Exodontia

PRESENTED BY –
DR. SHEETAL KAPSE
1st YEAR, P.G. STUDENT
MODERATOR -
DR. SUNIL VYAS
DR. M. SATISH
DR. DEEPAK THAKUR
DR. MANISH PANDIT

EXODONTIA
Principles, techniques & complications

INTRODUCTION
Science the earliest period of history of the extraction of the
tooth has been considered a very formidable procedure by the
layman, & it is because of the horrifying experiences
associated with the tooth extraction in the past that even
today the removal of a tooth is dreaded by a patient almost
more than any other surgical procedure.
Many patients suffer from extractionfobia & are often difficult to
care for, despite modern methods of anesthesia.
Many dentists still believe that speed is essential when
extracting the teeth.

DEFINITION
• The ideal tooth extraction is –
The painless removal of the whole tooth, or
root, with minimal trauma to the investing tissues, so that
the wound heals uneventfully & no post-operative
prosthetic problem is created.
(Geoffray L Howe)

 The 1st dentist was an EGYPTIAN
– HESI RE (3100-2181BC)
The history of dental extraction forceps is very old and
goes back to the time of Aristotle (384 to 322 BC)
where Aristotle described the mechanics of oral surgery
forceps .This was over 100 years beforeArchimedes
studied and discussed the principles of the lever.

Dental history arabic dentist cauterizing
dental pulp
The Martyrdom of St. Apollonia, shows the
torturous extraction of teeth
Curing aToothache with FireThe
fumes from henbane seeds
GermanTraveling Dentist

Traveling Dentist in a DutchVillage
The Italian "Oral Surgeon"That Effortlessly
Removes Jawbones

 until the 16th century, dedicated dentists did not exist and
dentistry was practiced by general physicians and barbers.
 A number of tools were invented for performing this procedure.
Dental Pelican, which was invented in the 14th century by Guy de
Chauliac and used until the late 18th century.

The instrument is a combination of the
attributes of the an extracting forceps and a
toothkey 1843 to 1863
In the 20th century, the key was replaced by
the forceps, which are still in use today

1. Allen 1994 – caries in 48.8% cases – abscess
2. Periodontal diseases – in 40.7% cases – to prevent alveolar ridge
resorption
3. Tooth with necrosed pulp & periapical lesion – not responding to
endodontic treatment
4. Over retained deciduous tooth – but take radiograph first
5. Orthodontic purpose
6. Prosthetic purpose
7. Unrestorable tooth
8. Impacted tooth
9. Supernumerary tooth
10. Grossly decayed 1M / 2M – make room for 3rd molar
HOTZ & SMITH
11. Tooth in fracture line
12. Teeth directly involved by cyst & tumor

13. Teeth in the area of therapeutic irradiation
14. Teeth acting as foci of infection –
ex. – bacterial endocarditis
- rheumatic fever
RICHARDS (1932) – bacteremia after infected tooth extraction
OKELL & ELLIOTT (1935) – STREPTOCOCCUS VIRIDANS in
blood stream (75% of 40 patient)
Use of local anesthetic solution (vasoconstrictor) - rate of spread of
infection

 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.
 NUG / HERPETIC GINGIVOSTOMATITIS – spread of
infection & greater degree of systemic reaction.
 Previously irradiated area (within 1 year) – less trauma +
pre & post-op antibiotic prophylaxis

Other relative systemic contraindications –
 Acute blood dyscrasias – acute leukemia , agranulocytosis,
 Untreated coagulopathies – congenital or acquired
 Adrenal insufficiencies
 Within 6 months of myocardial infarction

A. Absolute : Central Haemangioma. May cause uncontrolled bleeding.
A-V malformation.
B. Relative :
When some precautions have to be taken.
1. Local Acute cellulitis.
ANUG.
2. Systemic Uncontrolled Diabetes Mellitus,
Hypertension.
Bleeding disorders.
Cardiovascular diseases.
Liver disorders.
Patients on long-term steroid therapy.
Teeth that have undergone radiation [6 months – 1 yr ].

Expansion of bony socket
specially for forcep extraction
sufficient tooth structure
elastic bone (children)
multiple small fractures of buccal cortical bone
1. Use of a lever & fulcrum
remove the tooth/root along the path of least resistance
basic factor governing the use of elevators

2. The insertion of wedge or
wedges between tooth-root
& bony socket wall

 Take history of –
1. general disease
2. nervousness
3. resistance to inhalational anesthesia
4. previous difficulty with extraction
 Oral hygiene status of the patient
oral prophylaxis
antiseptic mouth rinse
 Clinical examination of the tooth
 Clinical examination of the oral cavity- any prosthesis

 PREOPERATIVE RADIOGRAPHS –
Indications
i. H/O difficult & attempted extractions
ii. Resistance to forcep extraction
iii. Planning to remove the tooth by dissection
iv. Close approximation with important anatomical structures
v. Abnormal root pattern – third molars, in standing premolars, misplaced canine
vi. Tooth having periodontal problem & some sclerosis – hypercementosis
vii. Trauma to tooth – fracture of tooth, roots & alveolar bone
viii. Isolated & Unopposed maxillary molars
ix. Partially erupted, unerupted tooth & retained roots
x. Delayed erupting or having abnormal crown
xi. Condition indicating dental or dentoalveolar deformities –
osteitis deformans - hypercementosis
cleido-cranial dysosteosis - hooked root
therapeutic irradiation
osteopetrosis

GENERAL ANESTHESIA
• 5-10 min.
• uncooperative patients
• 30-45 min.
• No pre-op preparation
• Respiratory tract disease
• Cardiovascular diseases
LOCAL ANESTHESIA
General factors

Local factors
 Acute infection at the site of injection
 Hemangioma

 Is defined as –
removal of all micro-organisms from a given object.
 Hands of operator
 Instruments
 Operation area
 Engines, lights & chairs are inevitably sources of cross-infection.
 Use the sterile gauze /cloth – to change the position of light.

1. Position of the operator –
- Stand erect , equal distribution of weight on both feet
- Force delivery – with arm & shoulder not with hand
- application of force without stress to shoulders & back
- generally on right hand side
- for Right posteriors – back side
- operating box

2. Position of the patient –
make the patient comfortable on dental chair
3. Height Of Dental Chair –
maxillary teeth – 8 cm / 3 inch below the shoulder level
of operator
mandibular teeth – 16 cm / 6 inch below the elbow of
operator

4. Angulation of the chair –
maxillary teeth – 45-60 degree
mandibular teeth – parallel or 10 degree
5. Light –
good illumination

6. Role of opposite hand
 Reflection of soft tissue
 Protection of other teeth
 Stablization of patient’s head
 Supporting & stablizing the mandible
 Supports alveolar bone
 Tactile information
 Compress socket
 Deliver the whole tooth, root, dislodged filling

7. Role of assistant
 Helps the surgeon to gain access & visualize the field
 Suction
 Protect the teeth of opposite arch
 Support the head
 Support the mandible
 Psychological & emotional support
 Avoid casual , offhand comments
– increase patient’s anxiety
- decrease patient’s cooperation

 Clear access to & vision of the surgical field.
 Use of controlled force
 Unimpeded path of removal

 Separation of tooth from alveolar bone with
crestal & principal periodontal fibers.
 Alveolar expansion
 Bleeding is arrested by pressure pack.

 Severing SoftTissue Attachment
The straight and curved desmotomes

Chompret elevators;
a straight, and b curved

A. Intra-alveolar extraction (closed
technique)
B. Transalveolar extraction (open
method)

1. forcep Technique
2. elevator Technique

 Commonly used
 Not used in – hypercementosis
- root deformities
- grossly decayed crown
- grossly decayed root
- brittle root
 Advantages - least trauma
- gingival fibers reduces the size of extraction orifice
so promotes healing

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.
HOWTO HOLDTHE FORCEP
Thumb – just below the joint
Handle in palm
Little finger – inside the handle

 Buccally & lingual parallel to long axis of tooth.
 Forced through periodontal membrane, towards apex.
 Firm pressure.
 1st apply on less accessible side of tooth under direct vision
 2ndly on other side
 Cervical caries - 1st movement towards carious part

Time spent in careful application of forcep
blades to the radicular portion of tooth is
never wasted.

 Pressure applied by the operator by moving his trunk
from hips not from elbow.
 Movements – linguobuccal & buccolingual
- firm, smooth & controlled
rotatory / figure of 8
loose
removal

 Maxillary buccal bone is thinner – buccally removal of teeth
 Mandibular buccal bone till molar is thinner - buccally removal of
teeth
 Mandibular buccal bone in molar region is thicker - lingually
removal of teeth
 Socket compression
 Avoid soft tissue laceration

 In multiple extraction cases canine should be extracted
prior to extraction of incisors, as prior extraction of
incisors weakens the labial cortex.

 Heavy bladed forceps are
used.

Factors –
1. Permanent successors
2. Limited access
So use fine blades
Warwick james
elevators can be used
Extraction of deciduous molar with forceps.
Forceps are positioned mesially or distally
on the crown and not the center of the tooth

 Works on lever & fulcrum principle
 It forces the tooth / root along the line of withdrawal R/G
 Fulcrum – bone or adjacent tooth
 Elevator grasping

 Application –
in periodontal space
450 to long axis of tooth
Placement of gauze between finger and
lingual side, for protection from injury in
case the elevator slips

Application of elevator –
Buccally
Mesially
distally

Movement –
rotate the elevator along its long axis

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

Positioning of straight elevator on the distal surface of the
root, either perpendicular to, or at an angle to the root

Removal of the root of mandibular premolar with the
special instrument (endodontic file-based action) for root
extraction

Separation of roots of the mandibular
first molar with fissure bur

Roots of mandibular first molar.
Extraction is accomplished by sectioning
roots using a straight elevator

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

Using an elevator withT-shaped handles to remove intraradicular bone

Diagrammatic illustrations showing luxation of the root tip of the
mandibular second premolar, using
double-angled elevators

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 elevator

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

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)

 Irrigation of the socket
 Squeezing of the socket
 Mouth rinsing with warm bland water for once
 Suturing if require
 Moist gauze pack
 Medication
 Post extraction instructions – verbal & written

1. Intra-alveolar attempt is failed
2. Retained roots in proximity with maxillary sinus & not accessible
to forcep
3. History of difficult or attempted extraction
4. Heavily restored tooth
5. Geminated / dilacerated tooth

Dens in dente of maxillary left canine
Fusion of teeth

Deciduous mandibular molar, whose roots
embrace the crown of the succedaneous
premolar. Risk of concurrent luxation with
the simple extraction technique.

Main components of transalveolar extraction –
1. Design of mucoperiosteal flap
2. Method to be used to deliver the tooth / root from socket
3. Bone removal used to facilitate tooth / root removal

Raise to render the operative site clearly
visible & accessible
Suture should not be placed over blood clot
Obliteration of buccal sulcus should be avoided
Base – broad

 Sharp scalpel
 Firm pressure
 Mucousa + periosteum
 Avoid Button hole formation in case of sinus
 Incision of sufficient length at once

Minnesota retractors for
retraction of the cheek and tongue
Austin’s retractor

 To expose root/tooth
 Facilitated by large flaps
 Provides point of application
 After tooth/root removal – remove all sharp edges & bone
prominences
 Instruments used -

 Round / rose head provides – less clogging, better control.
 It doesn't cut the tooth that easily
 Should not contact soft tissue
 Avoid overheating
 Postage stemp method
 then join with chisel

 Different line of removal for different roots
 Divide the root from furcation area
 Make space for application of forcep / elevator
 Osteotome / burs

 Engage the elevator in a notch on side of root
 If notch is not present then create it with round bur directed at 450
angle to the long axis of root.

 Irrigation of the socket
 Suturing
 Moist gauze pack
 Medication
 Post extraction instructions – verbal & written
 Recall after 48 hours
 Normally 7 days
 Within 2 days – if it was for control of hemorrhage
 OAC repair – 10 days

Steps in the surgical extraction of an intact
maxillary first molar. Reflection of the envelope flap,
sectioning of two buccal roots from the crown (a), removal
of the crown together with the palatal root, and then finally
removal of the mesial and distal roots (b)

An L-shaped incision is made and the flap is reflected.
The buccal plate covering the surface of the root is
removed, and the tooth is extracted using forceps

a, b. Surgical extraction of a mandibular
molar
with hypercementosis at the distal root tip.
The envelope
flap is reflected, part of the buccal plate is
removed, and the
tooth is sectioned buccolingually at the crown
as far as the
intraradicular bone

Extraction of the mesial portion of the tooth,
which includes the crown and root
Widening of the alveolus with a round bur, so
that removal of the root is possible without
fracturing the bulbous root tip

The surgical technique is indicated for its removal

Radiograph of roots of the mandibular first molar.The surgical
technique is indicated for their removal

INDICATIONS –
1. Patient Under Coverage of BISPHOSPHONATE
2. Hemophilic patients
PROCEDURE –
Dentin bulge (arrows)
preventing elastics from sliding
apically.
Root canal treated and split mandibular molar during
exfoliation process. Note extrusion of mesial root.

Atraumatic Teeth Extraction in
Bisphosphonate-Treated Patients
Eran Regev, DMD, MD,* Joshua Lustmann, DMD,†
and Rizan Nashef, DMD‡
© 2008 American Association of Oral and Maxillofacial Surgeons
JOral Maxillofac Surg 66:1157-1161, 2008
0278-2391/08/6606-0011$34.00/0
doi:10.1016/j.joms.2008.01.059

Sockets immediately after exfoliation of both teeth.

 Take careful history
 Take care of – airway, support of mandible & position of
patient’s head
The dental surgeon should never act as both
operator & anesthetist.

1. Accompanying person
2. No driving
3. 6 hrs of NPO
4. Emptying the bladder
5. Loose the tight clothing
6. Patient Comfortable in dental chair
7. Head slightly extended
8. Mandible should be parallel to floor
9. Arm & leg position of patient
10. Waterproof apron
11. Hearing of patient’s each breath

1. Identify the tooth
2. All prosthesis are removed
3. All instruments should be keep ready
4. Larger the anesthesia – increase risk of anoxia &
aspiration
5. Ideal time – 5-10 min.

1. Dental prop
2. Mouth gauge
3. Mouth pack
4. Efficient suction apparatus
5. Tracheostomy kit

1. Tooth priorities
2. Avoid excess force to mandible
3. Soft tissue injury should be avoided
4. Postpone – remove pulp if it is exposed
5. Fractured root v/s resorbed root

1. Hemorrhage & clot formation – 1-2 days
2. Organization of clot by granulation tissue – 3-7 days
3. Replacement of granulation tissue by connective
tissue & epithilialization of wound – 4-35 days
4. Replacement of connective tissue by coarse fibrillar
bone – 6-8 weeks
5. Reconstruction of alveolar process & replacement of
immature bone by mature bone tissue

1. Infection
2. Size of wound
3. Blood supply
4. Resting of part
5. Foreign bodies
6. General condition of the patient

Technological Advances in ExtractionTechniques and Outpatient
Oral Surgery
AdamWeiss, DDS*, Avichai Stern, DDS, Harry Dym, DDS
Department of Dentistry and Oral and Maxillofacial Surgery, The Brooklyn
Hospital Center,
121 Dekalb Avenue, Brooklyn, NY 11201, USA
* Corresponding author.
E-mail address: aweissdds@gmail.com
KEYWORDS
Powered periotome Polyurethane foam Piezosurgery
Immediate implants Orthodontic extrusion Bone grafting
Physics forceps
Dent Clin N Am 55 (2011) 501–513
doi:10.1016/j.cden.2011.02.008 dental.theclinics.com
0011-8532/11/$ – see front matter 2011 Elsevier Inc. All rights reserved.

Powertome® Assisted
AtraumaticTooth Extraction
The Journal of Implant & Advanced
Clinical Dentistry
Jason White, Dan Holtzclaw, NicholasToscano
September 2009Volume 1, No. 6

 Precise extraction of tooth
 Preserves bone & gingival architecture
 Option for immediate implant placement
 Mechanism of “WEDGINNG” & “SEVERING”
 Severs the periodontal ligament
 Multirooted teeth requires sectioning.

Presurgical radiograph of Case 1.
Powertome® blade advanced in a
”sweeping” fashion.
Rotational movement of root with forceps Atraumatic removal of the tooth

Presurgical clinical presentation Powertome® blade advanced down PDL
Extracted segments of maxillary canine

Presurgical radiograph Presurgical clinical presentation

 Piezosurgery is an innovative bone surgery technique that produces
a modulated ultrasonic frequency of 24 to 29 kHz, and a
microvibration amplitude between 60 and 200 mm/s.
 The amplitude of the vibrations created allows a very clean and
precise surgical cut.
 It works selectively, without harming soft tissues such as nerves and
blood vessels even with accidental contact with the cutting tip.
 The surgical control of the device is effortless compared with
rotational burs or oscillating saws because there is no need for an
additional force to oppose rotation or oscillation of the instrument.

 Despite the longer time of the procedure, the investigators also
noted that the piezoelectric osteotomy reduced postoperative
facial swelling and trismus.
 Uses of piezosurgery device to cut and elevate a precisely defined
bone lid on the lateral cortex of the mandible to provide access to
the teeth needing extraction or even a lesion that needs to be
excised. The bone window is then elevated with the help of a curved
osteotome.
 After the visual confirmation of an undamaged IAN and adjacent
tissues, the bone lid is placed back into its original position and
fixated with absorbable miniplates.

 For the surgical extraction of the teeth, the covering bone was first
ablated, layer by layer, using the Er:YAG laser.
 In the case of the fiber-optic Er:YAG [erbium:yttrium-aluminum
garnet ], laser the fiber is closely guided around the teeth, creating a
narrow gap with minimal bone loss.
 The benefits of laser therapy include the creation of a bloodless
surgical field and thus improved visualization during surgery,
decreased postoperative pain, and limited scarring and contraction.
 Time consuming, sound and smell, significantly inhibition the
laser cutting because of the overall volume of irrigation and blood
covering the bone surface.

 Third molars in close proximity to the IAN have a significant
negative impact on recovery for pain and oral function.
 The advantage of this technique is that the risk of direct trauma
to the nerve is eliminated, due to both the increased distance
between the roots and the mandibular canal and the decreased need
for surgical manipulation during the extraction.

 A potential problem with this technique is soft tissue damage from
impingement on the mucosa of the cheek and the gingiva.
 In addition, working in this area of the mouth presents great
difficulty, and the action of the masseter muscle leads to cheek
compression against the orthodontic appliances.
 This technique will be of no value for a tooth that cannot move
because of ankylosis.
 This technique should be used only in carefully selected cases in
conjunction with an orthodontist, being certainly difficult, time
consuming, and not always successful.

© 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6802-0032$36.00/0
doi:10.1016/j.joms.2009.07.038
J Oral Maxillofac Surg 68:442-446, 2010

Panoramic radiograph at initial consultation. The mandibular
third molars are mesially impacted with the roots close to
the alveolar canal.

Postoperative radiograph after second sectioning of
the right mandibular third molar. A pulpotomy has been performed.
More space was created distal to the right mandibular second
molar to allow further migration
Postoperative radiograph after the right mandibular
third molar was surgically sectioned. The space
distal to the second molar would allow mesial
migration of the impacted tooth.

3 months after odontectomy. The
third molar moved mesially.
However, the mesial root was still
in contact with the alveolar canal.
A second sectioning was required.
Periapical radiograph obtained 2 months after
second sectioning. At that time, the roots were
away from the alveolar canal, and a riskless
extraction could be scheduled.

 The Physics Forceps uses first-class level mechanics to atraumatically
extract a tooth from its socket.
 One handle of the device is connected to a “bumper,” which acts as a
fulcrum during the extraction.
 Together the “beak and bumper” design acts as a simple first-class
lever.
 A squeezing motion should not used with these forceps. By contrast, the
handles are actually rotated as one unit using a steady yet gentle
rotational force with wrist movement only.
 Once the tooth is loosened, it may be removed with traditional
instruments such as a conventional forceps

GMX-100R - Upper Right - Extracts Teeth 2 to 5
GMX-100L - Upper Left -
Extracts Teeth 12 to 15
GMX-100A - Upper Anterior - Extracts Teeth 6 to 11
GMX-200 -
Lower Universal -
Extracts Teeth 18
to 31

1*,3Oral and Maxillofacial Surgery, Oral and Maxillofacial
Department, Guys Hospital, Floor 23, Great Maze Pond,
London, SE1 9RT; 2Restorative Dentistry, Guys Hospital,
Floor 26, Great Maze Pond, London, SE1 9RT
*Correspondence to: Dr Vinod Patel
Email: vinod.patel@hotmail.co.uk
Refereed Paper
Accepted 29 April 2010
DOI: 10.1038/sj.bdj.2010.673
©British Dental Journal 2010; 209: 111–114
BRITISH DENTAL JOURNALVOLUME 209 NO. 3
AUG 14 2010
• Coronectomy is a technique that should
be considered for mandibular third molars
when it is felt there is an increased risk of
injury to the inferior dental nerve.
• Coronectomy is oral surgery’s approach
to minimal interventional dentistry.

 Coronectomy can be beneficial but success requires both good patient
selection and operator technique.
 Renton et al.reported no IDNI in 58 successful Coronectomy patients
and a 19% IDNI rate in those having traditional extractions.
 Leung et al. showed nine (5%) patients in the control group presented
with IDNI, compared with one (0.06%) in the Coronectomy group.
 Hantano et al. reported that in the extraction group six patients (5%)
suffered IDNI, of which 3 patients were diagnosed with permanent
injury, where as in the Coronectomy group one patient (1%)
complained of altered sensation post-operatively which resolved within
one month.
 The retrospective analysis of O’Riordan consisted of 52 patients that
underwent Coronectomy. In this study there were 3 cases of transient
IDNI which showed resolution one week post operatively. One patient
developed permanent IDNI, which was thought to be as a result of
perforation of the canal due to operator error rather than the
Coronectomy technique itself.

1, deviation of the canal 2, narrowing of the canal
3, periapical radiolucent area 4, narrowing of root;
5,darkening of roots 6, curving of root
7, loss of lamina dura of canal

Coronectomy: A, cutting crown below
cement-enamel junction (arrow);
B, trimming cutting surface to less
than 3 to 4 mm below alveolar crest.
Radiographic imaging
showing pre and
post coronectomy of the right
mandibular
third molar (48)

 To avoid traumatizing the surrounding bone during elevation,
implant drills were placed in the root canals to thin the root walls
giving way to extraction with the application of much less force,
thereby decreasing the chance of traumatizing the thin buccal bone.

1. FAILURE TO ACHIEVE ANESTHESIA / TOOTH
REMOVAL
2. FRACTURE OF TOOTH / SURROUNDING STRUCTURES
3. DISLOCATION
4. DISPLACEMENT OF TOOTH / ROOT
5. EXCESSIVE HEMORRHAGE
6. DAMAGE TO HARD & SOFT TISSUES
7. POSTOPRATIVE PAIN
8. POSTOPERATIVE SWELLING
9. TRISMUS
10. OROANTRAL COMMUNICATION
11. SYNCOPE
12. RESPIRATORYARREST
13. CARDIAC ARREST
14. ANESTHETIC EMERGENCIES

 Faulty technique
 Inadequate solution
 Test the efficacy of anesthesia
 Tooth could not be removed with intra-alveolar or
transalveolar procedure.

Crown / root –
 Grossly carious
 Tooth with Endodontic treatment
 Improper application of forcep
 One point contact
 Slip off of forcep
 Excessive force
 Hurry
 Tooth with divergent roots /hypercementosis
Then trans-alveolar method is indicated

Remove all the root fragments except –
1. 5 mm & requires excessive bone removal – well tolerated.
(Simpson 1958)
2. Apical 1/3 rd of palatal root of maxillary molars &
requires excessive bone removal
If removal is indicated – inform the patient
radiograph
If root is left in place – pulpectomy should be performed.

Causes –
 Excessive inclusion of bone within the forcep beaks
 Extraction of incisors before canine
 Intact versus torn periosteum
 Generally during extraction of maxillary 3rd molars
 Pneumatization of maxillary air cells
 Gemination

Management –
 Preoperative radiograph is essential
 Raise the mucoperiosteal flap
 Separate the tooth & bone from gingiva
 Mattress Suture
 10 days
 If tuberosity is excessively mobile –
i. Splint the tooth for 6-8 weeks
ii. Sectioning the crown & pulpectomy.

 Heavily restored adjacent teeth –in the line of
withdrawal
 Abutment teeth
 When used as fulcrum
 Uncontrolled force
 Under general anesthesia – gauge & props
 intubation

Causes –
 Excessive / incorrectly applied force
 Pathologic fracture
 Senile osteoporosis
Precautions –
 Peroperative radiograph
 Splint febrication
 Exraoral support
management –
 Inform the patient
 Reduce the fractured segment

 When used as fulcrum
 Improper use of elevators
 Give support to adjacent tooth from other hand
 Don’t apply the elevator mesial to 1st molar
Management –
 Place the tooth in socket & splint it

Causes –
 Improper use of mouth gauge
 Senile osteoporosis
Precautions –
 Take history
 Exraoral support beneath the angle of
mandible
Management –
 Reduce it immediately
 Reduction technique
 Instructions to patient

Causes –
 Abnormal root curvature
 Carious root
 Roots of premolars & molars involved by sinus
 Inadequate grasping of tooth
Precautions –
 Take past dental history
 Apply the forcep on sufficient tooth structure
 Leave uninfected apical 1/3rd of root
 Never force the root towards sinus
 Transalveolar method

Causes -
 Maxillary posterior teeth
 Involvement of sinus lining by – Periapical pathology
Diagnosis –
 Increased intra nasal pressure – air coming out from
mouth can be heard
 Amount of blood will be doubled
 Wisp of cotton wool will be deflected

Management –
 Mucoperiosteal flap rising
 Decrease alveolar height
 Interrupted horizontal suture
 Protect the clot with – acrylic, denture base, impression
material
 Give incision in sinus membrane
Precautions –
 Mouth rinsing with antiseptic solution before closure of
oroantral communication
 Passage of instruments from mouth to sinus should be
avoided.

Diagnosis –
 Air bubbles from socket
 Cotton wool deflection
 Fluid taken from oral cavity nose
Management –
 Take radiograph .
 Blow the air through nose
 Under general anesthesia – stop the general anesthesia
wait till regaining the cough reflex
 Suction + irrigation
 ½ inch wide iodoform gauze
 Sometimes incision in sinus membrane
 Caldwell-Luc approach

 Mostly maxillary third molars
Management –
 Extend the incision posteriorly
 Blunt dissection
 Grasp the tooth carefully
 Or wait for several weeks until it becomes somewhat
encapsulated.

Reflect the soft tissue flap on lingual aspect of mandible as
forward to the premolars
gently dissect the mucoperiosteum
Detach the mylohyoid muscle.

If the root is not appearing in the oral cavity/pressure pack
 Ask the patient to cough & spit
 Turn the patient towards the operator & position with the
mouth towards the floor.
 Radiograph of alveolar socket/ sinus/ chest
 Re-examine the patient after 3 days
 Patient is asked to report immediately- fever, cough,
chest pain occurs.

Perioperative hemorrhage –
 Oozing of blood during operation
Management –
 Wipe
 Sucker
 Hot 50 degree celcius for 2 min.
 Hemostate
 Local anesthetic solution having vasoconstrictor
 Gelatine sponge
 oxidized cellulose
 After tooth removal – moist pressure pack for 10min.
horizontal mattress suture

Postoperative hemorrhage –
 Instructions to the patients –
1. Pressure pack
2. Less talk for 2-3 hrs.
3. Tea bag
4. No smoking for 12 hours
5. No staneous exercise
 Psychological approach
 Determine site & amount of hemorrhage
 Remove excess blood clot
 Provide firm gauze pack with tannic acid

Horizontal mattress suture into mucoperiosteum
Wait for 5 minutes after placing gauze pressure on suture
Gelatin / fibrin foam
&
All post extraction instructions and avoid frequent aggressive
mouth rinsing

Gingiva
Lower lip – mechanical & thermal injury
Tongue & floor of mouth

Causes –
 Compression with clot or bone debris
 Partially or completely torn
Precautions –
 Preoperative radiograph
 Elevator should not be forced below tooth
 Resect 1 root before tooth elevation
Management –
 Reposition the ends at close
approximation
 Decompression
 Microsurgical reanastomosis
 Nerve grafting

Causes –
 Transalveolar extraction of premolars
Precautions –
 More Bone reduction mesial to 1st premolar & distal
to 2nd premolar
 Retraction of nerve with mental retractor

 Burs
 Management – drilling the groove around it .

 Submucosally & subcutaneously
 Older patients – increased capillary fragility
decreased tissue tone
weaker inter cellular attachments
 Onset 2-4 days
 Resolve within 7 – 10 days

Cause –
 Suture without adequate bony foundation
 Suturing the wound under tension
 Mostly in the region of mandibular 2nd & 3rd molar
(internal oblique ridge)
Management –
 Leave the projection – slough out within 2-4 weeks
 Smooth it with bone file under local anesthesia.

1. Due to traumatized hard tissue –
 Bruising from bone during intrumentation
 Excessive heating from bur
 Sharp bony edges
 Avoidance of tissue toileting
2. Due to traumatized soft tissue –
 Incision only through mucous membrane
ragged flap - heals slowly
 Too small flap – much traumatic retraction
 Injury from bur.

Synonyms :
 alveolar osteitis (AO),
 localized osteitis,
 postoperative alveolitis,
 alveolalgia,
 alveolitis sicca dolorosa,
 septic socket,
 necrotic socket,
 localized osteomyelitis,
 fibrinolytic alveolitis

Postoperative pain in and around the extraction site, which
increases in
severity at any time between 1 and 3 days after the
extraction
accompanied by a partially or totally disintegrated blood clot
within
the alveolar socket with or without halitosis.
I. R. Blum: Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization,
etiopathogenesis and management: a critical review. Int. J. Oral Maxillofac. Surg. 2002; 31: 309–317. 2002
International Association of Oral and Maxillofacial Surgeons

 Mostly 1–3 days after tooth extraction .
 Within a week - In 95% and 100% of all cases.
 Unlikely - before the first postoperative day.
because the blood clot contains anti-plasmin that must be
consumed by plasmin before clot disintegration can take place.
 The duration of alveolar osteitis varies to some degree, depending on
the severity of the disease, but it usually ranges from 5–10 days.

1. The denuded alveolar bare bone may be painful and tender.
Initially blood clot appears dirty gray disintegrates
grayish yellow bony socket bare of granulation tissue
2. Some patients may also complain of intense continuous pain
irradiating to the ipsilateral ear, temporal region or the eye.
3. Regional lymphadenopathy (occasionally).
4. unpleasant taste (occasionally).
5. Trismus is a rare occurrence in mandibular third molar extractions
probably due to lengthy and traumatic surgery.

 Multifactorial origin
 Following have been implicated most commonly as etiological,
aggravating and precipitating factors:
1. Oral micro-organisms - Treponema denticola
2. Difficulty and trauma during surgery
3. Roots or bone fragments remaining in the wound
4. Excessive irrigation or curettage of the alveolus after extraction
5. Physical dislodgement of the clot
6. Local blood perfusion & anesthesia
7. Oral contraceptives - estrogens, like pyrogens will activate the
fibrinolytic system indirectly.
8. Smoking

1. Previous experience.
2. Deeply impacted mandibular third molar (risk factor is directly
proportional to increasing severity of impaction) .
3. Poor oral hygiene of patient .
4. Active or recent history of acute ulcerative gingivitis or pericoronitis
.
5. Associated with the tooth to be extracted .
6. Smoking (especially >20 cigarettes per day) .
7. Use of oral contraceptives .
8. Immunocompromised individuals .

 BIRN : (BIRN H. Etiology and pathogenesis of fibrinolytic alveolitis (‘dry socket’). Int J Oral
Surg 1973: 2: 215–263.)

Factor
XIIa
CLOTTING
SYSTEM
KININ
SYSTEM
FIBRINOLYTI
C SYSTEM
COMPLEM
ENTSYSTE
M
Factor XII
CONTACT
This conversion is
accomplished in the presence of tissue
or
plasma pro-activators and activators.

Plasminogen
Activators
IndirectDirect
1. Factor XII
dependent
activator
2. urokinase,
1. Tissue plasminogen activators
2. Endothelial plasminogen activators
1. streptokinase
2. staphylokinas
e
plasminogen
activator
complex
Intrinsi
c
Extrinsic

Fibrinolytic system
Plasminogen activator
(kallikrein, XIIa, leukocytes,
endothelium)
Plasminog
en
Plasmi
n
C3 C3a
Fibri
n
Fibrin
split
products

References in the literature correlating to the
prevention of alveolar osteitis can be divided
into
1. Non-pharmacological and
2. Pharmacological preventive measures.

Non-pharmacological
measures
1. Use of good quality current preoperative radiographs
2. Careful planning of the surgery
3. Use of good surgical principles
4. Extractions should be performed with minimum amount of
trauma and maximum amount of care
5. Confirm presence of blood clot subsequent to extraction
(if absent, scrape alveolar walls gently)

6. Wherever possible preoperative oral hygiene
measures to reduce plaque levels to a minimum
should be instituted
7. Encourage the patient (again) to stop or limit smoking
in the immediate postoperative period .
8. Advise patient to avoid vigorous mouth rinsing for the
first 24 h post extraction and to use gentle
toothbrushing in the immediate postoperative period .
9. For patients taking oral contraceptives extractions
should ideally be performed during days 23 through
28 of the menstrual cycle .
10. Comprehensive pre- and postoperative verbal
instructions should be supplemented with written
advice to ensure maximum compliance .

1. Antibacterial agents -
2. Antiseptic agents and lavage Chlorhexidine (CHX)
3. Antifibrinolytic agents - para-hydroxybenzoic acid (PHBA),
4. Steroid anti-inflammatory agents - polylactic acid (PLA)
5. Obtundent dressings
6. Clot supporting agents

1. Remove any sutures to allow adequate exposure of the extraction site.As
the socket may be exquisitely tender local anaesthesia may be required.
2. Irrigate the socket gently with war sterile isotonic saline or local anaesthetic
solution, which is followed by careful suctioning of all excess irrigation
solution.
3. Do not attempt to curette the socket, as this will increase the level of pain.
4. Prescription of potent oral analgesics.
5. The patient is given a plastic syringe with a curved tip for home irrigation
with chlorhexidine solution or saline and instructed to keep the socket clean.
6. Once the socket no longer collects any debris, home irrigation can be
discontinued.

 Under block anesthesia
 The clot devoided socket is thoroughly curetted, both from the
floor of the socket as well as from the bony walls.
 The sharp margins were trimmed, rounded.
 Any foreign bodies if present were thouroghly removed.
 The detached gingival margins were also scraped.
 The desired medications as well as precautions .
 Patient was not only without pain, but was also comfortable both
physically as well as psychologically from the very next day.
S.C.Anand,V. Singh, M. Goel, A.Verma, B. Rai: Dry Socket An Apriasal
And Surgical Management. The Internet Journal of DentalScience.
2006Volume 4 Number 1. DOI: 10.5580/e31

 Normal oedema
After multiple teeth extraction
surgical tooth extraction
 Traumatic oedema
Blunt instrumentation
Excessive extraction of badly designed flap
Too tight suture
Management –
 Ice pack application
 Heat application

Subcutaneous emphysema –
 Air into connective tissue of intramuscular & fascial
spaces
 Swelling is of sudden onset.
 Crackles can be felt under finger
 Resolves within 1-2 days
Due to infection of wound –
 Preoperative antibiotic
 Prevention of entry of micro-organism into wound
 Mild infection – intraoral hot saline mouth wash

 It is defined as inability to open the mouth due to muscle
spasm.
Causes –
 Post operative oedema
 Hematoma formation
 Inflammation of soft tissue
 After mandibular block
 Traumatic arthritis of TMJ
 Multiple injections

Management –
 Treat underlying cause
 Intraoral heat application
 Antibiotics & specialist treatment.

 Transient loss of consciousness and postural tone
characterized by rapid onset, short duration, and spontaneous
recovery due to global cerebral hypoperfusion that most often
results from hypotension.
Sign & symptoms – dizziness, weakness, nausea skin is cold,
pale & sweating.
Management –
 Position
 Oxygen administration
 Blood pressure & pulse measurement
 250 mg aminophylline is given slowly.

 Skeletal muscle become flaccid
 pupil dilate widely
management –
 Patient flat on the floor
 Clean the airway
 Pull the mandible forward
 Extend the neck fully
 Pulmonary resuscitation so that chest is seen to rise every
3-4 sec.
 Brook airway can be inserted over tongue
 Check carotid pulse & apex beats at regular intervals

Sign & symptoms –
 Deathly pallor & grayness of skin
 Cold sweat
 Pulse & apex beat can be felt
 Heart sounds can not be audible
Children -
 Beginning of heartbeat if the sternum is tapped sharply
Adult –
Patient flat on the floor
Cardiac compression at 1 second interval

 Syncope, respiratory arrest & cardiac arrest complicate the
general anesthesia.
 Management –
i. Clear the airway
ii. Remove all the packs, debris & apparatus from mouth.
iii. Pull the mandible forward
iv. Extend the neck
v. Head – downward /forward in dental chair
- upward if lying on the floor
vi. Oxygen
vii. Larygotomy
viii. Tracheostomy

RESOURCES
Text books
1. The extraction of teeth by – GEOFFREY L HOWE
2. Oral & maxillofacial surgery volume 2 , by – DANIEL M. LASKIN
3. Oral Surgery by - FRAGISKOS D. FRAGISKOS
4. Contemporary Oral & maxillofacial surgery by- HUPP, ELLIS,
TUCKER
5. Text book of Oral & maxillofacial surgery by – S M BALAJI.

RESOURCES
1. Technological Advances in Extraction Techniques and Outpatient Oral Surgery
Adam Weiss, DDS*, Avichai Stern, DDS, Harry Dym, DDS Dent Clin N Am 55 (2011) 501–
513 doi:10.1016/j.cden.2011.02.008 dental.theclinics.com 0011-8532/11/$ – see front matter
2011 Elsevier Inc.
2. Powertome® Assisted Atraumatic Tooth Extraction, The Journal of Implant & Advanced
Clinical Dentistry, Jason White, Dan Holtzclaw, Nicholas Toscano, September 2009
Volume 1, No. 6
3. Staged Removal of Horizontally Impacted Third Molars to Reduce Risk of Inferior Alveolar
Nerve Injury Luca Landi, DDS,* Paolo Francesco Manicone, DDS,† Stefano Piccinelli, DDS,‡
Alessandro Raia, DDS, PhD,§ and Roberto Raia, DDS, J Oral Maxillofac Surg 68:442-446,
2010
4. Enhancing Extraction Socket Therapy Robert A. Horowitz, Michael D. Rohrer, Hari S. Prasad,
Ziv Mazor, The Journal of Implant & Advanced Clinical Dentistry, Jason White, Dan
Holtzclaw, Nicholas Toscano, September 2009 Volume 1, No. 6
5. Coronectomy – oral surgery’s answer to modern day conservative dentistry V. Patel, S. Moore
and C. Sproat, Refereed Paper Accepted 29 April 2010 DOI: 10.1038/sj.bdj.2010.673 ©British
Dental Journal 2010; 209: 111–114, BRITISH DENTAL JOURNAL VOLUME 209 NO. 3
AUG 14 2010

RESOURCES
6. Atraumatic Teeth Extraction in Bisphosphonate-Treated Patients Eran Regev,
DMD, MD,* Joshua Lustmann, DMD,†and Rizan Nashef, DMD‡
2008 American Association of Oral and Maxillofacial Surgeons © J Oral Maxillofac
Surg 66:1157-1161, 2008 0278-2391/08/6606-0011$34.00/0
doi:10.1016/j.joms.2008.01.059

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