Anaesthesia & Exodontia Third Year

1. ‫سبحان ال وبحمده سبحان ال العظيم‬
Principles of Exodontia
Lec. # 4
Dr. Adel I Abdelhady
)BDS, MSC, (Egypt) PhD (USA , Egypt
.Oral and Maxillofacial Surgery Dept
.College of Dentistry, KSA
20/01/14

2. Principles of Exodontia
Lec. # 4
20/01/14

3. 20/01/14

4. Preparations before exodontia
Patient and surgeon
preparation regarding
proper position of the
patient and proper
standing of the
operator. Chair
position for forceps
extraction
20/01/14

5. Techniques of Extraction
 1- INTRA-ALVEOLAR EXTRACTION
 FORCEPS or CONVENTIONAL
 This is by using dental forceps and
elevators.
 2- TRANS-ALVEOLAR EXTRACTION
 This is by using Surgical Flaps technique
with bone removal and tooth sectioning
20/01/14

6. FORCEPS PARTS
BLADES
20/01/14
JOINT
HANDS

7. Requirement of the Dental Forceps
INTRA-ALVEOLAR EXTRACTION
All forceps has blades and
handles united by a hinge
joint.
1-The handles must
possess a suitable size to
rest comfortably in the
operator’ s hand and
should long enough to
afford use of strong and
steady extraction
movements. Also it must
be suitable in shape and
design to suit the area of
the tooth.
20/01/14

8. Intra-alveolar Extraction
Requirement of the Dental Forceps
2- The blades must be
sharp to be introduce
under the free gum
margin. In multirooted
teeth the blades should
be designed to grip the
different root patterns.
The angulation design of
the blades in relation to
the joint and handles
should be made to
facilitate gripping of the
tooth at CEJ
20/01/14

9. 3-The joint of the dental
forceps must have
free movement for
easy manipulation but
must be free from
rolling movement
20/01/14

10. Upper Forceps
Upper Anterior central;
lateral incisors and canine
teeth
Upper Premolar
Upper Left Molar
Upper Right Molar
Bayonet Forceps for
wisdom teeth
 Lower Forceps
Lower Anterior
Lower premolar
Lower molar
20/01/14

11. Preparations before exodontia
• Patient and
surgeon
preparation
• Patient and
surgeon position
for forceps
extraction
20/01/14

12. EXTRACTION of TEETH
Forceps
These have two blades with sharp
edges to cut the periodontal
fibers. The blades are wedgeshaped to dilate the socket
and are hollowed on their inner
surface to fit the roots
The blades are hinged which
allows them to close and grasp
the root the handle act as a
lever which gives the operator
a mechanical advantage. The
farther from the blades the
surgeon grasps the handles
the less effort he will have to
make to apply force to the
tooth. 20/01/14

13. 20/01/14

14. Extraction of teeth with
forceps
The extraction of teeth is a surgical operation
based primarily on an anatomical appreciation of
their attachment in the jaw. First the soft tissues
of the gingival attachment and periodontal
membrane are cut to separate the tooth from the
bone .
Next the socket is dilated by moving the root to
expand its bony socket .Finally when the tooth is
loose it may be drawn out of the alveolus .When
completed with forceps extractions are
performed in two movement.
20/01/14

15. Extraction of teeth with forceps
First movement
This is same in all teeth of both jaws the forceps
are applied on the buccal and the palatal or
lingual aspects of the tooth, regardless of
whether it is normally or abnormally positioned in
the arch.
In multirooted teeth the blades must be kept on a
root , not the bifurcation .The blades are passed
carefully under the gingival margin of the tooth
and driven up or down in the same plane as the
long axis of the tooth to penetrate as far as
possible
20/01/14

16. Role of left hand of operator
20/01/14

17. Extraction of teeth with forceps
Considerable force is used
particularly in the upper jaw.
In the lower jaw this must be
limited to that the operator
can counteract by supporting
the mandible with his free
hand.
Whilst driving up the root in this
way the blades contact the
root surface not gripping it.
This movement cuts the
gingival attachment and the
wedge shaped blades to
dilate the socket
20/01/14

18. Extraction of teeth with forceps
Second movement :
The 1st movement completed ,the blades of the forceps are
closed to grasp the root and the second movement is
performed which by moving the tooth roots using them to
dilate further the socket , during this action, to prevent
the blades slipping off the tooth , a firm vertical pressure
up or down the long axis of the root must be maintained.
Avoid use of excessive force and every effort is made to
develop feeling through the forceps . This enables the
surgeon to recognise to excursions in certain direction
20/01/14

19. The combined use of forceps
and elevators
The combined use of these instruments will
facilitate the extraction the coupland elevator
driven vertically up the long axis this will cut
the periodontal attachment and dilate the
bony socket on both buccal and lingual
aspects and indicate if undue resistance is
present
20/01/14

20. The combined use of forceps
and elevators
The supporting Hand
The jaws should be adequately
supported by free hand of the
operator this particularly important
in the lower jaw the other function
of supporting hand is retraction of
the cheek, tongue and lip .This
done by placing the finger and
thumb on each side of the gum on
the buccal and lingual or palatal
aspects of the tooth ,and also the
operator is able to feel that the
blades of the forceps are under
the m.m. and the watching finger
can feel any slipping of the
forceps or any tendency of the
20/01/14
adjacent tooth to move

21. Extraction of Deciduous Teeth
In general deciduous teeth are much
easier to extract than the permanent ones
But some factors may complicate their
extraction:
1-Small mouth of the children patient
2-Permanent premolars are enclosed within
the roots of their predecessors , deciduous
molars have no root mass and caries
often invades roots making it difficult to
grip 20/01/14
them

22. Extraction of Deciduous Teeth
3-Pediatric forceps should be used
4-Care must be taken not to place
the beaks of forceps deep down
on the root of D. teeth because
great possibility of removing the
partially formed permanent teeth.
20/01/14

23. Hazard of Extraction
of Primary teeth
When this inadvertently happens, the
partially formed tooth should be carefully
freed from the primary roots and replaced
in the alveolus , the soft tissues are then
sutured over the alveolus to hold the bone
and the tooth in position
20/01/14

24. Modifications for extraction of
primary teeth
• Thin diverged roots
• Resorbed roots
20/01/14

25. Modifications for extraction of
primary teeth
• Successors
• Inferior alveolar
nerve
• Resilient bone
• Restricted access
20/01/14

26. Dental Elevators
20/01/14

27. Dental Elevators
Parts of Elevators:
1-Blade
2-Shank
3-Handle
20/01/14

28. Dental Elevators Classification
I-According to use:
1-Elevators designed to
remove the entire tooth,
straight elevators,
hospital pattern and
winter elevator
2-Elevators designed to
remove roots broken off
at the gingival line e.g.
Apexo elevator ,
Coupland and lido lavien
elevators
3-Elevators designed to
remove roots broken off
half way to the apex e.g.
curved elevator hospital
pattern, winter elevator
20/01/14
and Apexo elevator

29. Dental Elevators Classification
II-According to Form:
1-Straight all types
2-Curved right and left
3-angulated right and left
4-Cross bar “ handle at right angle to the
shank”
20/01/14

30. Types of Dental
:Elevators
.Straight e.g. 1
Copland's
.Curved e.g. 2
Cryer’s
20/01/14

31. Root Elevators
Used to loosen and frequently remove
teeth and roots.
– a small straight elevator
20/01/14
– a large straight elevator

32. Dental Elevator
”Cross bar “winter
Hospital pattern
Straight and
curved
Curved apexo
20/01/14

33. Choice of elevators
Choice of elevators according to:
• Remaining tooth structure
• Space available
• Availability and position of solid
fulcrum
• Direction of the required movement
20/01/14

34. Characteristics
• Has no joints
• Needs a fulcrum to
work
• Has to be wedged
between bone and
tooth
• Exerts less directional
force on the tooth
• Different sizes and
shapes
20/01/14

35. Indications of use
• Breaking down the periodontal attachment
• Luxation or removal of full tooth
• Luxation and removal of remaining roots
• Bone removal
• Mucoperiosteal elevation
20/01/14

36. Mechanical Principles
To obtain maximum mechanical advantage
of the elevator the fulcrum should be near
the point of resistance and the effort arm
should be longer than resistance arm
(Principle of class I levers )
20/01/14

37. Rules of Use of Elevators
• Palm grip
• Don’t use the neighbouring
•
•
•
•
tooth as a fulcrum
Don’t use the buccal or lingual
plate of bone as a fulcrum
Use the left hand for
reflection, guard and support
Take care of the surrounding
vital structures
Follow respectfully, root
curvature
20/01/14

38. Principles of Use of
Elevator
• Wedge principle: straight elevator
• Lever principle: Copland elevator, straight elev.
• Axel and Wheel principle: Cryer’s elevator
20/01/14

39. Principles of Use of Elevator
Wedge Principle
Some elevators are designed primarily to
be used as a wedge e.g. Apexo ,and
coupland. This elevators are forced
between the root of the tooth and the
investing bony tissue parallel to the
long axis of the tooth
20/01/14

40. Principles of Use of Elevator
Lever Principle:
On applying this principle
the elevator is a lever of
the first class the position
of the fulcrum is between
the effort and resistance
in order to obtain a
mechanical advantage in
a lever of the first class
the effort arm on one side
of the fulcrum, must be
longer than the resistance
arm
20/01/14

41. Principles of Use of Elevator
Wheel and Axle Principle
The wheel and axle is a simple
machine the effort is applied
to the circumference of a
wheel which turn the axle so
as to raise a weight. It could
be used as a sole work
principle in removing the
teeth, it is also used in
conjunction with a wedge or
lever principles
20/01/14

42. Danger in the Use of
Elevators
 1-Loosening or extracting the adjacent teeth
 2-Fracture the alveolar process or fracturing the
mandible
 3-Penetrating the maxillary antrum or forcing the
root into the antrum
 4-Forcing a root a root of a mandibular molar
through lingual plate of the mandible
 5-Damage of soft tissues by slipping of the tip of
the elevator
20/01/14

43. Elevation of teeth
Wedge elevator between
tooth and bone at neck of
tooth and rotate handle with
slight twisting, quarter-turn
movement
Observe for tooth movement
Do not use excessive force
•Crown fracture
•Loosen adjacent teeth
As tooth loosens, move
elevator more into bone
towards root end
20/01/14

44. Elevation of teeth
Uses leverage at a
mechanical advantage
point used to luxate tooth
in alveolar socket
Movement of tooth
expands alveolar bone to
allow tooth to be removed
Start with smaller elevator
and move to larger as
tooth luxates
20/01/14

45. Point to remember in
extraction of teeth
Never refer to the extraction of tooth as a
“simple extraction”. You may find yourself in
the embarrassing position of trying to explain to
the patient why this simple extraction taking so
much time and effort
Anticipate breakage by knowing all reason why
root and crown break. Forewarn the patient of
the possibility of breakage or fracture
20/01/14

46. 20/01/14

47. Mechanical principles involved in
tooth extractions
• Removal of bone
surrounding the root
• Sectioning the tooth
20/01/14

48. … Take time to laugh
It is the music of the
!heart
20/01/14

49. Removal of Fractured Root
Fractured root should be removed at the time of
extraction because it may cause the following
complication:
1-Large roots in the alveolus will be localized
source of inflammation
2-It may cause residual infection
3-RR may act as a mechanical irritant and set up
an inflammatory reaction which may give rise to
neuralgic pain of obscure origin
20/01/14

50. Reason of Root Breakage
1-Faulty application of instruments
or extraction movements, wrong
pattern forceps on a particular
tooth may cause its breakage.
Improper grip , inadequate
extraction movements.
Sudden or jerky extraction
movement, gripping of the crown
too superficially and not at CEJ
20/01/14

51. Reason of Root Breakage
2-Pulpless teeth, badly decayed, teeth with
abnormal root pattern or Hypercementosis
3-Excessive density of the surrounding bone
due condensing osteitis , or isolated tooth
and in old age patient
4-Lake of perfect control of instrument or
interference from the patient
20/01/14

52. Removal of broken single
rooted teeth
This includes the maxillary incisors and canines
and mandibular incisors, canines and premolars:
Removal of Roots Broken at the Gingival
Margin:
A-These root may be extracted with forceps ,
with careful adaptation of the beaks under the
gingival margin
B-Straight Apexo elevator or Coupland .The
angulated Apexo elevator used to remove
mandibular single rooted teeth apply moderate
force distal as will as mesial of the root till
complete delivery of the RR
20/01/14

53. Removal of the root broken
halfway of the apex
Generally , these are the cases which
require the reflection of mucoperiosteal
flap and removal of buccal and lingual
alveolar bone what we call it TRANSALVEOLAR SURGICAL EXTRACTION
20/01/14

54. Take the time to
… !hear
It is the power of
Intelligence
20/01/14

55. Removal of Roots of Upper and
Lower Molars
1-Removal of Broken Root of
Mandibular Molars :
1-When both roots are fractured at the
gingival line , the root trunk is still
present a lower premolar forceps can
be used, its beaks should be inserted
as far under the gingival margin
20/01/14

56. Removal of Roots of Upper and
Lower Molars
2-The other technique for removal of such
roots is a drill used to separate the roots
after this Apexo elevator may be used to
loosen the mesial root by inserting it into a
space between the lamia dura and the
surface of the root from the mesial and
distal surfaces until loosening of the root
occur . The other root could extracted by
using Winter or Cryer elevators
20/01/14

57. Removal of Broken Roots of
Maxillary Molars
Maxillary molars roots may be removed by
grasping the palatal and the distobuccal roots
with the upper roots forceps or with Bayonet
Forceps .
This procedure will either remove all three roots
or cause breaking of mesiobuccal root which
then can be removed by upper root forceps or
with Warwick James curved elevator inserted
into empty disto-buccal socket
20/01/14

58. Removal of Broken Roots of
Maxillary Molars
Another technique is
first to separate the
fused roots with drill
in the form of “ Y “
shape and then
remove them
individually by mean
of forceps or by
Warwick James
curved elevator
between the
separated roots.
20/01/14

59. … Take time to cry
It is the sign of a large
!heart
20/01/14

60. … Take time to Love
It is the secret of
!eternal youth
20/01/14

61. 20/01/14

62. 20/01/14

63. Post-extraction care and instructions
20/01/14

64. Post-extraction care
• Inspection of the socket
• Removal of debris and any
•
•
•
•
•
tooth fragments
Squeezing the socket
Insuring haemostasis (Gauze
pack)
Remove any septic granulation
tissue or granuloma from the
socket
Trim and smooth any sharp
edges from the alveolar plate
of bone
Clean the patient lips and face.
20/01/14

65. Post-extraction Instructions
1-Keep biting on gauze, sponges for about one
hour after extraction, by the time if bleeding is
controlled, discontinue pressure pack
2-No mouth wash for at least 24 hours after
extraction
3-Avoid any hot food or drink for the rest of the day
to prevent bleeding
4-The diet must be cold fluids or soft food to avoid
irritation of the wound
5-Avoid any hard labour and have an adequate
rest
20/01/14

66. Post-extraction prescription
• Pain killer (NSAI)
• Mouth wash (warm salty water)
• Antibiotics?!
20/01/14

67. Post-extraction instructions
• Instruction leaflet
• Food or drinks
• Smoking
• Rest
• Pack
• Emergency
20/01/14

68. Complications of exodontia
• During anesthesia
• During extraction
• After extraction
20/01/14

69. Complications of exodontia
 During extraction:
• soft tissue laceration
• Broken tooth
• Haemorrhage
• Oroantral communication
• Luxation of the neighbouring tooth
• TMJ problem
• Fracture jaw
• Tooth ingestion or aspiration
20/01/14

70. Complications of exodontia
 Post extraction
• Haemorrhage
• Infection, dry socket
• Pain
• Numbness
• Referred pain
20/01/14

71. 20/01/14

72. Dental Elevators
20/01/14