Indication and contra indication for extraction Patient and surgeon preparation Proper Chair Position for Extraction Proper Position for operator Steps of simple extraction Types of exodontia Elevators (selection + rules & techniques) Forceps (selection + rules & techniques) Post-extraction care & instruction

1. Principles of Exodontia
Dr. Giath Gazal
Associate Professor
Oral & Maxillofacial Surgery Department
Taibah Dental College

2. Objectives and Outlines
▪ Indication and contra indication for extraction
▪ Patient and surgeon preparation
▪ Proper Chair Position for Extraction
▪ Proper Position for operator
▪ Steps of simple extraction
▪ Types of exodontia
▪ Elevators (selection + rules & techniques)
▪ Forceps (selection + rules & techniques)
▪ Post-extraction care & instruction

3. EXTRACTION
Definition
Extraction is defined as a complete, painless
removal of tooth or root with minimal trauma to
surrounding structures, so
wound heals uneventfully with no post operative
prosthetic problems is created

4. Mechanical Principles for Using Dental Forceps

5. Introduction
• General practice
• Hospital

6. Indications of Exodontia:
Reasons for tooth extraction
• Caries (unrestorable)
• Apical abscess
• Periodontal disease
• Pericoronitis
• Crowding
• Other pathology
• Jaw fractures

7. Severe caries
Pulpal necrosis

8. Orthodontic reasons
Malposed teeth

9. Cracked teeth
Impacted teeth

10. Supernumerary teeth
Associated with
pathologies

11. Involved in fractures

12. Contra-indications of Exodontia
Absolute:
1. Local
▪ Haemangiomas: Benign vascular tumors
Hemangioma is considered as an absolute contraindication for tooth extraction if the lesion reaches the alveolar crest

13. 2. Systemic
▪ Leukemia &Lymphomas
• Low Platelet Count
• Patient need Platelet Rich Plasma (PRP) transfusion
If Platelet count < 50,000/mm3
• For extraction Counts should be above 75,000/mcL
• Teeth that have undergone radiation , dental treatment
should be in remission period [6 months – 1 yr ].
▪ Coagulation defects
• Such as Hemophilia
• Patient need Fresh Frozen Plasma before extraction

14. ▪ Myocardial Infarction
• No extraction within 3 months after MI
▪ Thyrotoxicosis
• Pain, anxiety and LA with adrenaline may lead to
Thyroid storm (tachycardia with severe hypertension)

15. Contra-indications
Relative:
1. Local
▪ Acute infection (Acute cellulitis)

16. ▪ANUG
▪Acute pericoronitis

17. 2. Systemic
Uncontrolled:
▪ Diabetes mellitus
• Normal fasting blood glucose < 100mg/dl and Random blood glucose <144 mg/dl
• The maximum permissible blood glucose level for dental extraction is:
- 180 mg/dl (10mmol/l) Fasting Blood Glucose. Or
- 200 mg/dl (11mmol/l) Random Blood Glucose.
• 234 mg/dl is a cut- off point for Emergency tooth extraction
- Give LA without adrenaline
- Give a Course of Amoxicillin 500mg for 5 days after extraction
▪ Hypertension:
▪ No LA /No extraction if BP > 180/110
• Blood pressure of 180/110 mmHg is a cut-off for any procedure
• Systolic ≥160 or Dystolic ≥100:
1- Patient with ischemic heart disease LA without adrenaline or LA with adrenaline, maximum 2 cartilages
2- Patient without ischemic heart disease Limit on LA with adrenaline

18. Extraction should be avoided in:
- Gestational diabetes
- Gestational Hypertension pre-eclampsia
Pre-eclampsia is high blood pressure, sometimes with fluid retention and proteinuria.
- First trimester: Organogenesis
• Second Trimester & First month of last trimester is considered to be a more safe period for dental extraction
• Avoid Supine hypotensive syndrome (Compression of inferior vena cava & aorta)
▪ Pregnancy

19. ▪Epilepsy
How often do you have seizures?
No extraction in:
▪ Unstable epileptic (not controlled)
▪ Status epilepticus
▪Liver & Kidney disorders.
▪ Patients with Hepatic disease may need vitamin K or fresh frozen plasma to correct coagulation and
therefore, should be managed in hospital
▪ Patients with renal disease may have upset fluid balance (coma, seizures, and cardiac arrest) and
platelet dysfunction which may lead to bleeding tendency.

20. Summary
➢It may be judicious
to delay the extraction until certain local or
systemic condition corrected or modified.
➢In the era of antibiotics acute infection of
odontogenic origin are not considered as
absolute contraindication of immediate
extraction.

21. Clinical Evaluation of Patient before
Extraction
• History
• Examination
• Radiograph
• Warnings
• Consent Form

22. Evaluation of teeth removal
1. Access to Tooth
2. Mobility of Tooth
3. Condition of Crown

23. Tremors caused by Parkinson's disease can make
the access to dental extraction is difficult

24. Radiographs
• Attempted extraction
• Grossly decayed
• Root canal treated
• Supernumerary teeth
• Impacted Teeth
• Root stumps
• Fractured Teeth

25. Radiographic evaluation
• Condition of the Tooth.
• Condition of the Bone.
• Relationship with associated
Vital structures.

26. Patient and surgeon preparation
▪ Infection Control is Mandatory

27. Cont
• For patient
1. A sterile disposable towel drape
(Napkin) should be put across
the patient’s chest
2. Proper oral hygiene is very
important before extraction

28. Preparation of dental chair,
operator and assistant

29. Chair Position for Extraction
▪ Positions of the patient, chair, and operator
are critical for successful extraction.
▪ Correct position allows the surgeon to keep
the wrists straight enough to deliver the
force with the arm and shoulder

31. General Rules for
Position of the operator
1. Stand erect , equal distribution of weight on both feet
2. Force delivery with arm &
shoulder not with hand
1. Application of force without
stress to shoulders & back
(This can be achieved by standing the operator generally on right hand side,
for right posteriors – back side and by using Operating box )

32. Chair Position for Extraction
Maxillary extraction:
Positioning when extracting upper teeth?
• Patient supine (angle of the chair back is 120 to 135 degrees with the floor)
• Maxillary plane 45- 60 degree to angle with floor
• Support alveolus
• Palm up grip
(handle at heel of hand)

33. Chair Position for Extraction
Maxillary extraction:
1- Chair should be tipped backward until
maxillary occlusal plane is at the angle between 45°
to 60° degrees with the floor.
2- The height of the chair should be at or slightly
below the operator's elbow level.
Note: Patient should be positioned with his mouth level with the operator’s elbow and the dental chair reclined so
that the upper arch lies at an angle of 45 -60 to floor

34. 8 cm below the shoulder level of
operator
How many cm is the maxillary
teeth below the operator's shoulder
when extracting upper teeth?

35. 8 cm

36. Maxillary extractions require maxillary
occlusal plane to be of what degree angle
with the floor?
45°-60° degrees

37. 45°

38. Chair Position for Extraction
Mandibular extraction:
1- Patient should be in a more upright
position(angle of chair back is 110 degrees with the floor),
mandibular occlusal plane is parallel to the
floor when mouth is opened
2- Chair should be lower than extraction of
maxillary teeth, and the surgeon's arm is
inclined downward to approximately a 120°
degree angle at the elbow which provides a comfortable, stable position that
is more controllable than the higher position.

40. 120

41. 16 cm below elbow
How many cm is the mandibular teeth below
the operator's elbow when extracting lower
teeth?

42. 16 cm

43. Positioning when extracting upper
teeth Quadrant 1&2?
• Stand at 7’Oclock
position
• Support alveolus
• Palm up grip
(handle at heel of
hand)
• Patient supine
• Maxillary occlusal
plane at 45° to 60°
with floor

44. Positioning when extracting Quad 3 teeth?
• Stand at 7’Oclock position
• Support alveolus/mandible
• Palm down grip
• Patient upright 110° degrees
• Mandible occlusal plane
parallel to floor
*Q3 -non-dominant two fingers and
thumb under mandible

45. Positioning when extracting Quad 4
teeth?
• Stand at 10’Oclock position
• Patient upright 110° degrees
• Mandible parallel to floor
• Support mandible/alveolus
*Q4 -non-dominant thumbs and first
finger, little finger under mandible

46. Role of opposite hand
Alveolar support

51. Why must the alveolar ridge be
supported by non dominant hand when
luxating?
• Maintain good visibility
• Reduce possible tissue damage
• Feel progress

52. Steps of simple extraction
1. Give local anaesthesia
2. Detach the gingiva by periosteal elevator (MOLT)
3. Luxate the tooth by straight/curved elevator
4. Extracting the tooth from the socket using
forceps/elevators & use the opposite hand to reflect lip/cheek and support buccal and lingual
alveolar bone
5. Squeeze the socket and apply pressure gauze
6. Give post-extraction instruction

53. Where does the operator stand when
administering LA in Quad 3?
• Behind the patient
(Everywhere else is in front)
• Quad 1, 2 & 4 is in front
• Pt must be supine or semisupine
Note: For the administration of any LA, it is best to have the patient lying in a supine position in order to reduce the likelihood of syncope.

54. 1. Give local anaesthesia
▪ Infiltration
▪ Regional local anaesthesia
▪ LA + Sedation
Profound local anesthesia is required
to prevent pain during extraction

55. 2. Detach the gingiva
Separation of Tooth from Soft Tissues
• Periosteal elevator (MOLT)
• Straight and curved Desmotomes
• Straight and curved Warwick James
These instruments are used to detach the
gingival tissues from around the neck of the
tooth prior to placement of extraction forceps:

56. Periosteal elevator has tow ends
1- Sharp pointed end
Used to cut gingival attachment at
cervical region. (tooth extraction)
2 - Broader rounded end
• Reflecting mucoperiosteum away
from the bone to prevent it being
crushed when the bone is used as
a fulcrum. (root extraction)

57. 1. Periosteal elevator is held with Pen Grasp and aligned with the long axis of the
tooth
2. Insertion begins at any aspect of the gingival sulcus as the entire
circumference must be incised
3. Rocking motion (stabbing motion) is applied Sharp/rounded end of
instrument is rocked slightly along its long axis with apical pressure in the gingival sulcus
4. Sharp end is systematically re-inserted continuing around
the neck of the tooth several times to accomplish thorough elimination of the fibrous attachment
Note: In surgical extraction:
• Push stroke is used for raising a flap. Broader rounded end is slide underneath the periosteum separating it from
underlying
• Twisting, Prying motion :It is used to elevate soft tissue in dental papilla
Methods to detach soft tissue:

59. 3. Luxate the
tooth by
elevators

60. Function of the elevators
To loosen tooth or root from
bony socket prior to placement
of the extraction forceps

61. Types of Elevators
1. Straight elevators (Couplands)
2. Cryer elevators
3. Apexo elevators
4. Warwick James elevators

62. Apexo elevator
Triangle
Blade
Shank Handle
Straight elevator Blade has one convex side
inserted toward the bone and one concave side
inserted toward the root surface

63. Couplands

64. Warwick James

65. Cryers

66. Apexo elevator

67. Elevators techniques
There are 3 actions used in elevation
• Wedge
• Lever
• Screwdriver (wheel & axle)

68. General Rules of Use of Elevators
1-Palm grip and finger guard
2-Place between tooth and bone
3-Must rest on bone (as fulcrum
point) and not adjacent teeth
4-Don’t use the buccal or lingual
plate of bone as a fulcrum
5-Turn around long axis to dislodge
tooth/root
6-Use the left hand for reflection,
guard and support
7-Take care of the surrounding
vital structures

69. What kind of grip should you use with an elevator?
Full grip & finger guard (to prevent slipping)

70. Wedge Effect for 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
I. Crown fracture
II. Loosen adjacent teeth
▪ As tooth loosens, move elevator
more into bone towards root end

71. Wedge movement with Elevator
▪ Apply elevator in periodontal
space parallel to long axis of tooth
▪ Push tip of instrument into mesial
aspect
▪ Use firm steady pressure to push
down from 2-5 mm
▪ Repeat on distal aspect
▪ Start with smaller elevator and
move to larger as the tooth luxate

72. Describe Lever Effect
▪ Works on lever & fulcrum
principle
▪ Forces the tooth / root along
the line of withdrawal
▪ Used on root stumps after
mobilizing with wedging
effect
▪ Fulcrum is crestal bone or
adjacent tooth
▪ NEVER use this principle to
remove an intact tooth

74. Describe the screwdriver action
Wheel and axle movement
▪ Involves rotation of the
elevator around its long axis
▪ Should not be used on teeth
that have not been first
mobilised considerably

75. Screwdriver action used for extraction of single
rooted teeth with destroyed Crown
Positioning of straight elevator on the distal surface of the root,
either perpendicular, or at angle of 45° to the root
45°

77. Application
Apply elevator in periodontal Space 45° or
90°to long axis of tooth
Placement of gauze between finger on lingual
side, for protection from injury in case the
elevator slips

78. Point of application
Application of elevator:
• Mesially
• Distally
• Buccally (only lower molars)

79. Movement
Rotate the elevator along its long axis
c. Photoelastic model showing
extraction of the third mandibular
molar using a straight elevator.
Using the adjacent tooth as a
fulcrum creates great tension
around the tooth, with a risk of
injury to tissues surrounding the
root
a. During luxation of a tooth, the alveolar ridge
is used as a fulcrum, not the adjacent tooth.
b. Incorrect
placement of the instrument.

80. Extraction is accomplished
by sectioning roots using a
straight elevator

81. Positioning of the elevator and the fingers of the left hand for separation of molar roots

83. Screwdriver action for cryer
elevators

84. Extraction of Root Tips by
elevators
Diagrammatic illustrations showing luxation of the root tip
of the mandibular second premolar, using Apexo elevator

85. Mesial root of a mandibular molar
Technique for removing the tip of a mesial root of a mandibular
molar. Removal of intraradicular bone and luxation of the root
tip using a double-angled (apexo) elevator

86. Removal of the tip of the distal root of a
maxillary molar

87. Removal of root tip
Removal of the root tip using an endodontic file. After the endodontic
file enters the root canal, the root tip is drawn upwards by hand (a),
or with a needle holder (b)

88. Types (Techniques) of
Exodontia

89. 1- Intra-Alveolar Extraction
(Conventional)
It is also called as Closed extraction.
Where tooth is luxated and elevated
out of socket with Elevators and FORCEPS

90. 2- Trans-Alveolar Extraction
This is a surgical technique
• Incision is placed and mucoperiosteal flap is
reflected
• Bone removal by using a bur or chisel and
mallet.
• Sutures are placed to approximate wound
margins.

92. Intra-alveolar extraction instruments
Two types of instruments for simple extraction
Forceps Elevator
Parts of the dental forceps:
➢Blades.
➢Joints.
➢Handles.

93. Forceps Parts
Blades
Joints
Hands

94. Forceps
• Blades have sharp edges to cut the
periodontal fibers.
• Blades are wedge-shaped to dilate
the socket and they 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.

95. Mechanical principles for using dental forceps

96. Mechanical principles for using dental forceps
There are three principles (movements):
• Primary Movement: Applying apical pressure
after Adaptation of forceps to tooth
• Secondary Movement: Luxation of tooth with
forceps (buccal – lingual +/- rotational
movements)
• Tertiary Movement: Delivery of tooth by
using traction force

97. Socket expanding movements
Aim to:
▪ Expand alveolar bone
by using apical pressure
▪ Maintain apical pressure
throughout buccal –
lingual and rotational
movements
*These movements are only
applied once adequate positioning
of forceps beaks from primary
drive

98. Choice of forceps depends on
• Morphology of the tooth
• Root anatomy
• Number of roots

99. General rules
▪ Lower forceps have handles at
right angles to the blades
▪ Upper forceps are straight for
anterior teeth and cranked for
the posterior one.

100. Lower forceps

104. Lower incisors and canines
English Pattern forceps
Lower root forceps
They can be used for lower anterior teeth
English Pattern

105. Lower premolars
English Pattern

107. Lower molar forceps
Cowhorn forceps

108. Upper Forceps

109. Upper left and right molars forceps

111. Forceps Style

112. 1. Forceps Technique
• Commonly used
• Not used in:
1. Hypercementosis
2. Root deformities
3. Grossly decayed crown or root
4. Brittle root
• Advantages:
1- Least trauma
2- Gingival fibers reduce the size of extraction orifice
and promote healing

113. Basic principles for forceps technique
• Beaks should seated as far apically as possible
• Beaks should be parallel to the long axis of
tooth
• Excess force should be avoided.

114. How to hold the forceps
• Handle in palm
• Thumb just below
the joint & four fingers around the end
of the serrated surface for the handles.
• Little finger inside
the handle (during the application of
the forceps to the tooth)
• Little finger outside
the handle (during the extraction of
the tooth)

115. Grip of the extraction forceps

116. Application of the forceps (Grip of the tooth)

117. Forces during extraction
• Apical force: Extraction forceps should be seated with strong apical pressure to expand the crestal
bone and to displace the center of rotation as far apically as possible.
• Buccal force: Buccal pressure results in expansion of the buccal plate, particularly at the crest of the
ridge. It also cause lingual apical pressure.
• Lingual force: Lingual pressure is expanding the lingual crestal bone, at the same time, avoiding
excessive pressure on the buccal apical bone.
• Rotational force/figure of 8: Single conical roots can be extracted by this method. it
causes internal expansion of the bony socket (Maxillary incisors and mandibular premolars). 8 figure pressure applied
on molars with proximal or fused roots
• Tractional force: Are useful for delivering the tooth from the socket once adequate bony
expansion is achieved.

118. Forces applied during extraction of tooth
(Apical force)
Apical Pressure

119. Apical pressure
• Since the tooth is moving in response to the force placed on it by the forceps, the forceps
becomes the instrument of expansion.
• If the fulcrum is high, there is a larger amount of force on the apical region of
the tooth, which increases the chance of fracturing the root.
• If the beaks of the forceps are forced a bit into the periodontal ligament space, the center of rotation is moved
apical, which results in greater movement of the
expansion forces at the crest of the ridge
and less force moving the apex of the tooth
lingually. This process decreases the chance for apical root fracture.

120. Extraction forceps should be seated with strong apical
pressure to expand the crestal bone and to displace the
center of rotation as far apically as possible.
Contact surface

121. Forces applied during extraction of tooth
(Rotational & Tractional force)

122. Anatomical consideration for
using forceps
Maxillary
buccal bone is
thinner –
buccally
removal of teeth
Mandibular
buccal bone till
first molar is
thinner -
buccally
removal of teeth
Mandibular
buccal bone in
molar region is
thicker – extra
lingual force for
removal of teeth

123. Conclusion
• Since maxillary buccal bone is usually thinner and the palatal bone is a thicker cortical bone,
maxillary teeth are usually removed by strong; buccal
forces and less vigorous palatal forces.
• In the mandible the buccal bone is thinner from the midline
posterior to the area of the molars.
• The incisors, canines and premolars are removed primarily
as a result of strong buccal force and less vigorous lingual
pressure.
• The mandibular molar teeth has stronger buccal bone and
usually require stronger lingual pressure than the other
teeth in the mouth.

124. Order of extraction
• Maxillary teeth should be extracted before
mandibular ones to prevent falling of debris or tooth material in to socket.
• Distal most tooth is first extracted to prevent bleeding
from socket of extracted teeth obscuring the field of operation .
• Canine should not be left last as alveolus may get fractured due
to its length.

126. Maxillary incisors
Movements:
▪ Firm grip
▪ Apply apical force
▪ Labial-palatal
movement (more labial)
with mesial rotation.
▪ Lateral incisor and
canine: Labial-palatal
movements.

127. Maxillary premolars
Movements:
▪ Firm grip
▪ Apply apical force
▪ Buccal – palatal (more
buccal) movement, with
increasing range of
movement every cycle,
until the tooth extracted
Note:
First upper premolars > 50% have two roots.
Bifurcation usually occurs in the apical one third to
one half.
- Extremely thin and are subject to fracture
(king of fracture)

128. Upper first premolar is
a king of fracture

129. Maxillary molars
Movements:
▪ Firm grip
▪ Apply apical force
▪ Buccal – palatal (more
buccal) movement, with
increasing range of movement every cycle,
▪ buccal expansion
associated with traction
until the tooth extracted

130. What tertiary movement is used
for maxillary molar teeth?
*Stepping down technique
(traction + buccal expansion)

131. What does the Stepping Down
technique help to prevent?
Root Fractures

132. Maxillary Third Molar
• Frequently conical fused roots BUT can
show wide anatomical variation
• Universal forceps
• Relation : maxillary sinus & maxillary
tuberosity

133. Mandibular incisors
Movements:
▪ Firm grip
▪ Apply apical force
▪ labial-lingual
removal in labial
direction.
Note:
Slight mesial to distal force might be applied
during extraction movements

134. Mandibular canine
Heavy bladed forceps are
used.
Root of mandibular canine is longer, and heavier than central
and lateral. (shorter and weaker than its maxillary counterpart)

135. Mandibular premolars
Movements:
▪ Firm grip
▪ Apply apical force
▪ Buccal – lingual with
slight mesio-distal
rotation.

136. Mandibular molars
Movements:
▪ Firm grip
▪ Apply apical force
▪ Buccal-lingual
movement with
second molar extra
lingual force
▪ Removal from
buccal side
• Roots of 1st molar more widely
divergent than those of 2nd molar
(more difficult to extract)
• Thick buccal plate

137. Mandibular Second molar
Buccal-lingual movement
with more pressure towards
lingual

138. Mandibular Third Molar
• Wide anatomical variation
• Thinner lingual plate and much thicker buccal
plate
• Relation : IAC ,lingual nerve and artery
• Movements: Depending on the anatomical structure of 3rd molar:
Linguo-buccal movement or
Buccal pressure and removal in buccal or
lingual direction

140. Extraction of deciduous teeth
Considerations:
➢ Permanent successors
➢ Limited access
➢ Use fine blades
(Warwick james elevators)
➢ Extraction of deciduous
molar with forceps. Forceps
are positioned mesially or
distally on the crown and not
the center of the tooth

141. Number of teeth to be extracted
per appointment
▪ Side by side with one week
interval is recommended
How many teeth?
Depend on the surgical difficulty. Patient’s health and
morale. But between 4 and 8 would
seem reasonable. But in our college no
more than 4 on condition that patient is fit &
well.

142. Post extraction Care
• Inspection of the extracted tooth and socket
• Sharp edges (smoothed with bone file)
• Irrigation of the socket
• Mouth rinsing with water for once
• Squeezing of the socket Squeeze socket between index finger and thumb
5 seconds)
• Moist gauze pack (Place rolled-up piece of gauze over socket
patient to bite firmly for 5 minutes)
• Medication
• Post extraction instructions

143. Inspection of the extracted tooth

144. Size of Pressure Pack

145. Failure of Socket Inspection

146. Postoperative Instructions
• Pressure gauze pack (20 to 30) minutes
• Eating after 2 hours
• Soft and cool diet
• Avoid sucking the wound, hot drinks,
spitting off and smoking for 24 hours after extraction
• Avoid exploring the wound with tongue or
fingers
• Pain killer. Analgesics paracetamol 1g paracetamol every 6 hours/NASID before the
numbness of injection wear off.
• Normal saline mouthwashes after 24 hours

147. Post extraction instruction video
https://www.youtube.com/watch?v=9wvRcNT
LZHk&t=23s
https://quizlet.com/21711618/la-11-
instruments-flash-cards/