Dr .

Abdel Aziz Baiomy Abdullah

Professor of OMS & Vice dean for education affairs
Faculty of Dental Medicine (Assiut) - Al-Azhar University
Member of AAOMS ,AAID,EAOMS
 Teeth extraction

Intra-alveolar Extraction Trans-alveolar Extraction

(Simple extraction) (complicated extraction)
1. A history of difficult or attempted extraction
2. Any tooth which resists attempts at intra-alveolar
extraction when moderate force is applied.
3. Brittle, malposed, supernumerary, unerupted and
impacted teeth
4. Teeth with dental decay extending sub-gingivally into the
root mass
5. Retained roots, which cannot be either grasped with
forceps or delivered with an elevator
6. Teeth shown radiographically to have abnormal root
patterns: long slender roots, internally or externally resorbed,
hypercementosed, ankylosed, geminated, dilacerated, locked,
hocked, and roots with conflicting lines of withdrawal
7. Bone sclerosis because of local or systemic causes such
as Paget's disease and osteopetrosis (marble bone disease)
8. Thin mandibles; where excessive force is required to luxate
the tooth. This excessive force may result in fracture of the
mandible
-DIAGNOSIS AND SURGICAL PLANNING:

Case history ,clinical examination and radiographic

examination and laboratory evaluation.
-ACCESS TO FIELD OF SURGERY
-REDUCTION OF RESISTANCE
A- BONE REMOVALE
B- TOOTH SECTIONING
-REMOVAL OF TOOTH STRUCTURE OR ROOTS
-DEBRIDEMENT OF SURGICAL FIELD
-CLOSURE OF WOUND
-POSTOPERATIVE CARE
 Case History
American Society of Anesthesiologists (ASA) Classification of
Physical Status
ASA I: A normal, healthy patient
ASA II: A patient with mild systemic disease or significant health
risk factor
ASA III: A patient with severe systemic disease that is not
incapacitating
ASA IV: A patient with severe systemic disease that is a constant
threat to life
ASA V: A moribund patient who is not expected to survive without
the operation
• EXTRA ORAL:

• Signs of swelling & redness of the cheek.

• LN’s - enlargment & tenderness.
• Anesthesia or paraesthesia of lower lip.

• INTRA ORAL:
• Mouth opening & any evidence of trismus
• State of eruption of tooth, signs of pericoronitis
• Elasticity of oral tissues
• Size of tongue
 Blood tests in relation to dentistry:

1- Complete blood count.

2- Bleeding time.
3- Coagulation time.
4- Prothrombin time.
5- Partial thromboplastin time.
6- INR.
7- Liver function tests.
8- Tests for detection of blood glucose level
• INTRA ORAL RADIOGRAPHS
– PA
– Occlusal

• EXTRAORAL RADIOGRAPHS
– OPG
– Lateral cephalometric

• DIGITAL IMAGING
– CT
– CBCT
 Localization of lesions or hard tissue
Involves
• inspection,
• palpation, and
• radiographic evaluation

PARALLAX TECHNIQUE: Two radiographs taken at different

horizontal angles with the same vertical angle.
Locates canine positioned buccally or palatally to other teeth
in the arch

SLOB rule- Same Lingual Opposite Buccal

MAGNIFICATION:
Based on the principle of image size distortion.
-objects further away from the film will be depicted more
magnified than objects closer to the film.

CBCT:
• Identify and locate the position of impacted canine
accurately.
• We can assess any damage to adjacent tooth roots and
amount of bone surrounding each tooth.
Surgical planning
• PATEINT
• SERGEON AND STUFF
• OPERTION SITE
• INSTRUMENT
Surgical tray for surgical tooth extraction
Principles:
• A sharp blade of the proper size should be used.
• A firm, continuous stroke should be used when
incising
• Avoid cutting vital structures when incising
• The blade should held perpendicular to the
epithelial surface.
• Incisions in the oral cavity should be properly
placed regarding to dental papilla
• Extraoral incision should be follow skin creases
Contraindications of incision
 INSTRUMENTS
INSTRUMENTS FOR
FOR INCISING
INCISING
TISSUE
TISSUE
• SCALPEL HANDIE NO 3
• SCALPEL HANDIE NO 7
Handling of blade to scalpel handle
Prevention of Flap Necrosis:

-Base > free margin

-Width of base > length of flap
- An axial blood supply in the base
• Prevention of Flap Dehiscence:
-Approximating the edges of the flap over healthy
bone,
-Gently handling the flap's edges,
-Not placing the flap under tension.
Prevention of Flap Tearing:
-It is preferable to create a flap at the onset of surgery
that is large enough for the surgeon to avoid either
tearing it or interrupting surgery to enlarge it.
 Push Stroke

Pry Stroke
Types of mucoperiosteal flap
 Tissue handling
• Toothed forceps or tissue hooks
• Tissue should not be retracted over
aggressively
• When bone is cut , copious amount of
irrigation is used
• Soft tissue should be protected from
frictional heats or direct trauma from
drilling equipments
Retraction of flap
 Hemostasis
• Why ?
1. Bleeding decrease visibility
2. To prevention of excessive blood loss
3. Prevent hematoma formation
• How ?
1. Pressure points or pack
2. Suture ligation
3. VC
4. Electro-coagulation
5. Use of hemostatic agents
6. Burnishing the bone with a small instrument
A- BONE REMOVALE

B- TOOTH SECTIONING
 Indications

• Gaining access to the tooth or root or intra-

bony lesion.
• Reduce the resistance around the tooth or
the root.
• To provide point of application to forceps or
elevators.
• To create a space into which the tooth or
root can be displaced.
can be removed using one of the following
methods:
• Chisel and mallet.
• Surgical burs.
• Rongeurs (bone cutting forceps)
• Piezosurgery
BONE REMOVING BY
RONGEURS
.SURGICAL MALLET AND CHISELS
.a Monobevel chisel
.b Lucas chisel with concave end
c Bibevel chisel
Chisels and Gouges
Osteotomes (bibevel): To shape and
sculpt bone, or section a tooth
Chisels (unibevel): To cut a window in
the bone cortex for access or to allow
harvesting of pure soft bone
Gouges (grooved ): To scoop away
strips of soft bone, especially in bone
grafting
Surgical burs
 Bone removal using Bone removal using
chisels surgical burs
Advantages Advantages
• Result in clean smooth cut in • Easy to perform
the bone. • Can be used to remove both
• Rapid bone removal. dense and brittle bone.
• No heat generation • remove bone accurately
Disadvantages Disadvantages
• Needs great deal of skill and • Heat generation can cause
experience. bone necrosis
• When performed under local • The bone cut leaves a rough
analgesia it may cause great edges of bone that must be
alarm and fright to the patient smoothened using bone files.
• Not advisable to be used with
dense or too brittle bone.
Sectioning of teeth
•Remaining root forceps
•Elevators
•Endodontic files
Remaining root forceps
 Dental Elevators

• Uses

•Types
•Rules
•Principles of action
 Classification of elevators:
According to shape:
•Straight
•Curved
•Cross- bar
According to use:
•Elevators designed to luxate or remove the entire
tooth
•Elevators designed to remove roots broken off at the
gingival line
•Elevators designed to remove roots broken off
halfway to the apex
•Elevators designed to remove the apical third of the
roots
•Elevators designed to reflect the mucoperiosteum
Potts elevators
Universal straight elevator
Apexo elevators
Cryer elevators
Buccal applicator

Socket applicator
 Rules governing the use of elevators

• Never use the adjacent tooth as a fulcrum, unless

the tooth is to be extracted too.
• Never use the buccal plate of bone as a fulcrum
except in case of removal of lower third molar.
• Never use the lingual plate of bone as a fulcrum.
• Always use finger guards to protect the
surrounding soft tissues from being injured in
case the elevator slips.
• Be certain that forces applied by the elevator are
under control
 Danger in the use of elevators
• Damaging or extracting adjacent teeth
• Fracturing of maxilla or mandible
• Fracturing of alveolar process.
• Slipping of the instrument into soft tissues with possible
soft tissue laceration or perforation of great blood
vessels or nerve
• Perforation of maxillary sinus.
• Forcing roots or tooth into maxillary sinus
• Forcing root or lower 3rdmolar into the mandibular canal
or through the lingual plate into sub-mandibular space.
 Principle of elevators

Lever principle
Lever principle
 Wedge
principle
Axial and wheels principles
Endodontic files
1—Small root tip less than 4 mm in size
2—No evidence of periapical pathology or infection
associated with root tip
3—Removal of root tip will cause destruction to
adjacent structures
4—Ill-feeling patient
5—Uncontrolled hemorrhage
PREPARING THE WOUND BEFORE CLOSURE

. Gently irrigate the wound with sterile warm saline .1

Remove residual fragments of tooth with any fragments of bone .2

.or filling in the tooth socket

Remove all pathological tissue, including apical granulomas or .3

.radicular cysts

.Smooth any sharp edges or projecting spicules of bone .4

If greater irregularities are present, a regular alveoloplasty may .5

.be done
6. Finally irrigate the wound before closure
 Aims of wound closure

• To hold the flap in position and approximate the

two wound edges (healing by primary intention)
• To aid in hemostasis
• may aid in maintaining a blood clot in the
alveolar socket. A special stitch, such as a
figure-eight stitch
The armamentarium
 Needles

1. Round tapered,
2. Oval tapered
3. Cutting , triangular with one of the
three cutting edges on the inside
of the semicircle),
4. Reverse-cutting triangular with
two cutting edges on the inside of
the semi-circle
Classification of suture materials
Resorbable sutures Nonresorbable surgical sutures
 Principles of suturing
• Suture needle → suitable size & sharpe
• Suture material → not be denser than
tissue
• Needle holder → grasp needle at ¾
distance from tip
• Suture needle → penetrate tissue 2-3 mm
from edge
• Suture needle → enter ┴ to tissue
• Knot should be 2-3 mm from incision line
• Suture ends should be cut 4-5 mm from
knot
• Sutures should pass from free to fixed side
• Suture should pass from dental papilla
base
The technique of suturing
SIMPLE INTERRUPTED
SUTURES.
CONTINUOUS SIMPLE
SUTURE.
 CONTINUOUS
LOCKING SUTURE
HORIZONTAL INTERRUPTED
MATTRESS SUTURE
VERTICAL MATTRESS
SUTURE
SUBCUTICAL
SUTURE
FIGURE – 8 SUTURE
Suture removal
the incidence of dry socket can be reduced significantly by using 0.2%
chlorhexidne gluconate mouth rinse perioperatively (twice daily, 1 day
before and 7 days after surgical extraction.
Cases of surgical extraction
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6