis sicca dolorosa/ Post
operative osteitis
• It involves part or whole of the walls of socket; or the lamina
dura.
• Geoffrey Howe, defined it as well recognized, but ill
understood complication of extraction of teeth.
• Characteristics: The condition is characterized by acute pain,
bony walls of the socket are denuded of blood clot. The bare
bone is extremely sensitive to the touch of probe.
• Etiology: Not clear/obscure.

143. Birn’s hypothesis, 1973 – trauma and infection cause
inflammation of the marrow spaces which releases fibrinolytic
agents. This fibrinolytic activity results in lysis of the blood
clot. Liberation of tissue activators which convert
plasminogen in blood clot to plasmin. This dissolves blood clot
and releases kinins from kininogen; which is present in blood
clot causing pain. The final result is of dissolution of blood clot
and severe pain
• Predisposing factors:
Infection of socket occurring either
before, during or after the
extraction
Trauma
Vasoconstrictor
Existence of systemic etiologic
Bacteriological origin

144. • Management
 Aim: (i) Relief of pain, and (ii) Speed of resolution
Irrigation of debris and debridement with warm
saline and dilution of hydrogen peroxide
Medicated dressing/Iodoform gauze or composed of
zinc oxide eugenol on cotton wool could be packed.
Broad-spectrum antibiotics if suppuration exists.
Analgesics, and hot saline mouth baths

145. 16. Infection/suppuration at the site
• Lack of aseptic technique, inadequate preparation of
the site, inadequate sterilization of instruments
• Use of antibiotics, and may be incision and drainage
17. Odema / hematoma
• Use of blunt instruments, excessive retraction of soft
tissues, badly designed flaps, tightly approximated
sutures
• Usually both the conditions regress if the patient uses
hot saline mouth baths for 2-3 days

146. 18. Creation of oro-antral communication
• Maxillary posterior teeth are in close proximity with
floor of maxillary sinus
• With advancing age, there is increase in
pneumatization
• Solitary molar tooth in atrophic maxillary alveolus
• Molar roots with large splayed roots close to antral
floor

147. • Management
 Inspection of extraction socket
 Nose-blowing test, fog test
 Instruments, such as, suction tips and probes through the
socket into the antrum in an attempt to confirm the defect.
Retrieval of the tooth/root
 Defect less than 2 mm: Blood clot gets organized
 Defect >2 and < 6 mm: Hemostatic agents are inserted in
the socket and the socket is sutured. Decongestant nasal
spray.
 Defects > 7 mm : Surgical closure by flaps
 Patients should be advised to avoid blowing the nose,
sneezing violently, sucking on straws, and smoking.

148. NEWER ADVANCES
1. Powered periotomes

149. 2. Using implant drills for extractions prior to
immediate implant placement

150. 3. Physics forceps

151. 4. Peizosurgery

152. 5. Use of LASER
• low-vibration bone cutting to allow precise bone ablation
without any visible, negative, thermal side effects
• Er:YAG laser can be used for surgical extractions to ablate the
covering bone layer by layer exposing the portion of the root.
• Once the tooth/root is uncovered, they can be conventionally
removed
• tend to be time consuming
• sound and smell of the laser surgical procedure
• lack of a feedback system for depth control

153. REFERENCES
1. THE EXTRACTION OF TEETH- GEOFFREY L HOWE
2. ORAL AND MAXILLOFACIAL SURGERY, VOLUME ONE, 5TH EDITION - W.
HARRY ARCHER
3. TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY, 6TH EDITION-
GUSTAV O. KRUGER
4. CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY, 7TH EDITION-
JAMES R HUPP, EDWARD ELLIS III, MYRON R TUCKER
5. ORAL AND MAXILLOFACIAL SURGERY, VOLUME TWO- DANIEL M
LASKIN