Principles of exodontia (2023)

Exodontia's services make up the bulk of the clinical practice of most maxillofacial surgeons in the United States. This article provides an overview of the principles of exodontics, including the physical principles underlying the proper use of dental lifters and tweezers. Failure to understand the instruments used and the principles of physics may result in extended operative time, iatrogenic injury to the patient, and unnecessary operator fatigue and/or injury. Advances in materials, technology and innovative design have resulted in new and interesting tools for the treatment of exodontia. New instruments were introduced and discussed, including periotomes, piezosurgery, physical forceps and vertical extraction systems.

Most important points

  • Exodontia's services make up the bulk of the clinical practice of most maxillofacial surgeons in the United States.

  • This article provides an overview of the principles of exodontics, including the physical principles underlying the proper use of dental lifters and tweezers.

  • New instruments are also being introduced and revised, including periotomes, piezosurgery, physics tweezers and vertical extraction systems.

    (Video) Principles of Elevator, Forcep in Uncomplicated Exodontia- Lever, Wedge, Wheel & Axle- Apexo, Cryer

The most common procedure performed by most oral and maxillofacial surgeons is the extraction of decayed or impacted teeth. According to the National Institute of Dental and Craniofacial Research, 92% of U.S. citizens between the ages of 20 and 64 have tooth decay in their permanent teeth, and 26% of adults in this age range currently have untreated tooth decay. Many patients require one or more extractions throughout their lives due to impaction, tooth decay, periodontal disease, broken teeth due to chewing or previous dental procedures, and failed root canal treatment. The ideal principles of exodontics should allow efficient, effective and safe extraction of teeth, with a primary focus on minimizing complications and maximizing patient and caregiver comfort. Failure to understand the instruments used and the principles of physics may result in extended operative time, iatrogenic injury to the patient, and unnecessary operator fatigue and/or injury. This article discusses the principles, techniques and instrumentation for exodontics and introduces new instruments currently being introduced to the market.

Preoperative assessment

A thorough history and physical examination should be performed prior to any surgical procedure. While most patients can safely undergo basic exodontic procedures, medical history and current medications allow the surgeon to anticipate intraoperative and postoperative complications, including bleeding problems, bone and/or soft tissue healing problems, and the best pain management strategy for the individual. patient. This assessment also includes predicting the specific tools that may be needed for the procedure. Informing the surgical team of the need for special instruments or hemostatic agents maximizes the effectiveness of the procedure. The examination process also includes diagnostic photos of the teeth to be removed to confirm the need for removal and assess potential complications. X-rays also allow the patient to visualize the teeth to be removed and participate in the informed consent process by seeing structures that may be at risk, such as the maxillary sinus cavity, inferior alveolar nerve canal, or adjacent fillings.

The use of cone beam computed tomography (CBCT) by oral and maxillofacial surgeons is becoming increasingly popular in the United States. Although most patients with routine exodontics do not require CBCT, CBCT may be indicated when impacted wisdom teeth are located near the inferior alveolar canal. Matzen and Wenzel conducted a comprehensive and well-designed assessment of the efficacy of CBCT prior to mandibular wisdom tooth extraction. In their review of over 300 articles, they discovered the lack of randomized controlled trials and ultimately concluded that periapical and panoramic imaging is sufficient for most patients undergoing wisdom tooth extraction. However, they found that CBCT may be indicated if traditional imaging suggests a high risk of inferior alveolar nerve proximity, and that CBCT would alter clinical decision-making, such as performing coronectomy instead of extraction.


The tools required for successful tooth extraction include optimal illumination, suction, and proper soft tissue retraction. A well-trained assistant is an important part of any successful procedure, providing suction, irrigation, and anticipation of instrumentation needs as the procedure progresses. The assistant can also be used as a last line of defense to verify the correct patient, procedure, allergy profile, completion of consent, and pre-procedure sedation requirements (e.g. non-profit status, adult driver). The value of a formal 'pause' checklist and strict adherence to the checklist by the surgical team cannot be overemphasized.

The position of the patient is important for the visualization of the surgical field by the entire surgical team and for the correct posture of the surgeon. Patient positions that cause the neck or back to bend or twist unnecessarily can, over time, lead to significant disability for the surgeon.

Tooth lifters are available in a wide variety of designs to facilitate tooth dislocation. However, forces acting on a tooth are governed by three physical principles: (1) lever, (2) wedge, and (3) wheel. The maxillofacial surgeon must understand these principles to maximize the effectiveness of the lifts while minimizing excessive or misdirected force. The purpose of dental lifters is to dislocate the tooth such that the periodontal ligament tears, allowing the tooth to be removed with forceps.

The auger is used as a wedge when the thin sharp edge of the instrument is directed parallel to the root surface with pointed force. This severs the periodontal ligament, but also lengthens the periradicular bone laterally and displaces the tooth coronally.

The jack is used as a class I lever (the fulcrum is between the source of effort and the source of resistance), when the tip of the instrument is placed between the bone and the root surface, using the alveolar ridge as the fulcrum (Figure 1). The longer the lever arm, the greater the force generated by the working end of the lift. A stable contact point on the tooth is essential to be able to exert sufficient force on the tooth. If the tooth has significant decay, a trough or dissection of the tooth may be necessary to obtain a purchase with stable tooth structure. Another technique is to create an anchor point on the tooth with a drill so that the crane pick can be used as a lever.


Principles of exodontia (1)

Class I leverage

Finally, the elevator (especially cryer elevators) is used as the wheel and axle. In the Cryer lifter, the handle acts as a shaft and the working end of the lifter acts as a wheel generating more force and an arc of rotation to lift the carrot. This is mainly used in the area of ​​the mandibular molars.

Often a combination of all three principles of physics is used simultaneously to wedge the elevator as close to the apex as possible for optimal hold/pivot point, then apply leverage and rotational forces to the tooth to quickly and efficiently drive the tooth. extract. The development of a sense of the proper application of these forces is critical and must be carefully and continuously re-evaluated as the surgeon's skill develops. Over time, you can quickly judge by feel whether the tooth can be lifted successfully or whether the use of a drill is most effective.

Dental pliers also come in many designs that can be customized for the specific teeth they are being used on. The fundamental operating principle of tweezers is leverage; however, some designs also create a wedge effect (e.g. No. 23 Tweezers or Thin Beak Tweezers). As with elevators, judicious use of force is key to avoiding complications. The handle, which is formed by conventional pliers, is a type I handle connected by a hinge. In this configuration, the hinge acts as a fulcrum, with the handle being a long lever and the beak a short lever.


Perhaps the greatest advancement in modern exodontics is the drill. The modern surgical drill is a sophisticated instrument that provides high speed, high torque drill rotation that can function in the presence of water and blood and withstand repeated sterilization cycles. The bur provides efficient removal of cortical bone and cutting of teeth. The generous use of irrigation to minimize overheating and subsequent necrosis of the surrounding bone is critical. Adequate illumination, retraction and suction are important to prevent iatrogenic damage to adjacent tissues. The influence of the surgical drill on the effectiveness of exodontics in practice cannot be overestimated and it is an invaluable surgical tool. The use of a bur provides a significant mechanical advantage by allowing apical positioning of the elevators, increased purchase and division of multi-rooted teeth.

New instrumentation/extraction techniques

Advances in materials, technology and innovative design have resulted in new and interesting tools for the treatment of exodontia. Here we discuss some of the new products that have been launched.

Physics pliers

Physics Forceps (GoldenDent, Roseville, MI) uses Class I leverage by placing a bumper in the buccal vestibule and a thin beak on the lingual side of the tooth. Subsequently, constant pressure is applied to the tooth for several minutes, lifting the root 1 to 3 mm from the socket. According to the manufacturer, the linkage of the lever arm combined with the release of hyaluronidase into the periodontal ligament space causes the release of the periodontal ligament. The tooth can then be removed with a rongeur or other dental forceps. The manufacturer claims that the forceps provide atraumatic extractions that minimize fractures of the alveolar root or bone and protect surrounding bone.Fig. 2shows the project to the instrument andAfb.3shows how tweezers are positioned to create a class I lever. El-Kenawy and Ahmed compared physical forceps to conventional forceps in terms of root, crown, and buccal plate fracture rates. The authors found a significant reduction in crown and root fractures with physical forceps. The physics forceps design replaces the buccal jaws of traditional forceps with a rubber bumper that rests against soft tissue deep in the vestibule. This creates a significant mechanical advantage for a Class I lever, analogous to using a hammer claw to remove a nail from a board. The manufacturer intends to use the tweezers with gentle, steady pressure for several minutes, as opposed to traditional tweezers that require frequent squeezing and twisting. Patel and colleagues used a prospective split-mouth method to compare physical forceps to conventional orthodontic extraction forceps. The study demonstrated a significant reduction in operative time and immediate postoperative loss of marginal bone and soft tissue when using physical forceps. Hariharan and colleagues found that the physics tweezers had an advantage over conventional tweezers in terms of pain assessment.

Principles of exodontia (2)

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(Video) Exodontia Basic principles


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(Video) 5 Steps Uncomplicated Exodontia Technique Principle Procedure with elevator & forceps Online Lecture


What are the principles of instruments in exodontia? ›

However, the forces applied to the tooth are encompassed by three principles of physics: (1) a lever, (2) a wedge, and (3) a wheel. It behooves the oral and maxillofacial surgeon to understand these principles to maximize the effectiveness of the elevators, while minimizing excessive or ill-directed force.

What is exodontia according to Geoffrey? ›

DEFINATION: According to GEOFFREY L.HOWE –”The painless removal of the whole tooth, or root, with minimal trauma to the investing tissues, so that the wound heals uneventfully and no post operative prosthetic problem is created”.

What is the most difficult tooth to extract? ›

What is the most difficult tooth to extract? Impacted wisdom teeth are wisdom teeth that have failed to erupt properly. They are generally considered to be the most difficult teeth to extract. The higher the degree of impaction, the more difficult the extraction.

What are the basic principles of endodontics? ›

Endodontic Principles That Govern

What are the positions for exodontia? ›

Chair position in exodontia

Extractions can be performed by operator either in sitting position or in standing position. Standing extractions are most commonly practiced as compared to the sitting dentistry.

What are the different types of extraction exodontia? ›

There are two main types of dental extraction, simple extraction and surgical extraction. Simple dental extraction is used to remove teeth that can be seen and are easily accessible, whereas surgical dental extraction typically requires an incision into the connective tissue to gain access to the tooth to be removed.

What are the 4 categories of dental instruments? ›

Most dental hand instruments fall into four categories, they include examination instruments, hand cutting instruments, restorative instruments and instrument accessories.

What is the principle of an instrument? ›

GENERAL PRINCIPLE OF INSTRUMENTATION. Head is relatively erect. Head in the least strained position vertically and horizontally. Eyes are directed downward in a manner that prevents head and neck strain.

What is the role of antibiotics in exodontia? ›

Antibiotics given just before or just after surgery (or both) may reduce the risk of infection and dry socket after the removal of wisdom teeth by oral surgeons. However, antibiotics may cause more (generally brief and minor) unwanted effects for these patients.

What is surgical exodontia? ›

It usually involves loosening the tooth and then removing it. Surgical extractions are for more complex cases. This requires more thought from the dentist or oral surgeon to extract the tooth. Gum tissue or even bone might need to be removed.

What is the meaning of emergence of teeth? ›

Tooth eruption is the movement of the developing tooth from its non-functional position in the alveolar bone to its final functional position in the oral cavity (occlusal plane).[1] The term eruption differs from emergence as the latter refers to the moment of appearance of any aspect of the crown through the gingiva.[ ...

Which teeth Cannot be pulled? ›

A tooth with a previous root canal: Teeth that have had root canals and have broken down are harder to remove than normal teeth. A root canal makes the tooth more brittle and susceptible to fracture during the extraction process making it more of a task for your dentist to remove the entire tooth.

Why experts now say not to remove your wisdom teeth? ›

That exposes the underlying bone and nerves and results in severe pain. More serious risks, which become more common with age, include nerve and blood-vessel damage. As with any surgery, wisdom-tooth removal does carry the very rare risk of death.

What is the hardest tooth to get a root canal on? ›

The maxillary molars, especially the second molars, have the most complicated root canal system in permanent dentition. There are many variations in canal number and configuration in maxillary molars. Treatment may be unsuccessful because the dentist may fail to recognize the unusual canal configuration.

How can I be a good endodontist? ›

Great Qualities Your Endodontist Should Have
  1. Specialized training. ...
  2. A commitment to your comfort. ...
  3. Skill with current technologies. ...
  4. A high experience level with endodontic procedures. ...
  5. A wide network of professional colleagues.
Feb 15, 2018

What makes a good endodontist? ›

Endodontists are there to help, and a good Endodontist cares about you as a patient first and foremost. This means that if you have a difficult tooth, they will take extra time for the procedure and not rush. If your tooth requires multiple visits to get the best result, they will recommend taking that route.

What are the complications of use of elevator during exodontia? ›

The immediate ones can be in the form of major complications such as jaw fracture, severe bleeding, severe dental displacement, and damage to the neighboring tissues.

What is the most common intraoperative complication of exodontia? ›

Dry socket/alveolar osteitis: Alveolar osteitis or dry socket is the most common postoperative complication following extraction of teeth.

What are the three basic types of extractions? ›

The three most common types of extractions are: liquid/liquid, liquid/solid, and acid/base (also known as a chemically active extraction). The coffee and tea examples are both of the liquid/solid type in which a compound (caffeine) is isolated from a solid mixture by using a liquid extraction solvent (water).

What are the 4 extraction methods? ›

Extraction is the first step to separate the desired natural products from the raw materials. Extraction methods include solvent extraction, distillation method, pressing and sublimation according to the extraction principle. Solvent extraction is the most widely used method.

What are the 2 methods of extraction? ›

There are two types of extraction, liquid-liquid extraction also known as solvent extraction as well as solid-liquid extraction. Both extraction types are based on the same principle, the separation of compounds, based on their relative solubilities in two different immiscible liquids or solid matter compound.

What is Principle 4 dentistry? ›

You must keep patient information confidential. This applies to all the information about patients that you have learnt in your professional role including personal details, medical history, what treatment they are having and how much it costs.

What does 4 mean in dentistry? ›

A 1 means you have some mild bleeding and plaque at the edges of your teeth. 2 means dead plaque hardened around your teeth, requiring gentle cleaning, while 3 means you might have gum disease. A score of 4 means you have gum disease that will need treatment.

What defines 4 handed dentistry? ›

Four-handed dentistry is a team concept where highly skilled individuals work together in an ergonomically designed environment to improve productivity of the dental team, improve the quality of care for dental patients while protecting the physical well-being of the operating team.

What are the 3 types of principle? ›

Three such fundamental principles, that of Justice, Rational Self-Love, and Rational Benevolence, are often called 'maxims', for they are not principles that simply state facts, but are those that serve as a guide for determining actions that ought to be done.

What are the 4 principles of measurement? ›

The four scales of measurement are nominal, ordinal, interval, and ratio. Physical quantities such as length, mass, and time are called scalar quantities or scalars. Physical quantities that require an additional specification of direction for their complete definition are called vector quantities or vectors.

What is a basic principle? ›

Definitions of basic principle. principles from which other truths can be derived. synonyms: basics, bedrock, fundamental principle, fundamentals.

What are 3 commonly used antibiotics in dental practice? ›

Dentists prefer to prescribe amoxicillin and metronidazole or co-amoxiclav to control dental infections. Moreover, clindamycin is an alternative drug in penicillin-allergic patients.

Why no ibuprofen after tooth extraction? ›

Always consult your dentist about which medications to take after a tooth extraction. Ibuprofen, for example, can cause side effects, such as an allergic reaction or stomach upsets.

What is the principle of management of odontogenic infection? ›

Adequate hydration, nutrition and control of fever are essential to optimise the medical care for patients presenting with odontogenic infections. Stabilisation of any underlying systemic disease (for example, uncontrolled diabetes) is extremely important.

What should I avoid after tooth extraction? ›

Don't drink with a straw, suck on candy or ice pops, slurp soups or other liquids, rinse your mouth vigorously, or smoke for 24 hours. These things create suction in the mouth. This may dislodge the blood clot. Don't drink alcohol or use mouthwash containing alcohol for 24 hours.

Does tooth extraction count as surgery? ›

Dental surgeons may classify extractions as simple or surgical. A simple extraction involves a tooth that is visible above the gums and that a dentist can remove in one piece. A surgical extraction is more complicated and involves the removal of gum tissue, bone, or both.

How do you remove bone fragments from your gums at home? ›

You may be able to remove very small tooth and bone splinters that have worked their way to the surface of your gums (are poking through) on your own. These bits can usually be flicked out using your fingernail, pulled out with tweezers, or pushed out by your tongue.

Is tooth emergence the same as tooth eruption? ›

In contrast to 'erupt', 'emerge' is momentary and neither infers sudden, forceful or dramatic breaking out nor does it designate dynamicity. Both 'eruption' and 'emergence' are used in the dental literature to describe the moment a tooth breaks out through the overlying mucosa, though eruption is used more frequently.

How fast do teeth emerge? ›

Teething takes about 8 days, which includes 4 days before and 3 days after the tooth comes through the gum. (You may see a blue-grey bubble on the gum where the tooth is about to appear.

When is a tooth considered erupted? ›

At birth people usually have 20 baby (primary) teeth, which start to come in (erupt) at about 6 months of age. They fall out (shed) at various times throughout childhood. By age 21, all 32 of the permanent teeth have usually erupted.

What happens if you don't replace a tooth after extraction? ›

After you undergo a tooth extraction, you will need to replace the missing tooth or teeth. If the teeth are not replaced, the bones in your mouth can weaken and lose density. Other teeth also might shift, and you might experience trouble eating.

What happens if tooth breaks during extraction? ›

Although the majority of tooth extractions are completed without any complications, there may be occasions where problems arise. During an extraction, the tooth can fracture, in which case the dentist should not go any further with surgery unless an x-ray has been carried out on the remaining roots.

How many teeth can a dentist pull at once? ›

How many teeth can I have extracted at once? There is no limit to the number of teeth you can have extracted at once. While having multiple teeth extracted during the same procedure is rare, it is sometimes the only option for patients with severe tooth decay.

Why didn't I get stitches after tooth extraction? ›

For "simple" dental extractions, sutures are not always required. When there is minimal manipulation of the gums and bones AND the patient has a healthy immune system, it is reasonable to expect that the tooth site will heal with no sutures.

How painful is tooth extraction without anesthesia? ›

If you are not sedated, during the simple extraction you will still be provided with local anesthesia at the site of the surgery. You should not experience any pain, however it is common to feel pressure during the actual extraction. The only way to feel absolutely nothing…. you have to be sedated.

What are the worst wisdom teeth to remove? ›

Full-Bony Impacted: This type of wisdom tooth removal is the most difficult because the wisdom tooth is completely stuck in the jaw.

What are the principles of extraction process? ›

The extraction of natural products progresses through the following stages: (1) the solvent penetrates into the solid matrix; (2) the solute dissolves in the solvents; (3) the solute is diffused out of the solid matrix; (4) the extracted solutes are collected.


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