Definition: The ideal tooth extraction is 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.

1. EXTRACTION
OF PRIMARY
TEETH
ALONG WITH
PERMANENT
TEETH
DR.ATASICHAKRABORTY
1ST YEARPGT,(PEDODONTICS)DR.R AHMEDDENTAL
COLLEGEANDHOSPITAL

2. CONTENTS:
• Definition
• Indication and contraindication
• Preoperative assessment
• Basic principles of extraction
• Difference between primary and permanent teeth
• Modification of techniques in deciduous teeth
• Chair position
• Types of forceps
• Extraction of deciduous teeth.
• Extraction of permanent teeth
• Techniques of exodontia
• Overview of extraction
• Role of operator’s hand
• After care
• Post operative instructions
• Recent advancements.
• Thank you

3. DEFINITION:
The ideal tooth extraction is 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.

4. EXTRACTION OF TEETH
INDICATIONS
• affected by caries,pulpal necrosis
• affected by periodontal disease
• Over-retained teeth,supernumerary tooth
• for esthetic reasons , for prosthodontic
reasons,orthodontic reasons
• Impacted and supernumerary teeth
• • Teeth involved in fracture line
• Teeth involved in tumors or cysts
• Tooth as foci of infection
CONTRAINDICATION
LOCAL
• Presence of acute oral
infection
• • Extraction of teeth in
previously irradiated
areas (at least 1 year
should be allowed for
maximal recovery of
circulation to the bone).
SYSTEMIC
• Acute blood dyscrasias –
Untreated
coagulopathies –
• Adrenal insufficiency –
• Uncontrolled diabetes
General debilitation for any
reason – Myocardial
infarction (wait for 6 months
period)

5. PREOPERATIVE ASSESSMENT
1. A history of general disease, nervousness
2. Sick or fatigued should rest before operative procedures.
3. Highly apprehensive patient should receive some form of sedation before the operation.
4. Patient under going general anesthesia instructed to omit the previous meal and to take
nothing by mouth for at least 6 hours before extraction.
5. Inflamed or infected gingival should use an antiseptic mouth rinse before the extraction.
6. Removable prostheses must be taken out of the patient’s mouth.
7. The administration of antibiotics is recommended as a prophylactic measure in all medical
compromised patient
8. Assessment of pre extraction radiograph

6. BASIC PRINCIPLES OF EXTRACTION
• For individual tooth and root mechanics principles for tooth extractions
• 1. Expansion of the bony socket.
• 2. The use of fulcrum and lever
• 3. Insertion of wedge of wedges
• 4. Wheel and axel

7. EXPANSION OF THE BONY SOCKET
• • Expansion of the bony socket
by use of the wedge-shaped
breaks of the forceps.
• • The forceps should be seated
with strong apical pressure to
expand crystal bones and to
displace center of rotation as
apically as possible.
Dilation is
accompanied by
multiple small
fractures of buccal
plate and
interradicular septa.

8. THE USE OF FULCRUM OR LEVER
• A lever is a mechanism for transmitting a modest force with the mechanical
advantages of a long lever arm and a short resistance arm into a small movement
against great resistance.
• When an elevator is used for tooth extraction, an acquired contact point can be
made on the root surface and a latter can be applied by the handle of the elevator
to elevate the tooth or a tooth root from the socket.
• The wedge principle is useful for the extraction of teeth in several different ways.
• 1. By using the beaks of the extraction forceps as a wedge.
• 2. When a straight elevator is used to luxate a tooth from its socket.

10. WHEEL AND AXEL
• When one root of a multiple- rooted
tooth is left in the alveolar process, the
pennant-shaped elevator is positioned
in the socket and turned
• The handle then serves as the axle and
the tip of the triangular elevator acts as
a wheel and engages and elevates the
tooth root from the socket.

11. DIFFERENCES BETWEEN PRIMARY AND PERMANENT TOOTH
• Size primary teeth are smaller in every dimensions than permanent.
• Shape- crown of primary teeth are more bulbous. The furcation of primary
molar root is positioned more cervically than permanent.
• Physiology - root of primary teeth resorb naturally where as in the permanent
resorption is normally a sign of pathology.
• Support- the bone of alveolus is much more elastic in the younger patient.

12. MODIFICATION OF EXTRACTION TECHNIQUE IN CHILDREN
• Type of forceps :- the beaks & handles are smaller, & to accommodate more
bulbous crown the beaks are more curved in forceps designed for removal of
primary teeth.
• • The wide splaying of primary molars roots means that more expansion of the
socket is required.
• • Due to relatively cervical position of the bifurcation in primary molars it is
injudicious to use forceps with deeply plunging beaks.
• • Avoid blind investigation of primary socket.
• • Because of physiological resorption it is often preferable to leave small fragments
in situ if root fractures.

13. POSITION
OPERATOR’S POSITION
• When removing upper teeth under LA the
operator stand in front of the patient with
straight back & the patient mouth at a level
just below the operator shoulder.
• When extracting any tooth except the right
mandibular molars,premolar,and canine
operator stands on right-hand side of the
patient.
• For the removal of right mandibular cheek
teeth by the intra-alveolar method, the
operator stands behind the patient
• Sometimes the operator must stand upon a
raised platform or operating box' in order to
achieve the optimalworking position.
PATIENT’S POSITION
• The child should be seated in a
dental chair reclined 30° to the
vertical for extraction under LA &
under GA- supine position.
• For adult –maxillary tooth-chair
tipped backwards so that maxillary
occlusal plane is at 60 degrees.
• Mandibular teeth- occlusal plane
parallel to the floor.

14. Maxillary tooth extraction-site
of operation is 8cm below the
shoulder level.
Mandibular teeth-site of
operation is 16 cm(6inch)
below operator’s elbow.

15.  TYPES OF FORCEP
For the upper cheek teeth lower
lip and mandibular incisors
prevent the sstraight forcep to
be positioned properly,so two
bends are introduced

16. EXTRACTION OF DECIDUOUS MAXILLARY TEETH
• CENTRAL INCISORS
 Have conical root
 Grasped with wide beak straight forceps
 Rotated in one direction and then other
 Pdl attachment broken
 Taken out in light traction

17. L A T E R A L I N C I S O R S :
They have slender roots which are often
. flattened on the mesial and distal
surfaces A fine bladed
forceps is used for the extraction of lateral
incisor
C A N I N E S : can be the most difficult upper teeth
to remove because of the length apical curvature of
their roots.
Since great force is needed to
dislodge these teeth, partial or total fracture of the
labial
wall of the alveolus is common. Forceps are placed as
high as possible under the gingival margin, and the
tooth
is then rotated back and forth while upward pressure
is
maintained and traction is applied for its removal.

18. strongest
and longest of which is the palatal root. The buccal
roots
are often curved distally. For the safe extraction of
1st
molar, careful rocking of the tooth buccally with
upper universal or bayonet forceps is used to
loosen the palatal root, and buccopalatal traction
aids in complete luxation of the tooth which is
removed without rotation.
2 N D M O L A R S : It can be removed by a
technique similar to
that used for 1st molar extraction.
Buccopalatal rocking and traction may be used
and even moderate torsion is
permissible to detach and remove the tooth.

20. EXTRACTION OF PRIMARY MANDIBULAR TEETH
C E N T R A L I N C I S O R A N D L A T E R A L I N C I S O R
 Lower incisors have fine roots with
flattened
sides.
 The supporting alveolar process is very
thin, and it
is easy to luxate the tooth when it is
rocked labially.
 Fine bladed forceps should be used to
grasp them

21. P R I M A R Y M A N D I B U L A R C A N I N E
It is long and bulky, firmly
embedded and difficult to
extract the apex is often
inclined distally.
A heavier bladed forceps
should be used and
movement in a buccolingual
direction is applied for
extraction of this tooth.

22. P R I M A R Y M A N D I B U L A R M O L A R S
• These molars are best
extracted with
• full molar forceps.
• often loosened by
buccolingual
• pressure and are best
delivered by secondary
rotation

23. EXTRACTION OF MAXILLARY PERMANENT
TEETH
CENTRAL AND LATERAL INCISOR
• Alveolar bone is thin on the labial side and heavier on the palatal side,
which indicates that the major expansion of the alveolar process will be
in the labial direction.
• The initial movement is slow. steady, and firm in the labial direction,
which expands the crestal buccal bone.
• A less vigorous palatal force is then used, followed by a slow, firm,
rotational force. Rotational movement should be minimized for the
lateral incisor, especially if a curvature exists on the tooth.
• The tooth is delivered in the labial-incisal direction with a small amount
of tractional force

25. MAXILLARY CANINES
• Its root is oblong in cross section and usually produces a bulge called the canine eminence on the
anterior surface of the maxilla.
• The result is that the bone over the labial aspect of the maxillary canine is usually thin In spite of the
thin labial bone this tooth can be difficult to extract simply because of its long root and large surface
area available for periodontal ligament attachments.
• The upper universal (No. 150) forceps are the preferred instrument for removing the maxillary
canine, after elevation.
• The initial move ment is apical and then to the buccal aspect, with return pressure to the palatal. As
the bone is expanded and the tooth mobilized, the forceps should be repositioned apically. A small
amount of rotational force may be useful in expanding the tooth socket, especially if adjacent teeth
are missing or have just been extracted.
• After the tooth has been well luxated, it is delivered from the socket in a labial-incisal direction with
labial tractional forces

26. If the palpating finger
indicates that a small
amount of bone has
fractured free and is
attached to the canine
tooth, the extraction
should continue in the
usual manner, with
caution taken not to
tear the soft tissue
IF the palpating finger indicates that a large
portion of labial alveolar plate has fractured,
the surgeon should stop the surgical
procedure. Usually, the fractured portion of
bone is still attached to periosteum and,
therefore, is viable The surgeon should use a
thin periosteal elevator to raise a small amount
of mucosa from around the tooth, down to the
level of the fractured bone The canine tooth
should then be stabilized with the extraction
forceps, and the surgeon should attempt to
free the fractured bone from the tooth, with
the periosteal elevator as a lever to separate
the bone from the tooth root. If this can be
accomplished, the tooth can be removed and
the bone left in place attached to the
periosteum. Normal healing should occur
If bone becomes detached
from the periosteum during
these attempts, it should be
removed because it is
probably nonvital and may
actually prolong wound
healing.

27. MAXILLARY FIRST PREMOLAR
• The maxillary first premolar is a single-rooted tooth in
its first two thirds, with a bifurcation into a buccolingual
root usually occurring in the apical one third to one
half.
• These roots may be extremely thin and are subject to
fracture, especially in older patients in whom bone
density is great and bone elasticity is diminished.
Perhaps the most common root fracture when
extracting teeth extraction for in adults occurs with this
tooth. As with other maxillary teeth, buccal bone is thin
compared with palatal bone.

28. Which root can fracture and why?
When the tooth
is luxated buccally,
the most likely
tooth root to
break is the labial
root
. When the tooth is luxated
in the palatal direction, the
most like root to break is
the palatal root, which is
harder to retrieve.
Of the two root tips the
labial is easier to retrieve
because of the thin,
overlying bone. Therefore
as for other maxillary teeth,
buccal pressures should be
greater than palatal
pressures. Any rotational
force should be avoided

29. MAXILLARY SECOND PREMOLAR
• Single rooted tooth
apical
Buccal
Palatal
Rotational
tractional
Extracted in bucco
occlusal direction

31. MAXILLARY MOLARS
• 3 large roots
• Pre operative evaluation is must(sinus,divergence curvature of roots)
• paired forceps No. 53R and No. 53L are usually used for extraction of the maxillary molars.
These two forceps have tip projections on the buccal beaks to fit into the buccal bifurcation.
• Some prefer to use the No. 89 and No. 90 forceps. These two forceps are especially useful if
the crown of the molar tooth has serious caries or large restorations.
• The upper molar forceps are adapted to the tooth and are seated apically as far as possible in
the usual fashion .The basic extraction movement is to use strong buccal and palatal
pressures, with stronger forces toward the buccal than toward the palate. Rotational forces are
not useful for extraction of this tooth because of its roots

33. MANDIBULAR INCISORS AND CANINE
• Mandibular incisors are short and slightly thinner, and the canine roots being longer and
heavier.
• The incisor roots are more likely to be fractured because they are thin, and therefore, they
should be removed only after adequate pre-extraction luxation.
• Bone over the canine may be thicker, especially on the lingual aspect
• The lower universal (No. 151) forceps are used to remove these teeth.
• . The forceps beaks are positioned on teeth and seated apically with strong force. The extraction
movements are generally in the labial and lingual directions, with equal pressures both way
• Once the tooth has become luxated and mobile, rotational movement may be used to expand
alveolar bone further. The tooth is removed from the socket with tractional forces in a labial-
incisally.

35. MANDIBULAR PREMOLARS
• Easiest to remove
• Roots are straight.
• The overlying alveolar bone is thin on the buccal aspect and heavier on the
lingual side,
• The lower universal (No. 151) forceps are usually chosen for the extraction
of the mandibular premolars
• ROTATIONAL MOVEMENTS are used for extraction.

44. TECHNIQUES OF
EXODONTIA
A. Transalveolar (open method)
B. Intraalveolar (closed method)
• Forceps technique
• Elevator technique

47. HOW TO HOLD A FORCEP?
1.Beaks should seated as far apically
as possible
2. Beaks should be parallel to the
long axis of tooth
3. Excess force should be avoided.

49. MOVEMENT: •.
• Buccal or Labial : Pressure applied to tooth will expand the buccal cortical
plate towards the crestal bone with some lingual expansion at apical
end of the root.
• • Lingual or palatal : Pressure will expand lingual contical plate at crestal
area and slightly expand buccal bone at apical area .
• The initial linguo-buccal movement for extraction of lower second
mandibular molar.
• • Initial rotational forces it is useful for removal of teeth with conical
roots; such as maxillary central.
• • Tractional forces are useful for final removal of tooth from socket.
They should always be small forces, because teeth are not "pulled."
• The Final withdrawal movement for Most of the upper and lower
teeth is an outward- occlusal direction. Except the lower third molar
which should be in a lingual- occlusal way and maxillary 3rd molar
should be disto-buccal.xpand buccal bone at apical area

50. THE PROPER USE OF FORCEPS IN LUXATION AND
REMOVAL OF TEETH
• 1. The extraction movements are essentially
three movements which are outward, inward,
and rotatory movements.
• 2. Outward (buccal or labial) movement is
the initial movement of all teeth except the
lower second and third molar where the
buccal plate of bone reinforced by the
external oblique ridge.
• 3. Inward (lingual or palatal) movement is the
initial movement during the extraction of the
lower second and third molars.

51. CONTINUES…
. PRIMARY ROTATORY MOVEMENT IS THE INITIAL MOVEMENT USED IN UPPER
CENTRAL INCISOR AND LOWER SECOND PREMOLAR.
 IF A RESISTANCE IS FELT IN PRIMARY ROTATION, A BUCCO- LINGUAL
MOVEMENT SHOULD BE STARTED.
 IF ROTATORY MOVEMENT CONTINUED, A SPIRAL FRACTURED OF THE TOOTH
ROOT MAY OCCUR.

52. ONCE THE ALVEOLAR BONE HAS EXPANDED
SUFFICIENTLY AND THE TOOTH HAS BEEN
LUXATED, A SLIGHT TRACTION FORCE, USUALLY
DIRECTED BUCCALLY, CAN BE USED.
FINAL MOVEMENT IS THE MOVEMENT BY
WHICH THE TOOTH IS REMOVED FROM ITS
BONY SOCKET.
IT SHOULD BE ALWAYS DIRECTED OUTWARD
AND OCCLUSALLY TO AVOID TRAUMATIZING
THE OPPOSING TOOTH,
THE EXTRACTION FORCEPS BLADE SHOULD BE
APPLIED TO THE CARIOUS SIDE FIRST, AND THE
FIRST MOVEMENT MADE TOWARD THE CARIES.

53. TOOTH EXTRACTION TECHNIQUE OVERVIEW
i. Administer local anaesthesia
ii. Before attempts are made for extraction,gingival tissue of cervical region should be detached
with help of Moon’s probe
iii. Beaks of the forceps are inserted under the gingiva as far as possible
iv. Forceps are adapted and root is grasped firmly with the beaks parallel to the long axis of the
tooth
v. For maxillary tooth-one hand is needed to reflect cheeks or lips and stabilise head
vi. Mandibular tooth- one hand is needed to support the mandible and retract cheek or lip.
vii. The handles of the forceps are grasped with enough force to hold the tooth firmly but not to
grasp it
viii. Socket dilated carefully until PDL attachment broken and tooth is taken out of socket

54. ROLE OF OPERATOR’S HAND
• The opposite hand plays an important
role in supporting and stabilizing the
lower jaw when mandibular teeth are
being extracted.
• The opposite hand supports the
alveolar process and provides tactile
information to the operator
concerning the expansion of the
alveolar process during the luxation
period.

55. AFTER CARE
. Irrigation of the socket with normal saline or
the other antiseptic solution .
2. Curettage of the socket to remove bony
fragment and granulation tissues .
3. Break down of the bony sharp edge at the
socket world and inter radicular bone.
4. Squeezing of the socket
5. Mouth rinsing with antiseptic solution once
. 6. Suturing (if required)
7. Moist gauze pack to prevent hemorrhage

56. POST OPERATIVE INSTRUCTIONS
1. Remove the cotton/ gauze pack at least 1 hour later.
2. Take cool and soft diet for at least 24 hours.
3. Avoid hot and hard diet for at least 24 hours.
4. Do not rinse forcefully and do not brush of the site of extraction for at least 24
hours
5. Maintain the oral hygenie
6. If stitch is given ,come one week later to cut it.

57. RECENT ADVANCEMENTS
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58. PHYSICS FORCEP

59. THANK YOU