basic principles of exodontia

lecture given 8/4/2026

t/f extractions are just about force

false! its the intersection of medicine, surgery, and physical mechanics

what should you look out for in reviewing age, medical history, and medications?

patient age, medical conditions and medications including anticoagulants and bisphosphonates, any recent medication changes, ER or hospital visits, lab work, physiologic states that may require modifying the approach

t/f you just need to get clearance from a physician

false! you want the pt optimized, not just cleared

what local anesthesia should be used for mandibular extractions?

inferior alveolar nerve block, supplemented by long buccal nerve block or profound buccal and lingual infiltration

what local anesthesia should be used for maxillary extractions?

infiltration

what are the common anesthetic solutions used?

lidocaine 2% w 1:100K epi

articaine 4% w 1:100k epi

mepivacaine 3% no epi

bupivacaine 0.5% with 1:200k epi- long acting

when is local anesthesia challenging?

teeth with acute symptoms (aka hot tooth)

teeth near the midline or where nerve supply crosses

what should you be looking for during an extraoral exam?

neck swelling or lymph node enlargement

TMJ exam

mouth opening/presence of trismus

extraoral sinus tracts, fistulae, or changes to overlying skin

what should you be looking for during an intraoral exam?

teeth/tooth in question- mobility, pain

large restorations or crowns on adjacent teeth

any obvious pathology on clinical and radiographic exam

what imaging should be used prior to exodontia?

periapical, panoramic (for wizzies), and 3D

what are the indications for exodontia?

periodontal disease, caries, periapical pathology, root fracture

teeth associated with pathology, ortho, pts planned for head/neck radiotherapy or bisphosphonate therapy, in prep for orthopedic or cardiac surgery

what pt factors complicate an extraction?

age (denser bone with higher age)

significant gag reflex

pts unable to cooperate

endo treated teeth (minimal PDL space, roots close to adjacent teeth)

long, divergent roots

tooth adjacent to a large crown or restoration

minimal coronal structure

tooth close to vital structures

impacted teeth

curved or dilacerated roots, extra roots, hypercementosis

when may local anesthesia not be the best option for exodontia?

extractions will be significantly more difficult

multiple extractions are required along with tori/exostosis removal

pt is extremely anxious, unable to cooperate, or has a medical necessity for GA

what are relative contraindications to extraction?

severe, uncontrolled metabolic disease

pregnancy

uncontrolled leukemia or lymphoma

history of radiation to the maxilla or mandible

history of bisphosphonate therapy for osteoporosis or metastatic bone disease

what airway protection is needed for extractions?

bite block to support TMJ

place gauze intraorally to prevent debris/tooth from falling toward the airway

where should the operator be positioned for maxillary extractions?

arch below the operator’s shoulder, operator stands in front of the patient

where should the operator be positioned for mandibular extractions?

arch below the operator’s elbow, operator stands in front of the pt for all quadrants

why raise a flap?

allows you to hold/access the tooth beyond the coronal structure

provides access to bone if removal becomes necessary

what instrumentation is needed for raising a flap?

no 15 blade

periosteal elevator

how should a flap be designed?

keep the base of the flap broader than the free margin, to preserve adequate blood supply

most flaps in exodontia are full thickness flaps

what simple machines are elevators, and how should they be used?

primarily lever

a long lever arm and short effector arm covert modest force into a small movement against great resistance

which instruments use wedge action, and how?

elevators and forceps

an elevator forced into the PDL space can displace the root/tooth from the socket

forceps beaks are narrow at the tip and broaden going up- the narrow tip is forced into the PDL space to expand bone and push the tooth from the socket

where should the tip of forceps beaks be?

parallel to the long axis of the tooth

go down as far as possible along the root

what order should you apply force by forceps?

socket is expanded by inserting the beaks into the PDL

the first force applied is apical pressure

the center of rotation is displaced apically, this helps avoid root tip fracture

what is the purpose of buccal and lingual force when using forceps?

buccal pressure expands the buccal plate at the crest of the ridge, and also produces lingual apical pressure

expands lingual bone

what is the purpose of rotational force when using forceps?

produces internal expansion of the socket

useful for teeth with a single conical root- maxillary incisors, mandibular premolars

NOT useful for multi-rooted or curved roots

what is the purpose of tractional force when using forceps?

used to delivery the tooth from the socket

gentle forces only- if more force seems necessary, spend more time luxating the tooth first

what considerations need to be made for extracting maxillary canines?

long roots, part of the labial alveolar bone may fracture and come attached to the tooth

what considerations need to be made for extracting maxillary first premolars?

two roots, root fracture is common

what considerations need to be made for extracting maxillary first molars?

check root divergence, a long palatal root, and proximity to the sinus

what considerations need to be made for extracting mandibular incisors?

can be hard to anesthetize

what considerations need to be made for extracting mandibular premolars?

among the easiest teeth to remove

what considerations need to be made for extracting mandibular molars?

thick alveolar bone with strong, long, divergent roots

what considerations need to be made for extracting isolated molars in elderly pts?

notoriously difficult!

what are some post extraction instruments?

irrigation, currettage, and bone smoothening prepare the socket before closure

what is part of the post-op checklist?

check hemostasis and pain control

review post-op instructions and what to expect

discuss medications

arrange follow-up if needed

code for simple extraction

D7140

code for surgical extraction (bone removal and/or sectioning of the tooth)

D7210