Exodontia

Exodontia:

Exodontia or extraction is a minor oral surgical procedure performed for the therapeutical removal
of teeth from the oral cavity, using proven technique and specialised instruments, causing minimal
trauma to the attaching apparatus, least injury to the surrounding tissues in a pattern conductive to
uneventful healing in order to achieve best possible prosthetic rehabilitation.

INTRA-ALVEOLAR (closed) extraction of teeth is the wrenched removal of an crupted tooth by

expansion of the bony alveolar socket alone using the principles of level, wedge and wheel.

TRANS ALVEOLAR (open) extraction is a minor surgical procedure performed for the therapeutic
removal of impacted, unerupted teeth that includes access through a surgical flap of visualisation
and appropriate bone removal to create a path for delivery and facilitate extraction.

INDICATIONS FOR EXTRACTION:

Deeply carious tooth with pulpal pathology.

Teeth with apical pathology

Periodontitis

Malpositioned and over erupted teeth.

Impacted

Retained deciduous teeth

Tooth in the line of fracture

Teeth with fractured root

Orthodontic purposes

Prosthetic purpose

Before radiation therapy

Prophylactic extraction

Root fragments

CONTRA INDICATIONS FOR EXTRACTION:

Absolute contra indications

Uncontrolled diabetes

Leukemia

Renal failure
Liver cirrhosis

Cardiac failure

Hemangioma

Thyrotoxicosis

AV malformation

Relative Contra indications:

Diabetes:

If extraction is carried out in an uncontrolled diabetic patient he/she would be more prone to
develop infections. Wound healing mechanism is impaired due to defective chemotactic
mechanism and patients undergoing minor surgical procedures may precipitate into diabetic
ketoacidosis.

Hypertension:

Essential hypertension- Unknown cause

Secondary hypertension – Secondary to any systemic disease

Extraction can be carried out when systolic is less than 200mmHg and diastolic less than 110mmHg
Blood pressure ASA Classification Dental therapy considerations
<140 and <90 I Observe dental management,
recheck in 6 months.

140-159 and 90-94 II Observe blood pressure for 3

consecutive appointments,
implement stress reduction
protocol.

160-199 and 95-114 III Recheck bp in 5 minutes, if still

elevated take medical help.
Implement stress reduction
protocol.

>200 and >115 IV Recheck bp in 5 minutes, if still

elevated do not perform any dental
procedure and refer to a hospital.

Cardiac disease:

The cardiac conditions that most frequently complicate exodontia are myocardial infarction, angina
pectoris and cardiac decompression.

Antibiotic prophylaxis needs to be given in patients at an increased risk of bacterial endocarditis

prior to the extraction.
Patients on steroid therapy:

Patients show insufficient adrenal secretion to withstand the stress of extraction. Hence, detailed
history of systemic complication should be obtained pre-operatively to avoid adrenal crisis. Steroid
dose is doubled prior to the procedure.

Pregnancy:

Emergencies because of pain, infection or other acute problems can be accomplished under general
anaesthesia bearing safety norms and by performing them in the safe trimester. If general
anaesthesia is necessary, combination of an intravenous short acting barbiturate muscle relaxant
and nitrous oxide is the method of choice.

Drugs to be avoided in pregnant patients are:

Aspirin and other NSAIDS, carbamazepine, chloral hydrate, chlordiazepoxide, cortico steroids,
diazepam, morphine, pentazocine, propoxyphene, tetracycline metronidazole.

Blood dyscrasias:

Anaemia haemorrhagic diseases such as Hemophilia and leukaemia present problems during
extraction.

Profuse bleeding complications should be dealt with careful evaluation. A pre-operative lab
investigation and expect opinion from a haematologist can be considered.

Other problems include:

Patients on anticoagulant therapy- may face prolonged bleeding post operatively and Hence should
be examined for BT, CT, PT, INR.

Toxic goitre- Under thyroid crisis, symptoms like altered consciousness, delirium, cyanosis thread
rapid pulse and high temperature are seen. No dental procedure can be performed in this condition.

Jaundice/Hepatitis- Post operative complication manifested would be uncontrolled haemorrhage

post operatively. To prevent this, large doses of Vitamin K can be given before the extraction.

Renal disorder- Extraction of a chronically infected tooth can provoke acute nephritis. Patients on
dialysis and heparination can undergo extractions under certain protocols.

Medically compromised- Any associated syndromic condition can affect the dental treatment.
Iatrogenic effects due to drug interaction should be avoided.

Assessment of teeth for extraction:

A tooth can be a traumatically and successfully extracted from the socket depending upon the
technique used morphology, position and condition of the bone surrounding the tooth.

The preoperative assessment includes

1] Chemical assessment

2] Radiographic assessment

Morphology of the crown

1) Normal

2) Abnormal deformed

3) Macroform/microform

Morphology of the roots

1) Dilacerated

2) Fused

3) Impacted

4) Ankylosed

5) Divergent

The density of the bone surrounding the tooth.

The relationship of the tooth to adjacent teeth.

Presence of any pathology.

Surgical plan:

Based on complete evaluation of the patient. The surgeon must decide whether the treatment
should be undertaken in the hospital or in the dental office. Also to be considered are the types of
anaesthesia local or general, the number and frequency of visit.

Supportive measure such as pre-operative sedations, antibiotics, dietary supplements and other
drugs must be considered based on surgical plan and patients’ general condition.

Anaesthesia:

Most of the minor surgical procedures can be performed under local anaesthesia successfully;
however in certain situations, general, anaesthesia may be necessary e.g. when the patient is allergic
to the local anaesthesia, unco operative patient.

Take into consideration:

Condition of operative site

Patients’ preference

Setup

Principles of Tooth removal:

(1) Access and Visual Field: Good access and clear visual field is important for
successful removal of teeth.
 (2) Use of controlled force: The forces applied to remove teeth should always be kept in control
forceps and elevators should be used judicially.
(3) Unimpeded path of removal: Whenever there is any resistance to the removal, sectioning of
the teeth should be considered. Malposed, impacted and deeply caries teeth do no have a
clear path of removal and therefore must be sectioned.

Techniques of Extraction:

Closed or intra-alveolar: In this technique the tooth is extracted in a simple manner using forceps.

Open or trans-alveolar: In this technique a mucuperiostal flap is elevated and the tooth is
extracted surgically.

Intra Alveolar Extraction:

Position of the patient:

The position should be comfortable to both patient and surgeon. Position should allow the surgeon
to keep his/her arm close to his/her body, which lends stability, support and also allow to keep
his/her wrist straight.

Position of patient s head neck and trunk: The chair is adjusted in such a way that the head, neck and
trunk are in one line, this will nullify any strength caused by stretching it backward or pushing in
forward.

Angular of the chair: When the mouth is open, the chair is angulated in such a way that the
operative field is in the most visible accessible position. The chair should be angulated in such a way
that occlusal surface of the mandibular teeth are parallel or at 10 degree to the floor.

When the operator is working on the Mandibular teeth and standing in front of the patient. When
working on the maxilla, the chair should be angulated so that the occlusal plain of the maxillary
teeth is between an angel of 45 degree and 60 degree to the floor.

Height of the chair: Procedures on the mandible – Occlusal level of mandibular teeth should be at
or below surgeons shoulder.

Procedures on the maxilla: The occlusal plain of the maxillary teeth should be above the level of
surgeon’s elbow towards his/her shoulders.

Position of the operator during procedure:

For extraction of maxillary teeth: The surgeons should stand on the right side and in front of the
patient with bent elbow ( such that the occlusal plane is 8 cm or 3 inches below the patient’s
shoulder) for posterior and straight for anterior teeth and should apply the forceps on to the tooth
while the other hand holds the alveolus with the finger and thumb on the either side of the involved
tooth.

For the extraction of mandibular teeth: The surgeon should stand on the right side of the patient for
both the quadrants. For the extraction of the left lower side, the operator should stand in front of
the patient(such that the occlusal plane is 16 cm or 6 inches below the operator’s elbow) and for
the right lower side, behind the patient. Alveolus to be supported with thumb and forefingers,
supporting mandible.

Mechanical principles in tooth extraction:

The following mechanical principles are used in extracting a tooth.

(1) Lever principle of first order

(2) Wedge principle
(3) Wheel and axle

(1) Lever Principle- Three basic components: Fulcrum, effort and load.
Lever of first class: Position of the fulcrum in between the effort and load the force is
transmitted at the long effort arm and mechanical advantage is gained at a short wad arm.

(2) Wedge Principle- The wedge contains the two movable inclined planes with a base on one
end and blade on the other end which overcomes a large resistance at right angles to the
applied force. The effort is applied the base of the plane and resistance has its effect on the
slant side.
 (3) Wheel and Axle- Wheel and axle is a simple machine being a modified form of lever. The
effort is applied to the circumference of wheel which turns the axle so as to raise the weight.

Order of extraction:

Third molar

Second molar

Second pre-molar

First molar

First pre-molar

Lat.incisor

Canine

Central Incisor

Forces used to extract different teeth:

Maxilla:

1) Central incisor :apical pressure, labial pressure, then lingual pressure, then labial with mesial
rotation.
2) Lateral incisor :apical pressure, labial pressure, then lingual pressure, then labial
pressure with mesial rotation.
3) Cuspid: apical pressure, Labial pressure, then lingual pressure, then labial pressure with
mesial rotation.
4) First bicuspids :apical pressure, Labial- lingual and removal in labial direction.
5) Second bicuspids: apical pressure, Buccal-lingual-removal in buccal/lingual.
6) Molars:apical pressure, Buccal-lingual-distal rotation+buccal.
Mandibular:

1) Central incisor:apical pressure, labial-lingual-slight mesial to distal force and removal in the
labial direction.
2) Lateral incisor:apical pressure, labial-lingual-slight mesial to distal and removal in labial
direction.
3) First and second bicuspid:apical pressure, buccal pressure- slight mesiolingual-distal
rotation.
4) Molars:apical pressure, buccal-lingual-remove in buccal direction.
5) Third molar:apical pressure, buccal pressure-removal in buccal / lingual direction.

Complications of extraction:

1) Complications occurring during the surgical procedure:

Soft tissue injury
Extraction of wrong teeth Fracture
of teeth during extraction Fracture
of root
Fracture of alveolus
Fracture of tuberosity
Displacement of tooth into maxillary sinus
Creation of oro antral fistula
Fracture of mandible
Breakage of instrument
Luxation of adjacent tooth
Injury to inferior alveolar nerve
Swallowing of teeth
Aspiration
Dislocation of condyle

2) Complications occurring after the surgical procedure:

Presence of bony spicule
Haemorrhage
Dry socket
Infection