Exodontia or Extraction is the painless removal of 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. By-Dr. Prathamesh Fulsundar

2. EXODONTIA
According to Geoffrey L. Howe –
Exodontia or Extraction is the painless removal of 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.

3. COMPLICATIONS OF EXODONTIA
CAN BE DIVIDED INTO
TWO TYPES
1- INTRAOPERATIVE
2- POSTOPERATIVE

4. 1-INTRAOPERATIVE
COMPLICATIONS
 SOFT TISSUE INJURIES
1-Tearing of Mucosal Flap
2-Puncture wound of soft tissue
3- Abrasion injury
 COMPLICATIONS WITH TOOTH BEING EXTRACTED
1-Root Fracture
2-Root Displacement
3-Tooth lost into Oropharynx
 INJURIES TO ADJACENT TEETH
1-Fracture of Adjacent restoration
2-Luxation of Adjacent teeth
3-Extraction of Wrong teeth
 INJURIES TO OSSEOUS STRUCTURES
1-Fracture of Maxillary Tuberosity
 INJURIES TO ADJACENT STRUCTURES
1-Injury to Regional Nerves
2-Injury to Temporomandibular joint

5. 2-POSTOPERATIVE COMPLICATIONS
1. Presence of bony spicule
2. Haemorrhage
3. Dry socket
4. Infection

6. SOFT TISSUE INJURY
1-TEARING OF MUCOSAL FLAP-
•It is one of the most common soft tissue injury during
extractions.
•It occurs as inadequately sized envelope flap is retracted
beyond the tissues ability to stretch.
Prevention
 Create adequately sized flaps to prevent excess tension on
the flap
 Use small amounts of retraction forces on the flap.

7. CLINICAL APPEARANCE
MANAGEMENT
 The flap should bee carefully repositioned after
surgery and suturing aids in healing

8. 2-PUNCTURE WOUND OF SOFT TISSUE
 The instruments such as straight elevator or periosteal
elevators may slip from surgical field and puncture
into adjacent soft tissue.
PREVENTION
 Use of controlled force
 Special attention should be given to finger support and
instrument stabilization
 Use of other hand to retract tissues from surgical field

9. CLINICAL APPEARANCE
MANAGEMENT
 Apply a local hemostat in order to prevent bleeding
 Prevent infection at the site of injury
 Wound is usually not sutured

10. 3-ABRASION INJURY
Abrasions or burns of lips and corners of mouth usually
occurs due to rotating shank of the burs
PREVENTION
 When the surgeon is focused on cutting end the
assistant should beware of location of shank in
relation to cheeks and lips

11. Management
 Scars produced due to thermal injuries can be managed by the
application of petroleum jelly or topical antiseptic/analgesic.
 These abrasions usually take 5 to 10 days to heal.
Clinical appearance

12. FRACTURE OF THE TEETH DURING
EXTRACTION
Causes
 Application of wrong forceps
 Improper application of forceps
 Extensively carious tooth
 Endodontically treated tooth
 Curved or hypercementosed root
 Ankylosed root
Prevention
 Proper radiograph assessment of the tooth to be extracted
 Proper forceps technique

13. Management
 When the fracture involves the crown of the tooth appropriate
restoration should be placed.
Clinical appearance

14. FRACTURE OF TOOTH ROOT
Causes
 Improper technique
 Application of improper instrument and force.
 Ankylosed or Hypercementosed teeth
 Excessively curved roots
 Endodontically treated root
 Uncooperative patient
Consequences of retained roots
Retained roots may acts as a source if infection. They might
be chronic source of irritation giving rise to Neuralgic Pain.
Large retained tooth may interfere with the proper
functioning of prosthesis.

15. Methods of retrieval of fractured root
Using appropriate elevators, forceps with slender beaks and
Reamers for removal of fractured root at various levels.
Clinical appearance

16. DISPLACEMENT OF TOOTH INTO
MAXILLARY SINUS
Causes
 The roots of the maxillary posterior teeth are always in a close
proximity to the maxillary sinus
 With advancing age the antral walls become very thin. Thus
eventually the roots being covered only by thin lamellae of bone
which fracture easily and result in the displacement of the root
tip during its removal.
 Sometimes the tooth may slips into the maxillary antrum like
the ‘popping of an orange seed’ once the extraction forceps are
applied.

17. Prevention
 Application of appropriate force and proper handling of forceps.
 Avoid injudicious instrumentation to remove a broken tip.
 Proper radiographs should be taken before the extraction to access the
proximity of the root tip to the sinus
 Support the alveolus adequately before the extraction.
Management
 Confirm the presence and location of the tooth or root tip in the sinus
using radiograph.
 Once the location is confirmed, keep a nozzle connected to a powerful
suction devise at the entrance of the fistula to recover tooth
 Pack a piece long roller gauze into the sinus through the opening and
remove it with a jerk, the root tip might get removed with the gauze.
 If none of the above procedure works, then Caldwell-Luc operation is
carried out.

18. Radiographic appearance

19. TOOTH LOST INTO OROPHARYNX
Causes
 Careless handling of the instruments
 Improper technique.
Management
 Confirm the presence of teeth in the GIT.
 Confirm the expulsion of the tooth using serial radiographs.

20. RADIOGRAPHIC APPEARANCE

21. INJURIES TO ADJACENT TEETH
1-LUXATION OF ADJACENT TEETH
Causes
 Improper instrumentation.
 No support to the adjacent structures during extraction
Prevention
 Proper technique and careful handling of the instruments.
 Support the adjacent teeth adequately before extraction.
Management
 Reposition the tooth inside the socket and splint it
 The tooth should be treated endodontically after one
week.

22. Clinical appearance
Adjacent tooth

23. 2-FRACTURE OF ADJACENT RESTORATION
Causes
 Presence of large restorations on adjacent teeth
 Improper instrumentation
 Application of excessive forces
Management
 Patient should be informed about his fractured restoration
 Prevent the restorative material from entering the tooth
socket
 A temporary restoration should be done followed by a
permanent restoration after 3 to 4 days.

24. 3-EXTRACTION OF WRONG TEETH
Management
 Inform the patient
 Replace the tooth inside the socket as soon possible and
splint.
 If immediate replacement is not possible, place the tooth in a
proper medium like saliva, milk or water.
 Follow up as for re-implantation.

25. INJURES TO OSSEUS STRUCTURES
1-FRACTURE OF MAXILLARY TUBEROSITY
Causes
 In cases where the antrum extends into the tuberosity, the
extraction of the third molar can result in fracture of
tuberosity.
 Exertion of excessive force and improper force application
 Fusion of the roots of second molar with the un-erupted third
molar (concrescence)
 Divergent and hypercemetosed roots of the third molar.
Prevention
 Proper analysis of the radiograph of tooth and surrounding
structures.
 Correct technique of extraction with careful force application
 Support to the alveolus during extraction.

26. Management
 In case of small fractured segment, a mucoperiosteal flap is
elevated and the tuberosity is removed with tooth, followed by
wound closure.
 In case of large fractured segment, it should be replaced and
splinted
 Removal of tooth should be done after the healing of fractured
site.
Clinical appearance

27. FRACTURE OF MANDIBLE
Causes
 Atrophic mandible as in old age.
 Existence of any bony pathology.
 Excessive force application
 In case of removal of vertically impacted third molar.
Prevention
 Proper preoperative assessment of the type of impaction and
the density of the bone before extraction
 Proper support of the jaw during extraction
 Do not use excessive force.

28. Management
 Inform and reassure the patient.
 The surgeon should make sure that the soft tissues
has been replaced and repositioned over the bone
structure to facilitate rapid healing.
Radiographic appearance

30. INJURIES TO ADJACENT
STRUCTURES
 INJURY TO REGIONAL NERVES
The branches of the 5th cranial nerve
• Mental nerve
• Buccal nerve
• Lingual nerve
• Nasopalatine nerve
which innervate the mucosa & skin are mostly injured
during extraction.

32. NASOPALATINE & BUCCAL NERVE
 Theses nerves are usually sectioned during the
creation of flaps for removal of impacted teeth.
They reinnervate easily & thus can be surgically
sectioned without sequelae or complication.
MENTAL NERVE
 During surgical removal of mandibular
premolar roots or impacted premolar and
periapical surgery in that area, care should be
taken not to injure vthe mental nerve along its
course.
 If injured the patient may have paresthesia or
anesthesia of the lip and chin.

33. PREVENTION OF NERVE INJURY
 BE AWARE OF NERVE ANATOMY IN
SURGICAL AREA.
 AVOID MAKING INCISIONS OF AFFECTING
PERIOSTEUM IN NERVE AREA.

35. LINGUAL NERVE
 Lingual nerve located directly against the
lingual aspect of the mandible in the
retromolar pad region rarely regenerates if
severely traumatized.
 Incisions made for surgical removal of
impacted mandibular3rd molars should be well
enough to the buccal aspect.
INFERIOR ALVEOLAR NERVE
 IAN is very commonly traumatized during
mandibular 3rd molar extractions, patients
should be made aware of the possiblity of the
nerve injury.

36. Injury to temporomandibular joint
 Removal of mandibular molar teeth requires
application of substantial amount of force. If jaw is not
supported adequately during extraction the patient
may experience pain in this region.
 The use of bite block on the contralateral side may
provide adequate balance of forces so that injury &
pain do not occur.
 If pain is experienced the surgeon recommends use of
moist heat, rest for the jaw, a soft diet, 1000mg aspirin
every 4hrs for several days.

39. PREVENTION OF INJURY TO TMJ
 SUPPORT MANDIBLE DURING
EXTRACTION.
 DO NOT OPEN MOUTH TOO WIDELY.

40. OROANTRAL COMMUNICATION
 If maxillary sinus is large, no bone exists between the
roots of the teeth & maxillary sinus, if roots are widely
divergent, then it is probable that a portion of the
bony floor of sinus will be removed with the tooth.
 This may lead to postoperative maxillary sinusitis and
oroantral fistula.

42. MANAGEMENT OF OROANTRAL
COMMUNICATION
 If communication is small<2mm in diameter or
less surgeon should ensure formation of high
quality blood clot in socket & advice patient to
take sinus precautions. Patient adviced to to
avoid blowing the nose, violent sneezing,
sucking on straw, smoking.
 If communication is moderate size 2-6mm
additional measures should be taken. To ensure
maintenance of blood clot in the area figure 8
suture should be placed. Antibiotics like
penicillin or clindamycin should be prescribed
for 5 days.

44.  If the communication is large 7mm or larger,
the surgeon should consider closing the sinus
communication with a flap procedure. Most
commonly used flap is buccal flap.
PREVENTION
 Preoperative radiographs must be evaluated.
 If tooth roots are near the sinus floor closed
forceps extraction is avoided & surgical removal
with sectioning of tooth roots is done.
 Avoid excess apical pressure.

47. Postoperative bleeding
 Extraction of teeth presents severe challenge to the
body’s hemostatic mechanism.
 If the postoperative bleeding continues for more than
a day then it is a matter of concern.
 Prevention of bleeding is achieved by thorough
medical history of the patient.
 Patient should be enquired about any medication they
might be taking such as anticoagulants, anticancer
chemotherapy or alcoholism. These tend to increase
the postoperative bleeding.

49.  Patient suspected with bleeding disorders is
evaluated to determine severity of disorder by
measuring the status of intentional
anticoagulation with use of the International
Normalized Ratio (INR)
 Normal= 2.0-3.0

50. MANAGEMENT OF POSTOPERATIVE
BLEEDING AFTER EXTRACTION
 Different materials placed in the socket to gain
hemostatsis.
• Most commonly used, least expensive,
absorbable gelatin sponge. (e.g.Gelfoam)
• Oxidized regenerated cellulose.(e.g. Surgicel)
• Liquid preparation of topical thrombin.
(prepared from bovine thrombin)
• Collagen. (e.g. micro collagen- Avitene, plug
type collagen-Collaplug, tape type collagen-
Collatape)
• Damp tea bag. (tannin in tea stops bleeding)

54. PREVENTION OF POSTOPERATIVE BLEEDING
 Obtain history of bleeding.
 Use atraumatic surgical technique.
 Obtain good hemostasis at surgry.
 Provide excellent patient instructions.

55. PREVENTION OF POSTOPERATIVE BLEEDING
 Obtain history of bleeding.
 Use atraumatic surgical technique.
 Obtain good hemostasis at surgry.
 Provide excellent patient instructions.

56. Delayed healing & infection
 INFECTION
 WOUND DEHISCENCE
 DRY SOCKET

57. PREVENTION OF POSTOPERATIVE BLEEDING
 Obtain history of bleeding.
 Use atraumatic surgical technique.
 Obtain good hemostasis at surgry.
 Provide excellent patient instructions.

58. INFECTION
 Most common cause of delayed wound healing
but rare complication after routine extraction,
primarily seen after oral surgery.

59. WOUND DEHISCENCE
 Wound dehiscence is the
separation of the layers of a surgical wound; it may be
partial or only superficial, or complete with sep
aration of all layers and total disruption.
Wound dehiscence caused in these conditions- soft
tissue flap replaced & sutured without an adequate
bony foundation, suturing the wound under tension.

61. PREVENTION OF WOUND DEHISCENCE
 Use aseptic technique.
 Perform atraumatic surgery.
 Close incision over intact bone.
 Suture without tension.

62. DRY SOCKET
 Clinically the tooth socket appears to be empty,
with a partially or completely lost blood clot, &
bony surface of the socket are exposed.
 There is dull aching pain, usually throbs,
radiates to the ear. The area of socket has a bad
odor, patient has bad taste.
 Caused due to fibrinolytic activity.
 This condition in routine extraction is rare but
frequent in removal of impacted mandibular 3rd
molars.

64. MANAGEMENT OF DRY SOCKET
 Gentle irrigation of the tooth socket with
saline, entire blood clot not lysed, excess saline
suctioned, iodoform gauze soaked with
medication inserted in socket.
 Medication contains eugenol, benzocaine,
balsam of Peru.
 Patient experiences relief from pain within 5
minutes
PREVENTION OF DRY SOCKET
 Atraumatic surgery with clean incision & soft
tissue reflection.
 Preoperative & postoperative rinces with
antimicrobial mouth rinces- chlorhexidine

65. FRACTURE OF MANDIBLE
 Fracture of mandible during extraction associated with
surgical removal of impacted 3rd molars.
 Mandibular fracture result of application of force
exceeding that is needed to remove tooth with use of
dental elevators.

67. REFERENCES:
Contemporary Oral & Maxillofacial Surgery
Peterson, Ellis, Hupp, Tucker

68. Thank You