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Step by Step®
Clinical
Exodontics
Step by Step®
Clinical
Exodontics
(Extraction of Teeth including Impactions)
Pramod Bansi Mathur

Junior Specialist (Dental) Retd
Bikaner, Rajasthan, India
Sanjay Bansi Mathur

Dental Surgeon
Manisha Mathur
Lecturer Surgery
Chalana Medical Institute
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Step by Step Clinical Exodontics
© 2008, Jaypee Brothers Medical Publishers
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First Edition: 2008

ISBN 978-81-8448-415-1
Typeset at JPBMP typesetting unit
Printed at Ajanta
To
My Parents
Dr Brij Bansi Lal Ji and Smt Gur Peari
•
My Assistants
Dr Shamina Rehman, MDS
Dr Suman Rawat BDS, Ghanshyam ji Gaur,
Kameshwar Lal ji Nepalia, Nalini Parasher,
Rathore, Radhey Shyam and many others
•
My teachers, colleagues, patients, and known
Preface
If making of the denture is the butter for the dentist

then extraction of teeth is the bread.
This book contains all what is required before,
during and after the extraction of teeth, including
deciduous teeth, complicated extractions, broken root
pieces, root remnants, and details of extractions/
odontectomy of impacted third molars, canines,
mesiodents, and supernumeraries.
Sterilization, theater decorum, details of antibiotics,
and all that should be done to avoid infection
are discussed in detail. Emergencies, allergic mani-
festations, anaphylactic reactions, etc. are also
highlighted.
The tortuous operational technicalities are explained
in a very easy way with the help of photographs/
figures and video films. A surgeon faces many working
minute but important technical problems during
operations, which are generally not explained
anywhere, and are left to imagination of the surgeon
but these problems are well explained in this book.
The accompanying audio-video DVD explains even
the minutest technical details with the help of movie
clippings of various procedures including extractions,
impactions and other surgical procedures.
viii Clinical Exodontics
The use of simple language, pointwise explained
text, supported by figures, and video films will
certainly help the dental students, clinicians, and
teachers to make exodontia easy.
Pramod Bansi Mathur

Sanjay Bansi Mathur
Manisha Mathur
Contents
1. Introduction ............................................................ 1
Response of tissue, Anxious patient, Operation,
Tips to dentists, Premedication, Anesthesia,
Indications for extraction, Contraindications,
Local conditions, Systemic conditions, Clinic and
instruments required for oral surgery/exodontia.
2. Armamentarium/Instruments ............................ 13
Different types of instruments used in exodontia
and care of instruments, Varieties of dental chairs,
units, etc.
3. Sterilization of Instruments/Equipments ...... 25
Sterilization, Autoclaving, Boiling, Dry heat
sterilization, Chemical sterilization, Gas sterili-
zation, Chemical vapors sterilization, Radiation
sterilization, General observations regarding
sterilization.
4. Operation Room Decorum................................. 41
Scrubbing, Isolation of the patient from the
operative team.
5. Antibiotics ............................................................ 49
Goal of administration, Host defense mechanism,
Penicillin group (Erythromycin, Cephalosporin
group (generations), Trimethoprim-sulfamethoxa-
zole, Metronidazole, Chloramphenicol, Nystatin,
culture/sensitivity test, Choice of antibiotic,
x Clinical Exodontics
Narrow and broad spectrum antibiotics, Bacterio-
cidal and bacteriostatic antibiotics, Monitoring the
patient’s response, Indications, Contraindications
of antibiotic therapy, Use of prophylactic anti-
biotics, Prevention of wound infection, Infective
organism and antibiotic sensitivity, Dozes of
antibiotics during surgery, Prophylaxes of wound
infection, Prevention of metastatic infections (Sub-
acute-bacterial-endocarditis, (SBE)), American
dental association and American Heart society’s
recommendations.
6. Analgesics (Pain killers) .................................... 87
Analgesics and antipyretics, aspirin, salicylamide,
sodium salicylate.
• Amino phenol derivatives; Paracetamol.
• Trigeminal neuralgia; carbamazepine.
• Some commonly used drugs of this group.
• NSAID’s; ibuprofen, Nimesulide,
• Serratiopeptidase, ibuprofen+Paracetamol, ..
carisopodol+ibuprofen.
• Warning.
7. General Outlines for Exodontia ....................... 99
Anesthesia, Position of the chair, Preparation and
draping, Position of hand of the operator,
Extraction with forcep. After extraction care of
the patient, Order of extraction.
8. Anesthesia Used for Exodontia ...................... 109
Factors on which choice of anesthesia depends,
age and physical status of the patient, nature and
duration of operation, emotional status of the
patient, drug allergy.
Contents xi
9. Forcep Extraction of Individual Tooth ......... 123
Maxillary central incisors (11, and 21), Maxillary
lateral incisors (12 and 22), Maxillary canines (13
and 23), Maxillary premolars (14, 15 and 24, 25),
maxillary molars (16, 17, 18 and 26, 27, 28).
Mandibular incisors and canines (31, 32,33 and 41,
42, 43), Mandibular premolars (34, 35 and 44, 45),
Mandibular molars (36, 37, 38, and 46, 47, 48).
10. The Surgical Flap .............................................. 171
Indications, Flap design principles, Verities,
Procedure.
11. Complicated Exodontics .................................. 179
Alveoloplasty.
12. Removal of Broken/Chipped/Residual
Roots of the Teeth ............................................. 191
Maxillary roots, Mandibular roots, open-
reduction, Residual roots.
13. Principles of Elevators ...................................... 205
Verities and use (straight, winter, apexo-leaver,
etc. elevators).
14. Impactions ........................................................... 215
Cover of antibiotics, Ossisection of bone,
Preparation of the operator and the patient,
Classification of mandibular third molar
impactions, Mesioangular impaction, Vertical
impaction, Horizontal impaction, Disto-angular
impaction, Cautions while operating Maxillary
impactions, Maxillary disto-angular impaction,
Maxillary mesio-angular impaction, Maxillary
xii Clinical Exodontics
vertical impaction, Maxillary canine impaction
(palatal, lateral, intermediate types), Impacted
supernumeraries.
15. Removal of Deciduous Teeth ......................... 285
Indications. Anesthesia, When to operate,
Technique.
16. Emergencies in Dental Clinic ......................... 291
General considerations, Syncope, Delayed
reactions, Teeth displaced to oropharynx, Removal
of teeth under general anesthesia, Hospitalization
of patients, Management of acute infected tooth,
Complications of exodontia, Post operative/
extraction complications.
17. Complications of Exodontia ........................... 303
Hemorrhage, Dry socket.
Index ...................................................................... 311

ONE
INTRODUCTION TO
EXODONTIA /
EXTRACTION OF
TEETH
2 Clinical Exodontics
The perfect knowledge of anatomy of the tooth to be
extracted along with its surrounding tissues/structures
i.e. alveolar bone, mandibular or maxillary arches,
gums, mucosa, mucogingival folds vestibules position
of arteries, veins, nerves, etc. is mandatory. The
technique and skill development for various moments
of hand holding extraction forcep is an important factor
in successful exodontia practice.
Living tissues must be treated gently. Rough
handling, incomplete ragged incisions, excessive and
forceful retraction of tissues/flap, or irregular suturing,
though may not be painful at the time of operation
when the tissues are under anesthesia, but will result
into tissue damage or even necrosis and in turn shall
provide an excellent media for the growth of bacteria
and infection, excessive postoperative oedema, pain,
swelling, inflammation, ultimately delay in the process
of healing. On the other hand a gentle handling of
tissues, neat and proper closure of the wound by
perfect suturing will result in less painful and quick
healing process.
Tissue Response
The reaction of different people to the same stimulus
varies considerably.
Response to Pain
A person respond to pain as per his/her basic
psychology formed as a result of his/her past
experiences. This may vary from dull response to
extreme sensitive response.
Introduction to Exodontia/Extraction of Teeth 3
In experimental cases two groups were made out
of the postoperative pain of almost equal intensity.
One group was given painkillers, whereas the other
group was given placebo sugar tablets. 35% of the
patients on placebo tablets felt relief in pain. Likewise
some of the children fear white coat/apron of the
dentist. For this very reason most of the pedodontists
wear ordinary street clothes in their surgery/clinics.
Likewise intravenous blood collection needle prick
may be very painful for some individual, whereas some
one else may not even feel the prick.
Anxious Patient
Previous bad/painful experiences elicit more pain
perception just by mere odour, colour, situations, etc.
because of the psychology formed by previous
experiences of individual patients. Most of the people
fear operation. An experienced dentist will not extract
tooth of a fearful patient who prepares himself for the
forthcoming pain by holding the handle of the chair
firmly, and press his/her hand, so firmly on the
handles of the dental chair that even his/her knuckles
become white due to ischemia. Hence it is a wise step
to prepare the patient first psychologically for the
forthcoming pain.
Some tips for the dentists to prepare their patients
ready, before dental operation:
1. Prepare his/her psychology, by explaining the need
for the operation. The present pathological
condition that is much more painful and harmful
shall be cured completely and the operation will
take much less time and will provide much more
comfort forever. You will experience little or no
pain at all because of perfect anesthesia during the
operation, after the operation the painkillers will
not let you feel much pain.
2. The dental clinic may be made more comfortable/
formal with light music, calm and quite atmosphere.
Another good method is to put a fish-pond/
aquarium in view of the excited patient sitting in
dental chair (Watching fish pond is a proved
relaxation provider).
3. The dentist should prepare the patient psychologi-
cally and gain his/her confidence before starting
the surgery. An excited, hurrying, under confident
dentist shouting on his assistant, is likely to
transmit the same panic state to his patient. That is
why the dentist should remain calm and cool all
the time. This quality develops by constant effort
on part of the dentist. The personality and actions
of the dentist should radiate to the patient that he/
she is in the most safe and experienced hands.
Premedication
A. A light, easily digestable, healthy diet, relaxing
sleep a night before the operation will make the
patient more relaxed and perceptive for the opera-
tion next morning. The patient may be allowed a
light breakfast or otherwise as per requirement of
the anesthesia/operation.
B. Some questions asked to the patient, before
operation may help the operator to assess his/her
local and systemic condition.
C. How many pillows he/she is using while sleeping
at night? Does he/she get difficulty in climbing
stairs?
D. Did he/she had much bleeding, excessive pain or
any other postoperative complication after last
operation/or injury he/she sustained.
E. In cases of fracture of jaws/broken tooth/teeth,
etc. pre and postoperative X-rays are indispensable
for diagnosis/treatment planning/record purpose
to avoid any post-treatment dispute or medicolegal
complications.
RECORDING OF BLOOD PRESSURE

sometimes even the patient does not know about his/
her hypertension status, hence recording of blood
pressure before any operative procedure is mandatory.
Additionally the dentist generally uses local anesthetic
solutions containing adrenaline, which is also likely to
increase the blood pressure.
If any of the history is suggestive of any underlying
pathology, proper approach to detect the condition
should be executed and assessed before surgery is
undertaken.
Anesthesia
General or local is depending upon the experience and
need of the surgeon, his equipment, etc. and on the
patient’s part, his/her psychological aspect, ambulatory
or non-ambulatory and of course nature of the
operation, required/expected time of operation,
degree of muscular relaxation required, all these factors
will decide the selection of anesthesia between local/
or general. Normally in well-organized hospitals/
advanced operations of oral surgery requires general
anesthesia with proper premedication.
Most of the operations like extractions/periodontal
operations/root canal treatment and even impactions
are performed in clinics, out patient department under
local anesthesia with or without premedication.
Premedication
Premedication may vary from barbiturates to ataraxic
drugs taken orally by the patient at home before
starting for clinic or taken in waiting room of the dental
clinic should be sufficient.
20 mg of diazepam given intravenous, followed
immediately by local anesthesia Lignocane hydro-
chloride 2% with adrenaline 1: 80000 in the local tissue,
i.e. infiltration anesthesia or by regional/block
anesthesia is considered most easy safe and sufficient
for most of the oral operations.
A prophylactic doze of antibiotic is also given to
the patient 30 minutes to an hour before starting
surgery. This will safeguard the patient against
bacteremia, pyaemia, and septicemia and as per
Burke’s principle it is sufficient doze to cover short
durational operations like exodontia.
INDICATIONS FOR EXTRACTION

The function less tooth present in the mouth, which is
useless in dental mechanism, painful, uncomfortable
to the patient is indicated for extraction/removal.
1. Pulpal pathological condition of a tooth that
cannot be treated by root canal treatment and
apical surgery is indicated for extraction/removal.
2. Periodontal condition acute or chronic with
considerable loss of supporting alveolar bone
(class III or IV defects) that cannot be treated by
periodontal treatment needs extraction.
3. Any injury to tooth or its supporting structure
including alveolar bone, which is beyond repair,
is indicated for extraction.
4. Impacted tooth, which is not likely to be functional
and is agoning to the patient, is indicated for
extraction.
5. Any adventitious/supplementary/supernumerary
tooth not likely to take its proper position in
functional arches is indicated for extraction.
6. Prosthetic requirement for their stability in oral
cavity may indicate extraction.
7. In cases of orthodontia, where space is required
for moving the teeth into proper alignment, even
the fully developed and healthy teeth may require
extraction.
8. A pathological condition in the surrounding bone
of the tooth like cyst, oesteomylitis, tumor, bone
necrosis, etc. may necessitate extraction of offend-
ing/involved tooth/teeth.
9. A tooth adjacent to the line of fracture of maxillae/
mandible that is likely to be a hindrance in
reduction and fixation of the broken pieces is
indicated for extraction.
10. Teeth are some times required to be extracted
before radiation therapy in cases of jaw tumors.
“Teeth in line of fire” may become painful “pegs”
after radiation therapy and may cause problems
of wound healing if extracted after the radiations,
which destroys blood supplying arteries and veins.
Contraindications
1. Addisonian crisis: In this crisis mere injection of local
anesthesia prior to extraction may cause instant
death of the patient.
Some local and systemic conditions may be activated
into diseases, causing surgical interventions
absolute contraindication.
Local conditions: Infection and malignant tumors may
be local conditions in this category.
In case of acute infection with uncontrolled
cellulites, extraction should be postponed till the
acute condition is under control by conservative
treatment, otherwise the infection/cellulites may
spread further.
2. Acute pericronitis: should be managed first because
of presence of mixed strains of bacteria in that area.
Generally the third molar area is located in close
vicinity of deep facial planes of the neck and
removal of third molar necessitate ossisection,
which in turn may spread the infection into these
planes.
Systemic factors complicating: Here primary target
of treatment should be to control the toxemia,
infection and causative complicating factors first,
rather than extracting the tooth straightaway.
Before antibiotics were available tooth was never
extracted unless local acute inflammatory condi-
tions were brought under control. Pus drainage
used to subsides acute condition to chronic stage.
But in modern times the specific antibiotic therapy
is started and the operation may be performed as
soon as adequate blood level of the antibiotic with
control on systemic factors is achieved.
3. Acute infection: stomatitis are debilitating and
painful conditions, which may complicate the
extractions.
4. Presence of malignant disease complicates healing
of the wounds and because trauma, injury or
extraction can trigger the tumor to grow rapidly,
extractions should be avoided.
5. Jaws that are recently irradiated for the treatment
of malignancy, radio-oesteomyelitis may result as
complication of extraction of teeth. Dry-socket,
which is extremely painful condition, spread of
uncontrollable infection may occur because of
avascularity of the jaw bones and this condition
may result into fatal termination of the patient.
Systemic Conditions
Many systemic conditions or malfunctions can be
complicated by extraction; some of the common
conditions are listed below:
1. Cardiac diseases: Coronary artery disease, hyper-
tension, cardiac decompensation, valvular
diseases, rheumatic heart diseases, etc. These
conditions may require help of physician in proper
management of the patient before extractions are
undertaken. Normally a patient is considered
unsafe for six months after a cardiac infraction
(Heart attack).
2. Uncontrolled diabetes mellitus, which may result
into severe infection of the wound and absence
of normal healing process. Extraction should be
postponed until the uncontrolled diabetic
condition is well under control.
3. Blood dyscrasias: including severe and serious
anemia, hemorrhagic diseases, like hemophilia,
leukemia, etc. Extractions should be well planed
under strict advise/control of respective specia-
lists.
4. Suffering from any debilitating disease, the patient
is always of poor surgical risk.
5. Addison’s disease: or any steroid deficiency is very
dangerous. Even in well-treated cases with steroid
therapy, after one year of not taking any steroid,
there may not be enough adrenal cortex secretions
to withstand stresses of an extraction and may be
that the patient requires additional steroids.
6. Pyrexia of unknown origin: is generally worsened
by extraction. Underlying cause of pyrexia of
unknown origin may be subacute-endocarditis,
which may get worsened due to transient
bacteremia by extraction of tooth.
7. Nephritis: may create problems in a case of
exodontia.
8. Pregnancy: precautions must be taken as to posture
of the patient in dental chair and any undue
pressure on foetus should be avoided. The patient
should be guarded against low oxygen tension
condition. Fright, worry, tension, anxiety, etc.
should be avoided. Use of certain drugs like tetra-
cycline should be avoided because tetracycline
may stain the developing teeth in the foetus.
Generating bacteremia should be avoided, As such
second trimester is considered comparatively safer
period, if surgery is unavoidable it may be done
during that period.
9. Senility: is a relative condition, which requires
more attention and care avoiding prolonged
negative nitrogen balance.
10. Psychosis and neurosis: may complicate the exodontic
procedures.
CLINIC AND EQUIPMENT REQUIRED FOR ORAL

SURGERY/EXODONTIA
Generally the dentists use their clinics both for oral
surgery/exodontia as well as general dental practice.
Exclusive exodontia/extraction clinics are rare in our
country. So the clinic, which is equipped for general
dentistry should also have some additional equipment
for oral surgery cases.
1. Sterilized tray/basin: which is held in the lap of the
patient or held by the assistant or a suction machine
should be used. A heavy suction more powerful
than usual saliva ejector, etc. should be available.
2. If bone cutting burs: are to be used powerful electric
motor equipment along with distilled water/saline
spray should be used in properly sterilized hand
piece. Compressed air, however, should be avoided
as it may cause aerial pollution/spread of infection
and emphysema of soft tissue with infected air with
surprising suddenness.
3. Mayo stand should be available at the backhand
portion of the patient. Switches/water taps, etc.
should be all foot/or knee controlled, as the gloved
hands of the operating surgeon should not touch
any equipment other than properly sterilized/auto-
claved ones.
4. Oxygen cylinder: in perfect and ready condition
should be available at hand.
5. Radiograph viewer: should be in a convenient view
of the surgeon along with proper lighting system
and daylight should be available in plenty through
glass windows of the surgery/clinic.
TWO
ARMAMENTARIUM/
INSTRUMENTS
Proper instruments for specific operation/extraction
should be available rather than using universal
extraction forcep.
FORCEPS
Basically they are of two types:
1. English/or Ash pattern (commonly used in our
country (Fig. 2.1).
2. American pattern (Fig. 2.3).
The forceps along with their use on specific tooth
to be extracted with proper extraction movements
required during its use shall be discussed in the
chapter-9.
Elevators / Exolevers
Winter exolevers: 14R and 14L “Long winter exolevers”
are designed mainly for removing deep-seated
mandibular molar roots.
Winter exolevers: 11R and 11L “Short winter exolevers”
are designed to elevate roots nearer to rim of alveolus
(Fig. 2.6).
Straight shank no. 34 “Shoe horn exolevers”
designed to elevate roots as well as entire tooth.
Krough exolevers: 12B designed for third molar
impactions.
Root exolevers no. 1 and 3 “Hu-Friedy” are
designed to elevate fractured root apices.
Many other varities of exolevers are available as
per convenience and availability to individual surgeon.
Generally sharp, delicate instruments are considered
Armamentarium/Instruments 15
Fig. 2.1: Extraction forceps. English pattern. From left to right (i) Upper
incisor forcep (No.1 forcep) (ii) Special Root forcep (iii) Lower incisors
(iv) Lower root (v) Lower molar
Fig. 2.2: From left to right: (1) Upper third molar forcep (2) Lower cow-
horn forcep (3) Upper right cow-horn forcep (4) Upper left cow-horn
forcep (5) Lower third molar forcep right side (6) Lower third molar
forcep left side. Note in cow-horn upper forcep the bifid beak will
remain on palatal root to hold it firmly between two beaks, whereas
single sharp (cow-horn shaped) beak will hold firmly between two
buccal roots at bifurcation
Fig. 2.3: American pattern forceps. From left to right: (a) Lower molar
roots (b) Lower premolars (c) Lower incisors (d) Lower molar Rt and Lt
(e) Upper root forcep
Fig. 2.4: Lower third molar forcep Left; forcep for Left side molars, i.e.
36,37,38. Right; Forcep for Right side lower molars, i.e. 46,47,48. (Zoom
view) Note that the curve on forceps. The convexity will remain on
distal side for better hold, approach and visibility of third molar tooth
Fig. 2.5: Upper molar forceps. The triangular sharp beak remains on
buccal side to engage between mesial and distal roots, whereas
crescent shaped side fits on the single palatal root. In between two
forceps is the gum separator
Fig. 2.6: Elevators. From left to right; (1) Short “Winter” right and left
(2) Root elevators right and left (3) Straight elevator (Top upper and
lower)
better, but for a beginner tough instruments should
be of choice, because excessive or improper force
application to delicate instruments will damage them
in an inexperienced hand.
Generally these instruments are made in sets of
three, right, left and straight.
Pots; exolevers R and L are used for deciduous root
tips.
SURGICAL INSTRUMENTS
Bard-Parker knife handle no. 3 and 5 are generally
used with no. 10, 11, 12 and 15 blade.
Rongeur forcep: No. 4-universal is used for cutting/
chipping the bone.
Bone file no. 10. is used for smoothening the rough
edges of cut bone with rongeur or chisel.
Chisel: Gardner no. 52 and mallet/hammer standard
no. 1 is used for cutting or removing the alveolar bone
if chisel method is opted.
High speed motor, hand piece, and bone burs: if bur
technique is employed for removing/cutting the bone.
This hand piece should be coupled with spray/drop
dibbling system of distilled water/saline (Fig. 2.13).
Retractors “Austin”.
Curets: Molt no. 2 for universal use, including breaking/
separating periosteam before exodontia. Molt no. 5
and 6 same size angled to right and left. Molt no. 4 for
periosteal elevation and for removing large cysts.
Fig. 2.7: Chisels and the mallet
Fig. 2.8: Zoom view of the cutting edge

of the chisels. From left to right
Fig. 2.9: Front view of chisels shown in Fig. 2.8

Fig. 2.10: Top suture cutting scissors. Left lower, curved artery
forcep, mosquito, straight artery forcep, Ellis forcep
Fig. 2.11: (1) Top and extreme right; Needle holders (Two in number)
(2) Edentulous mouth gag (Left) (3) Rongeur
Fig. 2.12: From left to right; Rongeur, Gum separator, Periosteal

elevator, Bard-Parker knife, Bone cutting bur
Fig. 2.13: Zoom view of bone cutting bur.

Note minute serrations on cutting edges of the bur
Fig. 2.14: Top; Multi-doze 30 ml bottle of 2% lignocane hydrochloride

local anesthetic solution with 1:200000 adrenaline (Two different
commercial brands) Bottom; Disposable 2 cc plastic syringe
Fig. 2.15: Needles, needle holder and suture cutting scissors
Fig. 2.16: Old type dental chair, where the dentist used to stand by
the side of the chair/patient to do the dental surgery
Fig. 2.17: Modern (physiological) dental chair, where the dentist sits on
stool by the side of the patient to do the dental surgery (Unoccupied
chair)
Fig. 2.18: Modern (physiological) dental chair, where the dentist sits on
stool by the side of the patient to do the dental surgery (Occupied)
Needle holder: Mayo-Heger 15 cm (Hemostat is not
enough for holding needle for suturing).
Suturing needle: ½ round, cutting edge/smooth, round,
etc.
Suture material: Silk 000
Hemostats: Small curved (mosquitoes).
Allis forcep: Used for grasping soft tissues.
Single tooth forcep: Adson 11 cm. For delicate grasp of
tissue.
College Pliers
Russian forceps: V Mueller Co. 15 cm. For grasping tooth.
STERILIZATION AND CARE OF INSTRUMENTS

The best and sure way to of the sterilization for
instruments, gauze sponges, cotton, linen is by steam
autoclaving. Sharp instruments like knife, chisel,
scalpel; scissor, etc. can be sterilized by cold steriliza-
tion, by keeping them in cold sterilizing solutions but
for a long time.
The sharp instruments can also be sterilized in hot
oil sterilizer.
In general practice it is difficult to autoclave each
instrument every day and it is also difficult to maintain
sterilized condition of an instrument for a long-time.
The best way is to wrap the extraction forceps/
instruments in linen towels, autoclave able paper bags
marked with pencil/label as to make clear what that
pack contains, then it can be autoclaved and preserved
in sealed containers. These sterilized instruments
should be taken out of the sealed containers with
sterilized chital forcep, as and when required.
The instrument should be scrubbed with brush and
soap after each use to remove blood stains, debris,
etc. from them.
The hinges of the forceps should be freely moveable
at all the times. The patient looses confidence in
surgeons who opens the extraction forcep forcefully
just before use in front of the patient.
Rust should never enter the surgery/clinic.
The working point of all the instruments should
always be kept sharp and should be frequently send
for sharpening to the factory as and when they become
dull.
The chisel should be sharpened on a stone
(Arkansas) so that it can even cut a hair.
Scalpel blades and other disposable articles can be
changed frequently.
Methods of sterilization shall be discussed in detail
in forthcoming chapters.
THREE
STERILIZATION OF
INSTRUMENTS/
EQUIPMENTS
STERILIZATION OF INSTRUMENTS/ EQUIPMENT
The infection must be prevented, because once it occurs
it is very painful/agoning/costly to treat/uncomfort-
able and anxiety creator to the patient, who in turn
will loose all the confidence in the treating surgeon.
From medicolegal viewpoint also, this point may be
used under negligence act against the surgeon in the
court of law.
STERILIZATION
Sterilization means total destruction of bacteria, spores,
fungus, viruses, and all other pathogens either in
vegetative or spore form.
All other terms like sanitation, antisepsis,
disinfections are below par than sterilization.
Moist heat, i.e. steam sterilization is the best,
cheapest, surest way to perfect sterilization.
AUTOCLAVING
A steam autoclave is essentially a tank, which has an
airtight chamber. The instruments, equipment to be
autoclaved is placed into this chamber. Steam from
boiling water is filled into this chamber till required
pressure of steam is achieved The autoclave has a
pressure gauge connected to this chamber, which
confirms the pressure of steam attained in the chamber.
In the beginning the atmospheric air occupying the
chamber is removed with a vacuum pump or by
actively filling the chamber, with steam from the inlet
and letting the atmospheric air out through the exit
Sterilization of Instruments/Equipments 29
valve till the chamber is full of steam and no traces of
atmospheric air, which was initially occupying the
chamber is completely removed and is replaced
completely by moist steam. This point, however, is
very important, but usually neglected.
The production of steam by boiling water can be
done either by using electric or by gas stove, etc.
The temperature and timing for steam/ moist sterilization
are as follows:
Temperature Pressure Time
Autoclave 121°C or 15 lbs 15 minutes
250°F
Flash cycle. 134°C or 30 lbs 3 minutes
270°F
The timings and pressure maintenance will depend

upon following factors:
1. If the instruments to be autoclaved are wrapped in
towel/paper bag, etc. then the time of sterilization
will increase allowing enough time for the steam
to penetrate through the cotton towel coverings,
etc. to reach the instrument and sterilize it.
2. The timing should be counted from the point when
the steam in the chamber has attained the required
pressure as indicated by “pressure meter”. For
escape of excess steam than the required pressure
there is an outlet valve guarded by weight which
is lifted by inside excess steam pressure to let the
excess amount of steam escape and the required
pressure in the chamber is maintained constantly
(Like domestic pressure cooker).
3. Nowadays number of colour changing tapes/
papers are available to confirm the sterilization
process being done successfully, by change of their
colour. They are kept with the instruments in the
beginning and after the sterilization process is
completed the respective colour change of these
tapes/papers confirms completion of the sterili-
zation process.
4. The hand piece and other equipment used in motor
driven machines (with moveable parts) is difficult
to autoclave. But recent air turbine hand piece
without spray of liquid cooling and without escape
of forced air from front outlet into the patient’s
mouth are also available and can be easily auto-
claved. For example Hall’s surgical air turbine hand
piece with carbide bur assortments are designed
for use without need of liquid coolant sprays, etc.
Fig. 3.1: Vertical, autoclave

Fig. 3.2: Vertical, autoclave Fig. 3.3: Latest autoclave to be

(Sketch) kept on floor/ground
Fig. 3.4: Modern autoclave to be kept on tabletop

Fig. 3.5: Electric “boiling water” sterilizer
Boiling Water Sterilization

The boiling of the instruments/equipment in water at
100°C (212°F at sea level) for 30 minutes is insufficient
to irradiate bacteria in spore forms, though this
process destroys most of the vegetative forms.
Hence nowadays this method is not considered as
sufficient for perfect sterilization of instruments.
Dry Heat Sterilization

In modern dentistry for sterilization of dental hand
pieces/ oils/ powders/papers/cloth goods that cannot
stand boiling/autoclaving/or chemical sterilization,
dry heat in an oven at a pre-heated temperature of
170°C (340°F) for two hours is also used for perfect
sterilization.
The advantage of dry heat sterilization is that it
does not rust the instruments at all, and also does not
attack glass and plastic. The electric coil used for
heating lasts longer and is ultimately cheaper than
moist steam sterilization, except for the longer duration
of time required for the process.
Chemical Sterilization
70 to 90 per cent (by weight) solution of isopropyl
alcohol is widely used method for dipping the
instruments, but however, it is not effective against
body fluids, blood, pus, etc. and it does not give perfect
sterilization at all against spores, etc. Hence it is
inadequate method of sterilization.
Benzalkonium chloride: an aqueous quaternary
ammonium compound was also used, but proved
poorly active against many strains of bacteria, hence
nowadays it is rarely used except for general sanitation
and house keeping.
Glutaraldehyde: in 2 per cent aqueous solution has been
found useful to some extant in cold sterilization
process. They are marketed in alkaline or acid
solutions.
Hexachlorophenes: in concentration of 2 to 5 per cent is
also used as chlorinated bisphenol.
Hexachlorophene provides an effective bacterio-
static base both for gram positive and negative
organisms.
For effective cold sterilization a dip of 18 to 24 hours
is required in hexachlorophene solution.
Gas Sterilization
Ethylene oxide: is highly bactericidal when used with
controlled environmental conditions of temperature,
humidity and gas for a definite time of exposure.
Ethylene oxide is used at room temperature and
about 30 per cent humidity for a period of 12 hours.
The duration is directly related to the bulk of material
to be sterilized in permeable plastic bags, which are in
turn placed in metallic sterilization tank.
This method is used by manufacturers of disposable
plastic syringes and is quite handy in modern dentistry
to sterilize hand piece, etc. and other instruments
having moveable parts.
The gas, however, is extremely permeable; hence
proper aeration after sterilization is necessary.
Wrapped surgical packs should be aerated for 24 hours
whereas unwrapped solid instruments need no
aeration, as there is no penetration of the gas in it.
Caution; Ethylene oxide in concentration over 3 per
cent at room temperature could be explosive. Hence
the room where sterilization using this gas is being
done should be well aerated/ventilated.
Chemical Vapor Sterilization

The principle of this type of sterilization is similar to
that of ethylene oxide.
In a pre-heated chamber called chemiclave
vapors are created by heating deodorized-alcohol-
formaldehyde solution. These vapors are collected at
a temperature of 132°C (270°F) and are brought up to
a pressure of 20-40 psi. The efficiency of the process is
checked by spores test strips.
The advantages of this technique are:
1. Short cycle of sterilization of 30 minutes or so.
2. No rusting of equipment possible.
3. Readily available instruments after sterilization and
needs no aeration, etc.
Disadvantages are:
1. Chemiclaves/equipment is not easily available.
2. Costly process.
STERILIZATION ON BULK LEVEL

There is increasing demand of disposable equipment
(single time use), due to increase of population, the
mass sterilization is becoming popular which is time
saving, without any maintenance of equipment, man-
power, to run sterilization equipment, in individual
clinics.
In the past hermetic sealing of sterilized products
was also not available, hence the dependence was
mostly on steam, gas, or bactericidal solutions.
Nowadays use of beta and gamma rays on wide,
industrial stage, military, etc. has being acceptable in
food and drug technology.
The packing material having a perfect hermitic
sealing is also a contributory factor in bulk sterilization
process of modern times in contras to old times, when
such methods were not available.
Nowadays sterilization can even be done on
conveyer belt system in bulk, fast and efficient steriliza-
tion process on industrial level.
RADIATION SOURCES
Mainly two types of ionizing radiation sterilizations
are available.
1. From machines of low energy but high output
(electron accelerators).
2. Radioisotopes.
The machines convert the electron output in similar
way as X-rays are produced. Cobalt 60 and cesium
137 emit very high penetrating gamma rays.
These electron accelerator machines are very
advantageous and shall ultimately replace other
isotopes used for the purpose of sterilization.
At present time this type of sterilization by
radiation is quite costly and rare, but it may be the
future sterilization equipment for small clinics as well
as large hospitals/industries.
GENERAL OBSERVATIONS REGARDING

STERILIZATION
1. Oil and grease are major difficulties in the process
of sterilization. Hence they should first be
completely wiped off from the sterilized equip-
ment by proper scrubbing with soap and water.
2. The rusting will occur only if instruments are
sterilized by moist sterilization and are kept in
air in wet condition. If they are completely
immersed in boiling water, they will not rust,
because dissolved oxygen in water is expelled out
of water by boiling process and is not available
for rusting. For rust , moisture plus oxygen both
should be available for quite some time on the
instrument.
For this reason after boiling/sterilization by
moist heat, the instrument should be wiped dry
with sterilized towels, before storage.
3. If the instruments are boiled in tap water, which
contains lime, salts which are likely to be deposited
on mobile parts of instrument, but if the instru-
ments are sterilized by autoclaving in steam, they
will require much less maintenance and oiling.
4. The hypodermic needles should always be
properly autoclaved before use to eradicate slow
incubating infections like hepatitis, which give
symptoms of infective jaundice months after
injection with infected needle.
5. The instruments after sterilization should be
preserved in muslin or paper packs, where their
sterilization state is maintained for about 30 days.
6. Sterilized pickup forceps (chital forcep) should
always be kept in cold sterilized solution to be
used to pick up sterilized bags/instruments from
the storage tank. Hand should never be used for
this purpose. The name of the instrument should
be marked on its cover with pencil, to avoid
opening of many bags to locate the required
instrument.
7. The air circulation system of the clinic/operation
theater, etc. should always be checked from time
to time taking proper samples and checking
these samples for any growth of bacteria. Air
conditioners, coolers, exhaust fan’s holes, ceiling
fans and every nook and corner should be kept
clean and aseptic as per protocol.
8. The sterilization equipment, oxygen cylinders,
floorings tiles, suction pumps, electric switches,
etc. should be paid due consideration and should
always be free from colonies of bacteria/fungus,
etc.
9. The pressure gauge, outlet valve, steam-holding
weight, safety valve, etc. on the equipment should
be checked from time to time for correct readings
(standard rating).
10. The shoes, slippers, etc. of the patient should not
be brought into the surgery. It is a wise step to
ask the patient to clean his/her feet properly and
then wear sterilized theater slippers, before
entering the surgery.
11. The attendants of the patient should not be
allowed into the surgery. A close circuit TV
system should be available for them to watch
highlights of the operation being done in the
surgery.
12. A nurse or an attendant should be present in the
surgery for helping during operation and for
evidence that no molesting, etc. was done with
the female patients. The close circuit with video
recording will also help to keep a record as well
as save the operator against any allegation of
molesting with female patient. Though such
episodes are generally fabricated ones, but they
are certainly very dangerous for the reputation/
and sometimes from medicolegal aspect against
the dentist.
SUMMARY
Method Temperature Time Comments

Autoclaving 121°C at15 lbs/ 15 min Most efficient form
per sq. in. of sterilization
Or 134°C at 3 min
32 lbs/sq. in.
Hot air oven 160°C 60 min Effective but time
180°C 20 min consuming
and chars fabrics
Glutaraldehyde Room 60 min Doesn’t sterilize,
temperature but kills most
20°C 20 min bacteria, spores
and virus
Ethylene-oxide Room 12 hours Duration is
temperature directly related
30% humidity to bulk of
material to be
sterilized. Highly
penetrative,
so the material
sterilized should be
exposed to air for
24 hours after
sterilization,
Explosive in over
3% concentration
FOUR
OPERATION ROOM
DECORUM
OPERATION ROOM DECORUM
Lister long back proved the adverse effect of infection
in the wounds by presence of bacteria.
Prevention is better than cure, hence certain
measures should be taken in the surgery to avoid/
eliminate infection specially cross infections, i.e. from
one patient who may be immune to certain strains of
bacteria being carried on him/her, whereas these
strains may be very virulent for some other patients
who catches them by cross infection.
The nose, throat, hands, sweat and exposed body
areas of the operating team are the most common cause
of wound infection.
Utilized or unutilized instruments and armamen-
tarium, etc. may also be potential source for wound
infection.
The sterilization of equipment and armamentarium
etc. has already being discussed.
The following techniques as regard checking of
cross infection transmission from one patient to an
other or from the members of the operating team to
patient or vice versa are discussed below.
SCRUBBING
1. The street clothes should be replaced with the scrub
suit. This consists of clean linen pants or pajamas,
and short sleeves shirt/bush shirt. The colour of
the clothes may be dark green or blue or may be
kept white as per choice of the surgeon and
considering contras colour scheme with the
equipment in the office.
Operation Room Decorum 43
2. The hairs are considered very difficult to sterilize.
This is the main cause of shaving of the part of area
to be operated. The hairs that cannot be shaved
should be well covered with sterile surgical towels.
The beard, mustaches, long hairs of members of
the operating team are the potential source of cross
infection. Hence they should be properly trimmed
and covered under head cap and large size of facial
mask, which may be a little uncomfortable but is
essential/mandatory. Sneezing, coughing, pan,
tobacco chewing and dribbling from corners of the
mouth of any member of the operator team is
prohibited, because that is the sure way to transmit
cross infection from the operating member to the
other members as well as to the patient.
3. Scrubbing of the hands should be done in the same
manner as is done in general surgery cases.
The hands upto elbows, nails, finger beds, fore
arms especially the crevices, etc. should be scrubbed
thoroughly with brush and soap (hexachlorophene
detergent) for 10 minutes and then cleaned with
sterile water. Cleaning/scrubbing of finger nail beds
may be done with sterilized orange wood sticks,
available for this purpose. If ordinary soap is used
for scrubbing a longer time and post cleaning with
alcohol/or septisol is recommended. Hands and
forearms are then washed with no contact with the
tap handle, the tap should preferably be run by
foot control.
4. The hands after wash are kept in air crossed in
front of chest, so that they do not come in contact
with anything accidentally when the surgeon moves
from scrub room to theater. The hands should be
dried with sterile towel after reaching the theater/
clinic. Now the bare hands are considered surgi-
cally cleaned, but not sterile.
5 The surgeon is helped by a surgical assistant/nurse
to wear the sterile gown. The assistant ties the
gown on the surgeon’s back. The area of body of
the surgeon on the back and below the waist is
considered unsterile.
Great care must be taken that the gown should
be touched with scrubbed hands of the assistant
only from the ventral/inside surface of the gown
and never from the outer surface, which is
considered sterile, because ventral surface of it is
not considered sterile.
6. Similarly the surgical gloves should be touched with
scrubbed surgically clean hands only from inside/
ventral surface.
The exterior surface of a glove should never
come in contact with inside/ventral surface of
gloves as it is considered unsterile (Figs 4.1
and 4.2).
It is difficult to slip/wear gloves over dry hands,
hence only minimum amount of surgical powder/
cream should be used to dust hands before
wearing/or slipping glove over the dry hand.
7. Hepatitis, AIDS, etc. makes it more essential for
the operator to use surgical gloves to protect not
only the patient against cross infection, but to
protect himself from these hazardous infections.
Fig. 4.1: Method of wearing surgical gloves by hand to hand and glove
to glove method. In wearing the first glove the surgically scrubbed hand
are touching only the inferior surface of the glove
Fig. 4.2: Method of wearing surgical gloves by hand to hand and glove
to glove method. In wearing second glove, the gloved hand touches
only exterior surface of the glove, which is sterile and not the inferior
surface, which is not sterile
ISOLATION OF THE PATIENT FROM THE
OPERATING TEAM
1. The site of operation is prepared by prior shaving
of hairs. The operation field is scrubbed with
detergent soap and brush, rinsed with clean and
sterile water and finally painted with antiseptic
solution.
2. The area except necessary for surgical approach
should be covered with surgical sterile towels of
approximately 120 × 200 cm. A second sterile towel
of about 120 × 180 cm is placed over the previous
draping for major isolation.
3. The head of the patient is covered by double sheet
technique using a sterile drape as lower layer and
sterile towel over it.
4. Sterile draping is secured with towel clips. Some
oral surgeons in certain cases requiring frequent
turning of head from side to side prefer to suture
the towel to the skin around the operation area to
avoid slipping of the towel during operation.
5. Area above the operation table is considered as
sterile. Any part of body of the surgeon, assistant,
instrument, etc. If lowered than the level of the
operating table is considered as contaminated.
6. The gowns, draping, etc. shall be considered as
contaminated if it gets wet.
7. The anesthetic section should be separated from
the main operation area by sterile screens.
Well! It is certainly very difficult to maintain
strict aseptic decorum as described above in all the
clinics, dental surgeries. Some surgeons believe that
so much of strictness for a fool proof aseptic system
is mandatory only in major operations, on contrary
to this some others believe that reasonable aseptic
conditions can suffice. But the basic rule is that the
infection does not differentiate between major or
minor surgery.
FIVE
ANTIBIOTICS
The major goal of antibiotic therapy is to reduce the
number of bacteria and increase/enhance the defense
mechanism of the patient.
Antibiotics are derived from living organisms like
molds, etc and they can severely harm the pathogens.
BACTERIA
The normal oral flora consists of aerobic and anaerobic
strains of bacteria.
Aerobic strains
Gram-positive Cocci; streptococcus. Veillonella
Rods; Lactobacillus, corynebacterium.
Gram-negative Cocci; Neisseria.
Rods; Haemophilus, and coliforms
Anaerobic stains
Gram-positive Cocci; Pepto-streptococcus and
pepto-coccus, Veillonella.
Rods; Actinomyces, eubacterium,
leptotrichia, clostridium, etc.
Gram- negative Cocci; Veillonella
Bacteroides, fusobacterium.
Recent studies shows that gram-negative bacteria

play greater roll than gram-positive, stepto and
staphylococcus. Generally the infections are by mixed
strains, out of which are 25% gram-positive and 75%
are gram-negative.
In the beginning the infections are by gram-positive
bacteria but the bacteria soon consume all the available
oxygen in the tissue and then the gram-negatives
become predominant.
Antibiotics 51
To treat infections culture and antibiotic sensitivity
test should be done by aspirating a little quantity of
pus from the abscess by 18 gauge needle (large bore)
and two swabs are prepared from this sample and
send to laboratory first under aerobic and the second
under strict anaerobic conditions for culture aerobi-
cally and strictly anaerobically on enriched agar plate
and small paper discs impregnated with different
“likely to be effective antibiotics” are placed into the
dish (Kirby-Bauer method). The report of aerobic
culture after 24 hours and that of anaerobic after 48
hours is noted by growth of bacteria around the anti-
biotics to which the strains are not susceptible, and
around effective antibiotic there will be no growth of
bacteria. Once the bacteria are identified and effective
antibiotic against them is known, the specific treatment
is started.
Fig. 5.1: Kirby-Bauer method for testing

sensitivity of bacteria to antibiotics
Host defense mechanism: A-Intact skin. (It does not
permit penetration of bacteria into deeper tissues)
B-Normal bacterial flora of the host. (They do not let
the pathogens grow/develop easily unless they are
disturbed or hampered or unbalanced or potent
pathogens over comes their defense mechanism.
Humoral defenses: (Systemic defense mechanism)
These immunologlobulins are derived from plasma
cells or sensitized B-lymphocytes. They neutralize the
bacteria and virus and activate host defense
mechanism. The main role of humoral defense
mechanism is to attract phagocytes to bacteria and
assist in phagocytes of bacteria and their lysis by
enzymes.
1-IgG: Most abundant, active against gram-positive
bacterias.
2-IgA: Second commonest (secretory immunoglo-
bulins), they prevent bacteria for binding them to
epithelial surface.
3-IgM: Third commonest. They are active against
gram-negative bacteria.
4-IgD: No definite activity known.
5-IgE: Least common; responsible for allergic
reactions.
Cellular defense echanism: Blood cells;
1. Polymorphoneuclear cells.
2. Granulocytes.
3. Monocytes.
4. Tissue macrophages. They reach the site of infection
and ingest the bacteria present there and by their
enzymatic action kill bacteria by lysis.
Antibiotics 53
5. Lymphocytes; T-lymphocytes; they have lesser roll
against bacteria, but their primary roll is in delayed
hypersensitivity, like in graft rejection and protec-
tion against tumor cells proliferation (AIDS).
6. Phagocytes; they engulf bacteria and kill them by
digesting them with enzymes.
SOME FACTS ABOUT ANTIBIOTIC THERAPY

The choice of antibiotic depends mainly upon the
variety of organism, to which antibiotic salt these
bacteria are sensitive, and the host patient.
The following points should be considered.
1. History of allergy: The renal and hepatic status of
the patient should be detected. Immune status, age,
sex, severity of the disease, and tolerance of the
patient are the basic factors on which the choice of
antibiotic, will depend. Pregnancy, breast-feeding
or use of contraceptives will also influence the
choice of antibiotic selection.
2. Viral infections do not need any antibiotic therapy,
except to check the secondary infections.
3. Blood and urine tests should be done from time to
time to monitor the adverse side effects of anti-
biotics.
4. The dosages of the antibiotics shall depend upon
age, sex, weight, renal function, hepatic function
and severity of the invading infection.
5. The route of administration of drug will depend
on severity of disease, and nature of the selected
antibiotic salt, life threatening infections needs
intravenous route for quick availability of drug in
the blood.
6. The duration of antibiotic therapy depends upon
as to how long time the bacteria takes to be
controlled. Excess of antibiotic should be dis-
couraged because of its side effects.
7. Antibiotic should be chosen by its quality of how
many strains of bacteria are sensitive to it, before
the specific antibiotic is selected, using sensitivity
test (Kirby-Bauer). No blind method should be
used to administer antibiotic without prior
sensitivity test.
Penicillin
Its low toxicity is the special feature, whereas other
antibiotics are ototoxic/nephrotoxic/hepatotoxic, etc.
Varieties
Amoxicillin, ampicillin, benzathine penicillin, benzyl
penicillin, and procaine penicillin, etc.
Advantages
Bactericidal, most of the compounds are cheaper.
Disadvantages
Major disadvantage is the drug allergy (1 to 5% cases).
Oral penicillin have more allergic reactions, but not of
very severe type. Anaphylactic reactions are rare. It is
important to take history of the patient for drug
allergy, like syncope, occurrence after injection
Antibiotics 55
therapy, or nausea and vomiting occurring after oral
therapy.
Mode of Action
They act by inhibiting cell wall synthesis of the
susceptible bacteria.
Narrow Spectrum Antibiotic

Benzathine penicillin, benzyl penicillin, procaine
penicillin. Active against gram-positive cocci and
spirochaetes. (Cloxacillin and flucloxacillin) Amoxy-
cillin, ampicillin (broad spectrum) E. coli, and haemo-
philus influenzae.
Uses
Treatment of infections caused by susceptible
organism, septicemia, bronchitis, pneumonia, SAB
endocarditis, meningitis, joint and bone infections,
gonorrhea, syphilis, etc. Amoxicillin, Ampicillin,
Cloxacillin are acid resistant, hence can be used orally.
Precautions
Care should be taken in known allergic patients.
Asthma, hay fever, urticaria, etc. It should also be used
with caution in lymphatic leukemia. Prolonged therapy
may result in overgrowth of non-susceptible organisms.
Side Effects
Skin rashes, pruritus, urticaria, serum sickness, nausea,
diarrhea, thrombocytopenia, eosinophillia, elevation
in “SGOT” SGPT” (ALT) level, irritation at the site of
injection and vein irritation/phlebitis if given by intra-
venous route.
In high dosage parental therapy CNS toxicity may
result into convulsions.
Penicillin-V
Phenoxymethyl penicillin; is more acid stable so
relatively high plasma level is achieved by oral
administration. It is best absorbed on empty stomach,
i.e. ½ an hour to 2 hours before or 2 hours after the
meals. The potassium salt has higher absorption than
sodium salt.
Dose
250 mg to 500 mg 4 to 6 hourly.
Action
Oral penicillin-V is generally enough to treat most of
the odontogenic infections. It should be used with
caution in rapid, severely progressive infection as it
does not attain enough blood level.
The following penicillinase resistant penicillin can
be taken orally as they are effective against
streptococcus/staphylococcus.
1. Cloxacillin. 250 mg-500 mg, 6 hourly.
2. Di-cloxacillin. 125 mg-250 mg, 6-hourly
Ampicillin (Extended spectrum group)

It is semi-synthetic penicillin, stable in presence of
gastric acid, and is well absorbed by GI Tract. It is
Antibiotics 57
excreted largely unchanged in the urine, and is
inactivated by penicillinase producing organism.
Indications
Respiratory, genitourinary, gastrointestinal, soft
tissues, skin, and generalized systemic infections.
Dosages
Adult
250 to 500 mg 8 hourly or as required.
Children
125 to 250 mg 6 hourly according to age.
Infants
50 to 150 mg/kg body weight in 2 to 4 divided dozes.
Contraindications
Hypersensitivity to penicillin.
Precautions
Allergic and anaphylactic reactions. Periodic blood
counts, renal, hepatic function assessments should be
done. It is safe in pediatrics, pregnancy, lactation, and
elderly patients.
Side Effects
Skin rash, pruritus, urticaria, diarrhea, and GI upset.
Table 5.1: Antibiotics used in dentistry
Name Active against Dozes Contraindication Side effects
of drug bacteria
Penicillin-G. Streptococcus, Sod penicillin-G H/o of Renal
(Benzyl Penicillin) Staphylococcus,0.5-5 million units hypersensitivity, impairment,
Neisseria, 6-12 hourly reaction to lymphatic
Treponema because plasma penicillin leukemia, H/o
level reaches in allergy
15 minutes remains
for 30-40 min in

patients with intact
kidneys Pot
Penicillin-G. Oral
use; 2-8 lakhs units
2 hours before or
after meals.
Cephalexin, 250- Respiratory, Adults; 1-4 gm. Daily in Known hyper- Gastrointestinal
500 mg caps kid genitourinary 4 equal divided dozes. sensitivity to disturbances, super-
tabs 125 mg/5 ml tract, skin and Children; 25-50 mg/kg cephalosporins, infections. Drug
dry syrup. soft tissue, bone body wt in 4 divided renal dysfunction, rashes.
Contd…
Contd…
of drug bacteria
125 mg/5 ml and joint infec- dozes. allergy, lactation
tions, Gonorrhoea,
syphilis, otitis
media
Benzathene Syphilis, strepto- LA-6LA-12LA-24 (Keep an allergic Renal impairment,
Penicillin-G coccal infections, Deep intramuscular drugs handy for G-I-tract
600000, units pyoderma, injection. likely reaction, 1; disturbances.
prophylactic in 1000 aqueous
rheumatic fever solution of epine-
phrine-hcl, soluble
corticosteroids,
aminophylin and
antihistamines)
Penicillin-V Mild to moderate 250-500 mg orally Similar to Similar to
Oral-250-500 mg odontogenic 4-6 times a day penicillin penicillin
tabs (Phenoxy- infections, not
methyl penicillin) suitable for severe,
(More acid stable, rapidly progressive
Antibiotics 59
Contd…
Contd…
of drug bacteria
should be taken infections, as
on empty adequate blood
stomach, 2 hours levels are not
before/or after achieved
the meals)
Penicillin-V Mild to moderate 250-500 mg, orally Similar to Similar to
Oral-250-500 mg odontogenic 4-6 times a day penicillin. penicillin.

tabs (Phenoxy- infections, not
methyl penicillin) suitable for severe,
(More acid stable, rapidly progre-
should be taken ssive infections,
on empty as adequate blood
stomach, 2 hours levels are not
before/or after achieved.
the meals)
Doxycycline Exacerbations of 200 mg 1st day with Hypersensitivity. Hepatic or renal
100 mg tabs. chronic bronchitis, meals, then 100 mg children impairment, blood
brucellosis, daily. below 8 yrs of age, dyscrasias, (check
Contd…
Contd…
of drug bacteria
rickettsia, plural unless no alternate regular blood count
effusion due to drug. Pregnancy; during long-term
malignancy or contraindicated, therapy), likely to
cirrhosis of liver, may stain teeth cause tooth discolo-
dental, ENT, of foetus. Elderly; ration, or enamel
Ophthalmic, safe. hypoplasia
Venereal diseases.
Ampicillin-250 mg Respiratory, 1-2 capsules 6 Renal impairment,
+ Cloxacelline urinary, bone hourly. lymphatic leukemia
-250 mg. cap. and joints, skin, h/o allergic
soft tissue
infections.
Erythromycin Respiratory Adult—250-500 mg/ Impaired liver Nausea, vomiting,
250-500 mg tabs. infections, 3-4 times a day. function, H/o abdominal
(Bacteriostatic.) whooping cough, Children—30-50 mg/ jaundice, stops discomfort,
pneumonia, kg. in 2-4 divided the drug immedia- Urticaria, rash,
syphilis, non- doses. tely if symptoms reversible hearing
gonococcual Pediatrics—reduced
Antibiotics 61
Contd…
Contd…
of drug bacteria
urethritis, chronic doze. Pregnancy— of cholestatic loss in large dozes.
prostatitis, diph- safe lactation— contra- jaundice develop.
theria prophylaxis, indicated. Elderly— hypersensitivity
(As alternate to safe.
penicillin in sensi-
tive patients)
Tetracycline 250- Exacerbations of Adults—1-2 gm daily Pregnancy, Tooth discoloration,

500 mg; caps. chronic bronchitis, in 4 divided dozes. lactation, enamel hypoplasia,
1.0 gm. Inj. brucellosis, ricke- Children—25-50 mg/ severe renal or gastric disturbances,
kg daily in 4 equal
tisia, plural doses. Absorption is hepatic allergic reactions
effusion due to better on empty impairment. (discontinue
malignancy, or stomach. Tetra- the drug), and super
cirrhosis, acne cycline has chelating infections. Avoid in
vulgaris. Mixed properties to form children below 8
bacterial infection insoluble and years
of respiratory, unabsorbable
genitourinary, and compounds with
Contd…
Contd…
of drug bacteria
GI system. calcium, and other
metals. Milk, iron,
non-systemic antacids,
reduce their absorp-
tion
Metronidazole Prevention and Adults-400 mg thrice Blood dyscrasias, Pregnancy,
200 mg, 400 mg treatment of daily. active CNS disease, lactation,
tabs infections due to Children—7.5 mg/kg Don’t mix with GI distress,
anaerobic body wt 10% dextrose, furred tongue,
bacteria Thrice daily. penicillin-G pota- unpleasant taste,
ssium and ringer, angioedema, dark
lactate sol due to urine, neuropathy
chemical incompa- on long term use,
tibility. avoid anticoagu-
lants, alcohol,
phenobarbitone.
Trimethoprim- Urinary tract 2-tabs, twice daily Blood dyscrasias, Nausea, vomiting,
80 mg + sulpha- infections, acute renal or hepatic skin rashes, glossitis,
Antibiotics 63
Contd…
Contd…
of drug bacteria
methoxazole exacerbations of insufficiency, blood dyscrasias,
400 mg. Tabs. chronic bronchitis, pregnancy, do foliate deficiency,
acute otitis media, regular blood
treatment and checks in long
prophylaxis of term therapy.
P Carini
pneumonia and
toxoplasmosis
Nystatin 500000 Candida (manila) 1 tab 3-4 times Diarrhoea in high
units, tabs. albicans; especially daily.For oral doses
intestinal thrush; the tab
moniliasis. may be sucked,
or crushed and
mixed with glycerin
for topical use in the
mouth.
Antibiotics 65
Drug Interaction
Simultaneous use with oral contraceptives may lead
to bleeding or pregnancy.
ERYTHROMYCIN
This is the drug of choice as far as odontogenic
infections are concerned, especially in those cases,
which are sensitive to penicillin.
It is effective against gram-positive cocci,
Streptococcus and Staphylococcus. It is resistant to
penicillinase and thus impotent drug against infections
caused by Staphylococcus bacteria. It is moderately
effective against oral anaerobic bacteria, but it is
bacteriostatic drug.
It is well absorbed from gastrointestinal tract,
except slight local disturbances like nausea, vomiting,
and diarrhea. If given in very high (over 2.0 g/day)
for prolonged period, i.e. 15 to 20 days, the patient
may develop obstructive jaundice. Parenteral forms
though available, yet they are undesirable because of
pain, etc. associated with its administration.
Dozes: 250 mg to 500 mg/6 hourly.
If the drug is not effective, better change the drug
than to increase the dose.
CEPHALOSPORIN GROUP
Changes in expanding of antimicrobial spectrum, this
drug came out with many improvements step by step.
These steps of improvements are named as
“generations.”
Cephalosporins are considered as broad-spectrum
antibiotic, because they cover gram-positive, gram-
negative bacteria.
Their main roll is in the initial treatment (empirical
treatment), where the specific organisms are not yet
recognized.
CHLORAMPHENICOL
A broad spectrum, effective against gram-positive and
gram negative, and anaerobes, but aerobes develop
resistance against it soon, hence it remains potentially
effective against anaerobes.
Side effects: Include nausea, vomiting, optic and
peripheral neuritis, dry mouth, etc.
Its major toxicity is usually hematological, hence the
drug should be discontinued if the WBC reaches 3000
or platelets below 100000 (One lakh). Recovery to
normal blood counts usually occurs after a few days
of stopping of the drug.
Its major side effects also include irreversible bone
marrow depression resulting into non-doze related
aplastic anemia. If this condition do occurs, it
terminates into death of the patient.
Because of these toxities the use of this drug is
restricted to conditions where overwhelming infection
is present by bacteria sensitive to this drug and where
other effective drugs are contraindicated. Examples
are typhoid and paratyphoid fevers, H-influenzae
meningitis, and other salmonella infections.
Doze: 250 mg to 500 mg/ 6 hourly. (Preferred route
is intravenous route)
Antibiotics 67
NYSTATIN
In odontogenic fungus infection category, some times
antifungal drugs are needed for overgrowth of
“Candida” due to prolonged use of antibiotics, under
the dentures, etc. generally in old, debilitating patients.
The patient may be treated by topical application
of nystatin.
An aqueous solution of 100000 (One lakh)-units/
per ml is prepared.
Topically 5 ml solution is used for rinsing the mouth
for five minutes.
The patient should swallow rest of the solution.
The tablet may be chewed, sucked or crushed and
mixed with glycerin for local applications in oral thrush
cases.
This should be repeated 4 to 5 times a day. The
condition will recover without relapse within a week’s
time.
Use of Therapeutic Antibiotics

The roll of antibiotic is in most of the established
infections.
During infection the following sign/symptoms
establishes diagnosis:
1. Pain
2. Swelling
3. Erythema of overlying tissue
4. Elevated temperature
5. Feeling of malaise, etc.
The treatment is done in three steps;
A Surgical by incision and drainage for removal
of pus along with bacteria and relieving of tissue
tension.
B. Boosting of host defense mechanism; by
i. Proper hydration
ii. Nutrition
iii. Relief of pain so that patient can rest.
C. Anti-microbial therapy; for elimination of
bacteria and to resolve the infection.
It is conclusive from the above treatment plan that
the host defense mechanism is solely responsible for
irradiating the infection. Surgery and antibiotics are
just defense mechanism boosters, and the surgery, i.e.
incision and drainage is more important of the two.
Diagnosis;The diagnosis of pulpitis etc can be stablished
almost to certainty by history, sign/symptoms, etc.
Pain, swelling, malaise/rise of body temperature and
slight mobility of the effected tooth, may almost
confirm the diagnosis in favour of acute pulpitis.
1. Once diagnosis is made the second step would be
to diagnose the causative organisms. Although the
exact strains causing the infection may not be
diagnosed clearly, unless laboratory tests are done,
but for most of the patients under treatment in
OPD/ or clinic the laboratory tests are unnecessary.
Empiric antibiotic therapy combined with surgical
drainage is adequate. (If possible the culture test
should be done to diagnose the specific bacteria
causing the condition on very first visit)
Antibiotics 69
2. If the patient does not respond to empiric treatment
within 3 to 4 days, by that time the laboratory test
report will be available to start specific treatment
with appropriate antibiotics.
3. If the infection is recurrent, the culture test must
be made, because the bacteria may develop
resistance against antibiotic given previously.
4. If actinomycosis is suspected by history and clinical
findings, culture should be taken to confirm their
presence.
5. If the patient has oesteomyelitis, for future proper
long-term treatment of specific organism, culture
test should be done.
6. If the patient is compromised/or amino-compro-
mised, it is important to use antibiotic as specific as
possible, hence taking a culture is a must in such
cases.
7. Postoperative infections have large variety of
causative organisms as compared to common
odontogenic infections. Hence it is necessary to find
the specific antibiotic active against the large variety
of organisms in postoperative cases.
Choice of Antibiotic
After identifying the causative bacteria, either
empirically or definitely, and the antibiotic suscepti-
bility determined the selection of antibiotic from many
choices may be selected for a particular case. The
selection of antibiotic will depend on the following
factors:
Narrow Spectrum Antibiotics
1. For a particular infection the ideal antibiotic is the
one that acts most against that particular strain of
causative organism.
2. Generally there is tendency to feel that the broad-
spectrum antibiotics are better, because they cover
many strains of bacteria. But this is just the reverse.
The only indication of use of broad-spectrum
antibiotics is in severe life threatening infections,
where there is no time to test for the appropriate
antibiotic.
3. Broad-spectrums have shortcomings, which make
them undesirable. They are effective against gram-
negative bacteria, so most of the potency of the
drug is lost in combating that type of bacteria and
there is less potency effect left for gram-positive
side bacteria. This fact applies to most of the
extended spectrum drugs also like, ampicillin,
cephalosporins, trimethoprim-sulfamethoxazole etc.
That is why these drugs are not suitable for
odontogenic infections. Sulphamethoxazole are also
not successful in odontogenic infections, because it
is not effective against streptococcus and some
anaerobes.
4. Intention of the treatment is not to sterilize the host
body. If the narrow spectrum antibiotics are used
they will not destroy the other strains than the
pathogens, but on contrary the broad-spectrums,
which kills most of the non-pathogen strains, are
likely to destroy even the normal flora bacteria
favourable to the host.
Antibiotics 71
5. By broad-spectrum antibiotic coverage, the bacteria
that were not harmful to the host, will develop
resistance and these resistant strains may turn into
harmful strains to the same host. The example is
high incidence of gram-negative pneumonia and
septic shock caused by P aeruginosa, due to antibiotic
resistance chances.
6. The bacteria become resistant not only due to
mutation, but also by transfer of their genetic
particles called plasmids. These plasmids can
transfer resistance to antibiotics, when the bacteria
are exposed to antibiotics, they rapidly develop
resistant strains.
7. Dentist, treating odontogenic infections, should use
narrow spectrum antibiotics like;
a. Penicillin-V
b. Erythromycin
c. Clindamycin
d. Metronidazole
Rather than use of drugs like, amoxicillin, cephale-
xin, cefaclor, and trimethoprim sulphamethoxazole.
Use Least Adverse Reaction Causing Drugs

The goal of antibiotic is to get maximum killing of
bacteria with least harm to the host, and minimum
side effect and allergic reactions, etc. There are certain
side effects of the antibiotics; the surgeon should make
the patient aware of these side effects of the antibiotics,
like nausea, vomiting, abdominal cramps, etc. (Asso-
ciated with erythromycin).
Bactericidal and Bacteristatic Antibiotics
1. A bactericidal drug effect on bacterial cells, and
cause lysis and death of the bacteria.
2. Whereas bacteriostatic drug inhibits cell growth
and activity.
3. Bacteriostatic drugs are not effective during fast
multiplication (log-stage) of bacteria. If the growth
is slowed or ceased bactericidal drugs have limited
effect.
4. If the fast growth (division) of the bacteria has
ceased in that stage bacteriostatic drugs will be
more effective, because they will not let the residual
bacteria grow fast.
5. Combination of bactericidal and bacteristatic drugs
should not be used.
6. Less expensive drug should be used, if the merits
of the cheaper and expensive drugs are the same.
Methods of Administration
a. Manufacturers recommendations should be
followed in choosing the dosages regimen/ timings,
of the drugs.
b. The drug should be taken regularly for 4 to 5 days,
when the effect will be evident. The drug may have
to be continued for 6 to 7 days.
c. If the infection resolves slowly the drug should be
continued, In certain cases it may have to be
continued for about 6 months or so.
Antibiotics 73
Monitoring Patient’s Response
If the proper antibiotic with the required surgery is
completed, the results will appear within 24 hours.
If the patient does not respond to treatment,
additional surgery may be considered. The common
causes of failure of antibiotic therapy are given below:
1. Failure to do proper surgery (incision and drainage)
resulting into inadequate drainage of the abscess
because the intra-abscess septum are not properly
broken resulting into retention of pus into them/
pockets). In case of salivary gland abscess the ducts
must be properly opened and should not remain
obstructed.
2. The host defense mechanism might remain
depressed.
3. Presence of non-vital, infected tooth, sequestra “of
oesteomyelitis” (foreign body).
4. Failure of antibiotic to reach the site of infection
like in oesteomylitis. (Due to hampered blood
supply).
5. Inadequate dozes of antibiotic.
6. Wrong diagnosis regarding identification of
bacteria.
7. Wrong selection of antibiotic.
The patient should be checked for development of
any adverse reaction of the drug and should be
informed about reoccurrence/relapse of the condition,
If the relapse do occur, the treatment must be restarted
at the earliest date.
Indications and Contraindications of
Antibiotic Therapy
1 Normally antibiotics are not recommended till there
is established infection with systemic manifestations
like, pain, fever, malaise, and swelling, etc.
2. Acute dentoalveolar cellulites/abscess, acute
pericronitis with trismus, oesteomylitis and
compound fractures of the jaws generally require
antibiotic therapy.
3. If the infection is well localized, a surgical incision
and drainage should be enough and there is no
need to give antibiotics.
4. Hot saline gargles/local cleaning of debris below
the pericoronal flap, and removal of offending tooth
can treat pericoronitis without trismus and systemic
symptoms. There seems to be no roll of antibiotics
in such conditions.
5. Painful pulpitis without any swelling and systemic
symptoms does not need antibiotic, only local
treatment of removal of infected pulp by endo-
dontic treatment with topical use of antibacterial
agents, will suffice.
6. The patient with “Dry-socket” may not need any
systemic antibiotics for treatment, except local
irrigation of the socket and placing of sedative
dressings with the goal to give relief to the patient
till the socket heals.
Use of Prophylactic Antibiotic

For simple description prophylactic use of antibiotic
can be categorized into two sections;
Antibiotics 75
1. For prevention of wound infection to spread into
the facial planes/spaces.
2. To prevent metastatic or distant infection; defective
heart valves causing murmurs, causing subacute
bacterial endocarditis (SBE), and metastatic foci of
infection causing multiple abscesses in the lungs/
kidneys/brain, etc.
As such in normal cases with normal defense
mechanism of body needs no antibiotics for extrac-
tions, etc.
But if the host has a compromised defense
mechanism or the nature of the surgery is major then
the patient may require prophylactic doze of antibiotics.
Prevention of Wound Infection

In the past it was a very controversial question as to
whether antibiotics should be used during surgical
operation or not?
In 1961 Burke came out with some prophylactic
principles, which are applied essentially in modern
surgery or sub-specialities.
1. In patients with intact defense mechanism the
infection rate is 1 to 3%. If the antibiotics are added
as prophylaxes. This rate, however, remains the
same, i.e. 1 to 3%. Therefore, it is clear that in clean
surgery in an uncompromised patient, antibiotics
are useless, except in cases where:
a. Where there is increased/excessive contami-
nation of the wound. The mucosa of the mouth
cannot be scrubbed before incision/surgery,
hence chances of its getting contaminated is
higher.
b. The length of surgery; after three hours of
continued operation the chances of infection
rapidly increases, regardless of clean or slightly
contaminated surgery. Hence, operations lasting
over three hours need cover of antibiotic during
the surgery.
c. If a free bone graft (where nonvital bone acts as
implant) or an implant is given, there are chances
of infection as the host defense mechanism is
not able to kill the bacteria that exist near to the
implant. Larger the implant size, better are the
chances of infection.
Increased Rate of Infection due to

Compromised Host Defense Mechanism
Generally in compromised patients, rate of infection
is increased. Following three categories are to be
considered:
1. Poorly controlled metabolic disease; diabetes
(specially in ketosis stage) needs a cover of
antibiotic, but in well-controlled diabetic patient
antibiotics are not required. Highly uremic,
alcoholic or malnourished patient are more
suspected to get infection, hence needs prophylaxes
of antibiotics.
2. Patients who have diseases, which interfere with
resistance against infection like leukemia where
WBC (white blood cells) are abnormal. Other
conditions are lymphomas, multiple myeloma, and
variety of other cancers. All these patients need
cover of antibiotics.
Antibiotics 77
3. Patients who are taking drugs, which compromise
the defense mechanism such drugs include cancer
chemotherapeutic drugs like, Actinomycin-D,
DTIC, BCNU, 5-Fluorouracil, 6-Mercaptopurine,
Mitomycin-C, Procarbazine, Vincristine, etc.
These drugs depress the defense mechanism
by their therapeutic action. They are given for a
period of six months to twelve months. During this
period surgery should be avoided. Even after
twelve months of stopping of these drugs the host
depressed mechanism is not normal and hence need
prophylactic antibiotic coverage.
4. Another set of drugs that increases incidence of
infection is the immunosuppressive drugs. These
drugs are given to a patient, who has received organ
graft, so to reduce or irradiate chances of rejection
phenomenon. The following drugs are generally
used;
a. Azathioprine (Imuran)”commonest”
b. Glucocorticoids (Chemotheraptic and immuno-
suppressive action)
c. Cyclosporine-A, it is effective, but does not
affect the function of phagocytes, as compared
to the two drugs mentioned above. This,
however, reduces the incidence of infection in
the host.
d. When steroids are used, prophylaxes should be
given.
Infective Organism and Antibiotic Sensitivity

For preventing infection in particular area of body of
the host, appropriate antibiotic should be selected on
the basis of microorganism, which are likely to cause
the infection at that site. Like in surgery of abdominal
area most likely infection would be coliform bacteria,
either aerobic or anaerobic. Similarly, in oral surgery
gram-positive cocci or gram-negative anaerobes shall
be the most likely bacteria, which are all sensitive to
penicillin. Hence though oral infections are likely to
be caused by multiple strains, but they all are sensitive
to a single, non-toxic antibiotic.
Timing of the Antibiotic Administration

As per Burke’s principle, the initial doze of antibiotic
must be given long enough before infection to attain
blood or plasma and tissue levels.
If given by intravenous route, the surgery can be
started after 10 to 15 minutes. If given by oral route,
the oral surgery can be started 40 to 60 minutes after
the prophylactic doze of antibiotic is given.
The purpose of attaining adequate tissue level of
prophylactic antibiotic is to prevent the bacteria to
prepare a biochemical environment in the tissue of the
host to favour their growth.
It is important to know that the effect of antibiotic
on bacteria is more, before they can establish them-
selves on the tissues, rather than already established
infection.
As per Burke, the chance of incidence of infection
increases by delaying in providing antibiotic to the
tissues.
If the antibiotics are not given till the operation is
complete and sutures given, the incidence of infection
Antibiotics 79
remains the same, as if no antibiotic was given at all.
Similarly, the effect of antibiotic remains the same if it
is given 24 hours earlier or given one hour earlier,
than the operation.
The Dozes of Antibiotics during/after Surgery

For avoiding fall of plasma level of antibiotic, beyond
effective level against bacteria for penicillin-G or V,
the doze should be repeated after 1 to 2 hours, whereas
for cefazolin, after 4 hours.
Last Doze Immediately after Surgery

Burke’s final rule is that the antibiotic administration
following surgery is of no use. According to his
principle from start of surgery till elapse of 3 hours
after the first incision is given is the critical period.
SUMMARY
1. Prolonged antibiotic prophylaxes is of no use, on
the contrary it causes doze related toxicities and
complications.
2. For OPD/or clinic operations lasting less than 30
minutes only a single doze of prophylactic antibiotic
is sufficient.
3. For longer procedures one doze immediately and
final doze after 2 hours of start of surgery is
necessary/sufficient.
4. There is no use of antibiotics after the operation is
concluded and the sutures are placed.
Table 5.2: Prophylaxis of wound infection

Name of drug Preoperative During opera- Postoperative
doze tion doze doze
Penicillin; 1 million units 1 million units 1 million units
IV IV. IV
Cefazolin 1.0 g IV 1.0 g IV 1.0 g IV
Clindamycin 600 mg IV 600 mg IV 600 mg IV
(Penicillin
allergic cases)
Table 5.2A: Oral regimen

Name of drug Preoperative During opera- Postoperative
doze tion doze doze
Penicillin V 2.0 g 30 min 1.0 g just 1 g 2 hours
before before after start of
operation operation operation
Erythromycin 1 g 1 hour 500 mg Just 500 mg
before before 2 hours
operation operation after start
of operation
SUMMARY
1. Initial high dozes of prophylactic drug should be
given, because the incidence of infection is highest
in the beginning of the surgery.
2. Choose proper drug salt and use right timing of
administrating the drug.
3. The drug should be available in appropriate concen-
tration in the tissue and high plasma level should
be maintained during the surgery.
4. The final doze should be given at the end of the
procedure.
Antibiotics 81
5. As further dozes have no benefit, except to cause
toxicity and other complications and also increase
in the ultimate cost of the treatment, hence should
be avoided.
6. Most of the healthy persons, who undergo surgical
procedures like, extractions, periodontal surgeries,
endodontic surgery, removal of impacted teeth,
and other minor surgeries, need no antibiotics.
7. But when the patient is having compromised host
defense mechanism, during all above mentioned
conditions, antibiotic prophylaxes must be given.
8. Most of the major oral surgery operations, con-
suming sufficient length of time or are likely to have
sufficient contamination, needs prophylactic anti-
biotic cover.
Prevention of Metastatic Infection

During localized compromised defense in certain
organs, transient bacteremia following oral surgery
may cause metastatic infection spread to those organs
and result in serious problems, like subacute bacterial
endocarditis, etc.
There are two considerations in this:
1. Recognization of those conditions, in which
metastatic bacteria can cause infection.
2. Prevention and control of development of such
conditions.
Transient Bacteremia
Is the term used for the condition of presence of
bacteria in the circulating blood, caused by surgery.
These bacteria are removed from the circulation
soon by reticuloendothelial system. (RE cell system).
Septicemia
Septicemia is the term used for chronic condition of
presence of bacteria in the blood, occurring secondary
to an established chronic infection somewhere else in
the body.
Subacute Bacterial Endocarditis (SBE)

The following is the sequence of circumstances essential
for the development of this heart condition.
Three separate sets of sequences must occur to
result into SBE.
First Set of Sequences (In the heart)

1. Presence of the damaged heart valve, which does
not close properly (Mitral stenosis/aortic regurgi-
tation, etc.).
2. The jet of blood from high-pressure side to low
pressure side causes damage to the endothelium
of the heart and exposes underlying collagen fiber
layer.
3. The exposed collagen fiber layer attracts platelets,
which adheres and aggregate at the site of exposed
collagen fibres deposition of fibrin, resulting into
formation of a sterile platelet-fibrin thrombus.
4. This thrombus is harmless till it remains sterile.
Antibiotics 83
Second Set of Sequences
(In the blood)
a. Now there is occurrence of transient bacteremia
from any source. In case of oral flora, Streptococcus
viridans are the most notorious.
b. In the blood circulation, there is reorganization of
these bacteria by IgG antibodies in the process of
opsonization. (In opsonization process the IgG stick
to the surface of the bacteria, making them attracted
towards the phagocytes and help them to be
phagocytized more easily.) This bacteria-antibody
complex so formed, acts as a new antigen, which in
turn is recognized by other antibodies, which are
agglutinating. This single antibody engulfs many
of the bacteria+IgG, thus collecting many bacteria
together; this causes the individual bacterias to club
together to form minute colonies.
THIRD SET OF SEQUENCES

(IN THE HEART)
1. These tiny colonies of the bacteria get lodged on
the sterile platelet-fibrin thrombus and if the
bacteria survive, they start multiplication and
colonization.
2. Once this happens it results into formation of
infection focus. What a single bacteria was unable
to do (to infect platelet-fibrin thrombus) the minute
colony of bacteria could do.
3. This process takes about 7 days to 30 days time.
Table 5.3: Recommended SBE prophylaxis regimen:

Combined parental-oral therapy
Preoperative Postoperative
Parenteal route:
Single doze 30-60 min. Eight dosage in total, i.e.
before operation. (6-hourly for 2 days)
Adult:
a. Aqueous Penicillin-G 1 Penicillin-V 500 mg/6 hourly.
million units IM
b. Procaine penicillin-
G 60000 units IM
Children:
a. Aqueous penicillin- Penicillin-V
G 30000 units/kg Less than 60 lbs: 250 mg. 6hourly
IM Over 60lbs: 500 mg.
b. Procaine penicillin-
G 60000 units IM
Oral route: Single doze
30-60 min. before operation
Adults:
Penicillin-V 2.0 g Penicillin-V 500 mg/ 6 hourly
Children:
Penicillin-V Less than Penicillin-V
60 lbs 1.0 g Less than 60 lbs. 250 mg 6hourly
More than 60 lbs 2.0 g More than 60 lbs. 500 mg.
For patients allergic to
penicillin
For adults:
Preoperatively 1-2 hours Erythromycin. 500 mg/6 hourly
before operation.
Erythromycin. 1.0 g
For children:
Erythromycin. 20 mg/kg Erythromycin. 10 mg/kg body
body weight. wt/6 hourly
Antibiotics 85
4. This process could be stopped/checked if the
bacteriocidal antibiotic was available in the blood
when the bacteria arrived. (Start of bacteremia)
Note:
1. It is recommended that in all the cases, having
history of heart disease/or suspected cardiac cases
like arrhythmias, coronary bypass, valvular graft,
etc. the patient should seek the expert (cardiologist)
opinion before start of any surgery/oral surgery.
2. In case of patients where artificial joint prosthesis
are fixed/or chronic infection focus is present, in
such cases the SBE regimen may be followed,
because systemic condition causing the infection are
almost similar in both the cases.
SUMMARY
1. All the cardiac diseases and joint diseases, etc.
should be treated early and aggressively for all
types of odontogenic infections.
2. All the precautions of preoperative antibiotic
prophylaxis should be strictly followed during any/
even the minor/oral surgeries performed.
3. Though controversial, yet SBE prophylaxis should
be strictly followed, as recommended by American
heart association and American dental association.
Viral Conditions (Hepatitis-B)

Dentists especially the oral surgeons are “most likely”
to get this infection.
The following precautionary measures may be taken
for prevention.
1. In suspected patients of Hepatitis-B, especially
HBsAg test should be done. If the test is negative
no particular precaution is needed, but in positive
cases, the operator should wear gloves, while
treating the cases. The instruments should be
properly sterilized after the use in that particular
case. If disposables are used, they must be properly
destroyed by incineration.
SIX
ANALGESICS
(PAIN KILLERS)
Pain is the only single feature, which a dentist or an
oral surgeon has to encounter in almost every patient.
The odontogenic ailments are normally associated with,
pain, inflammation, swelling, and rise of body
temperature. Hence brief descriptions of drugs used
against pain are mentioned here for ready reference
of the reader.
ANALGESICS AND ANTIPYRETICS
Salicylates
Include; Aspirin, salicylamide, sodium salicylate.
Action
Salicylates exert, analgesic, antipyretic, and anti-
inflammatory effect. Their antipyretic, anti-inflam-
matory effect is due to inhibition of prostaglandin
synthesis. Their analgesic effect, however, is due to
their peripheral anti-inflammatory (removal of cause
of pain) as well as their effect on central (hypothalamus)
level. Aspirin also inhibit platelet aggregation.
Uses
1. It is used as anti-inflammatory, in rheumatoid
arthritis, rheumatic fever, osteoarthritis, and other
rheumatic conditions.
2. It is also used in acute conditions like, headache,
toothache arthralgia, myalgia, and other non-
specific conditions requiring mild analgesia.
3. It is also used as antipyretic.
Analgesics (Pain killers) 89
4. (In low dozes, 80 to 100 mg/per day), it is also
used as inhibitor in vascular diseases, like transient
ischemia attacks, prevention of infract, etc. in
patients of hypertension (high-blood pressure)
Contraindications
Peptic, gastric, or duodenal ulcers cases, pregnancy,
lactation, renal or hepatic disorders, bleeding dis-
orders.
Special care should be taken in cases of bronchial
asthma, low prothrombin level. If salicylates are
combined with NSAIDs or alcohol the damage to the
gastric mucosa will be enhanced.
Side Effects
Nausea, vomiting, bleeding, tinnitus, urticaria. Over
dosages may cause, headache, hypoventilation,
dizziness, lassitude, sweating, thirst, dehydration, etc.
Aminophenol Derivatives
Paracetamol.
Actions
Analgesic, antipyretic, effect, but it does not exert anti-
inflammatory effect.
Uses
Relief of mild pain and antipyretic action.
Side Effects
Usually well tolerated in therapeutic dozes. Habitual
use may be associated with analgesic neuropathy. In
acute over dozes, fatal liver failure with major
manifestations like, jaundice, hypoglycemia, and
acidosis may result.
Trigeminal Neuralgia; Carbamazepine
It reduces the frequency and intensity of Trigeminal
neuralgic pain during acute stage. It has no effect on
other type of headache.
Dozes
Dozes should start from 100 mg, once or twice a day,
and dozes may be increased till best results are
obtained. Normally 200 mg/3 to 4 times a day, but
some cases may require even higher dozes of 1.6 g per
day in divided dozes. Sometimes, extreme dizziness
occurs; hence it is always safe and best to start with
small dozes and then increase the dozes gradually.
Some patients respond to “Phenytoin” given alone
or in combination with carbamazepine. Combination
dozes are given to those patients who do not tolerate
high dozes of carbamazepine alone.
NSAIDs (Nonsteroid anti-inflammatory drugs)
Effect
They exert their effect due to inhibition of synthesis
of prostaglandins. Prostaglandin causes oedema,
Table 6.1: Commonly used analgesics in dentistry
Name of drug Action/Effect Doze Contraindications Side effect
Acetylsalicylic acid Mild to moderate 1-2 tabs/ 4 Peptic ulcer, Allergic or
200 mg + Caffeine pain, fever, times a day hemophilia, bleeding asthmatic
30 mg + Codeine migraine, disorders, lactation reactions,
phosphate 60 mg. musculoskeletal GI intolerance
Tabs pain, and inflam-
mation
Paracetamol Symptomatic Adults 0.5-1g to Renal or hepatic Nausea, rash,

500 mg. Tabs. relief of pain 4 g daily in impairment hematological
Syrup: and fever. divided dozes. changes,
Paracetamol. Children: dyspepsia rarely
125 mg/per 5 ml. 3 months-1
Drops: Paracetamol. year: 6-8 drops
150 mg/ml 1-3 years:
10-15 drops.
1-3 years: 2.5 ml.
3-7 years, 5-10 ml.
7-12 years, 10 ml.
Contd…
Contd…
Ketorolac trome- Short-term Orally- 10-30 mg/ Peptic ulcer, allergy, Ulcers, GI
thamine; . management 6 hourly or as coagulation disorder, disturbances,
10 mg, tab of moderate to required. Inj. 30- pregnancy, lactation. hemorrhage,
severe pain. 60 mg by IM inj drowsiness,
sweating, acute
renal failure,
oedema.
Carbamazepine Trigeminal Initially 100- Glaucoma, pros- Gastric upset,
100, 200, neuralgia 200 mg, once or tatism, severe cerbro- diplopia
400 mg Tabs. twice a day, vascular impair-
increasing slowly ment, psychosis,
to otimum 600- 1st trimester
800 mg/day in of pregnancy,
divided dozes, elderly, check
max doze blood count
1.6 g/day. regularly.
cellular exudates, and pain. NSAIDs inhibit the cyclo-
oxygenase enzyme, which is responsible for converting
arachidonic acid into prostaglandins. The modern
prostaglandins can be categorized as follows on the
safety bases of their side effect of toxicity to the GI
tract.
Lowest Risk
Ibuprofen.
Intermediate Risk
Piroxicam, ketoprofen, indomethacin, naproxen,
diclofenac.
Highest Risk
Azapropazone.
It is advocated that low risk NSAIDs should be
used as far as possible.
Warning
The drugs mentioned in this chapter should be
prescribed to the patients after consulting the
manufacturers instructions. And clear written
instructions should be given to the patient regarding
dozes of the medicine.
Some commonly used NSAIDs are listed below:
Table 6.2
Ibuprofen. 200 mg Pain and inflamma- 400-600 mg/ Active peptic ulceration Dyspepsia,
400 mg, 600 mg tion in rheumatic thrice daily or Asthma, bleeding GI tract
Tabs diseases and other as required disorders, cardio- bleeding, rash,
musculoskeletal vascular diseases, etc.
disorders. Mild to those cases receiving
moderate pain anticoagulants.
including
dysmenorrhoea,
and dental pains.
Nimesulide Osteoarthritis, pain 100 mg twice Active peptic ulcer, Headache, nausea,
100 mg tabs of malignancy, daily. hepatic impairment, vomiting,
postoperative pregnancy, lactation, heartburn,
trauma, sports Care should be diarrhea, rash,
injury, ENT, taken in elderly pruritis, dizziness,
dental, and patients.
gynecological
disorders.
Contd…
Contd…

Serratiopeptidase Pain and inflamma- 1-2 tabs thrice Patients with blood
5 mg tabs tion after opera daily. coagulation
tions and traumatic abnormalities, severe
injuries, engorge hepatic and renal
ment of the breast. disturbances.Note- it
pericronitis, alve should not be used
olar abscess. with anticoagulants.

Ibuprofen 400 mg Neo-articular 1 tab. Thrice Active peptic ulcer, Dyspepsia, GI
+ Paracetamol rheumatic daily or as asthma, renal or bleeding, rash,
325 mg Tab. conditions, desired. heptic disorder, etc.
(Most commonly rheumatoid or cardiovascular
used combination oesteo-arthritis, disorders, and those
spondylosis, receiving antico-
infective agulants, bleeding
inflammation, and disorders, pregnancy.
dental conditions,
pain, fever
Contd…
Contd…
Carisoprodol Relief of pain, 1 tab thrice daily Active peptic ulcer, Dyspepsia,GI
175 mg + inflammation and after meals. Not pregnancy, lactation, bleeding,
Ibuprofen muscle spasm recommended bleeding disorders, drowsiness,
400 mg Tabs associated with for children. asthma, NSAID’s dizziness, nausea,
sprains, strains, allergy, avoid long flushes, lassitude,
backache, rheuma- term use, withdraw constipation,
toid/osteoarthritis, gradually. rarely thrombocy-
dental pain, and topenia.
postoperative
pains.
Morphine sulphate; Prolonged relief Adults:If pain is Respiratory Constipation,
10, 30, 60, 100 mg, of severe pain. intolerable by depression, coma, nausea, vomiting,
Tab weaker opioids, airway distress, sedation,
initially 30 mg acute hepatic tolerance and
may control the disease, dependence
pain for 12 hours. alcoholism, head may develop.
Minimize dozes to injuries, shock.
Contd…
Contd…
control pain for

12 hours.
Children; initially
0.2 to 0.8 mg/kg.
for 12 hours.
Note: Not recommended
for postoperative

pain in children
SEVEN
GENERAL OUTLINES
FOR EXODONTIA
After recording the history, radiographs and clinical
examination, etc. are completed and the exodontic
procedure explained to the patient, the premedication
and anesthesia to the patient is started as planed. Pre-
medication may be started at night before extraction
in extremely apprehensive or difficult procedure
surgery cases, or it may be given in the waiting room
after the patient arrives for surgery.
ANESTHESIA
The patient should be seated comfortably in the chair.
All instruments are placed on the Mayo-stand and
covered by sterile napkin. The patient is covered with
a paper/cloth napkin and local anesthesia either by
infiltration or by regional/block is administered.
The patient is engaged in talks, while the operating
lights are switched off. After about 3 to 10 minutes
when the effect of anesthesia is confirmed, the position
of the patient is adjusted for surgery.
POSITION OF THE PATIENT IN THE CHAIR

The chair should be as low as possible for extraction
of mandibular teeth.
For extraction of the upper teeth the position of
the chair should be so as to bring the maxilla of the
patient at the level of operator’s shoulder.
These positions allow the hands of the operator to
work in non-fatigue/non-exertion and comfortable
position.
The chair can be slightly tipped back for maxillary
teeth extractions.
General Outlines for Exodontia 101
The recent contour chair has the patient in semi-
recumbent position, which is ideal for oral surgery.
The most latest chair (In experimental stage) has an
edge that it can be tilted on sides (right and left) so
that the operator does not have to bend and can stand
erect comfortably without any exertion whatsoever.
The position of the patient my be changed/shifted to
right or left as much as required by the operator instead
of bending himself to adjust for that required position
as in present available chairs.
PREPARATION AND DRAPING

The light on the unit is turned on. The assistant scrubs
and wears gloves as per protocol. The paper napkin
(now a days plastic napkins are also available) is now
placed over the neck and chest of the patient. A sterile
surgical towel is then placed over this napkin, so that
sterile gauze, cotton, instruments or sponges may be
placed over this sterile towel.
If the patient exhibits fear and wishes so, a sterile
napkin may be placed over his/her eyes and tied with
surgical pins on the back side/behind.
The operator and assistant put sterile towel to cover
their uniforms, fastening them with sterile towel
clamps.
The exposed portion of the patient’s face is wiped
with sponge soaked in alcohol.
A sponge is kept in mouth to isolate the tooth to be
operated. This will help to keep the area free of saliva
and blood, etc. and will also avoid any bone chip/
tooth chip, etc dislodged during operation, to slip
towards posterior pharynx.
If continuous suction is used the sponge may be
avoided.
POSITION OF THE HANDS OF THE OPERATOR

The fingers of the left hand serves the purpose of
retraction of soft tissues and tactile sensations feeling
of the movements of the roots of the tooth as well as
movements of the alveolar bone giving way around
the tooth during the application of movements on
extraction forces during the process of extraction.
Generally one finger is kept on the outer (alveolar/
labial) plate and the other on the lingual side retracting
tongue or the lip. Third finger or the thumb helps to
guide the beaks of the forcep and avoiding forceps’s
accidental injury to the opposite teeth if the tooth
under extraction suddenly becomes loose and comes
out, while the force of the operator is still maintained.
In mandibular extractions left hand also provide
equal and opposite torque forces exerted by the forceps
to avoid any sudden jerk on temporomandibular joint.
This position of the fingers and the left hand varies
from area to area and tooth to tooth, but basically
remains almost similar (See Figures 9.48 to 9.54).
EXTRACTION BY FORCEP
The effect of anesthesia in the area of the numbness
felt by the patient on ipsilateral side is checked with a
sharp molt curette, which also serves the purpose of
separating the gums from the tooth especially the
epithelial attachment which must be thoroughly
separated, because sometimes if it is left in contact
with collar around the tooth, it may tear the gums
when the extracted tooth is pulled out of the socket.
No rough forces should be employed so as to alarm
the already excited patient.
Now the forcep should be brought from behind
the patient, hiding it from patient’s view as far as
possible. Mentally the operator should once again
confirm the correct identification of the tooth, which
is to be extracted. Then the beaks of the forcep are
guided by left hand’s fingers of the operator either
placing the buccal or lingual beak first. The long axis
of the forcep should be brought at right angles to the
tooth if we are using “Ash’ pattern forcep (English
pattern) or parallel to the tooth if American pattern
forcep is chosen.
If the beaks are improperly fixed into the exact slots
on the tooth and if the forcep is holding the tooth
loosely, or if the direction of the forcep is improper or
wrong anatomical forcep is selected by the operator it
is most likely to result into fracture of the tooth during
extraction.
Enough but not excessive force is applied on handles
of the forcep, so that it does not slip from the tooth
under extraction movements.
Every tooth, however, requires different forcep,
the forces applied for extraction, position of the
operator and position of the hand holding the forcep.
All these point are disused in detail in the Chapter 9.
AFTER EXTRACTION OF THE TOOTH
The socket should be examined for any granulation
tissue, alveolar bone spicules, calculus, and broken chip
of the tooth or any other foreign body, like old silver
filling, which was present in the tooth just extracted
and the filling was dislodged and was left in the open
socket. The remaining granulation tissue should be
curetted lightly from the socket, if present in
mandibular socket, but maxillary sockets in the danger
zone should never be curetted because the infected
material and thrombi may ascend into cranial cavity
and cause cavernous sinus thrombosis. The socket is
compressed with finger and thumb to re-establish its
normal width, which was expanded due to delivery
of the tooth.
A small gauze piece (7.5 × 7.5 cm.) should be folded
into four folds, moistened in the middle with sterile
cold water to avoid adhering of the gauze with
hematoma and is now placed over the socket and the
patient is asked to bite on it tightly for about five
minutes.
A cotton plug, which is generally used by many
dentists, may not put enough pressure on the bleeding
socket and secondly it may leave some cotton fibrils,
which may get entrapped, into the forming hematoma
resulting into a nidus for the bacterial growth later.
Some dentists prefer to put cotton roll enrolled in
a small gauze piece, which shall give a little improved
pressure than plain cotton roll, but will give a little
short results than the ideal.
How Many Teeth can be Extracted in a Single Sitting?
Well the answer to this question depends upon the
following conditions:
1. Age and physical fitness of the patient.
2. Condition of teeth, alveolar bone and other
surrounding structures of the teeth in that particular
patient.
3. Psychological behavior of the patient.
4. Experience of the dentist/operator.
5. The time and extent of operation required, i.e. are
the extractions only plain extractions or extractions
are combined with some other operations like
alveoloplasty, where blood loss may be up to 450-
500 ml of blood.
6. Healing response and tolerance of the patient for
postoperative effects of the extractions.
Generally when total extraction is planed in a
patient, the teeth from one quadrant are removed first,
provided all other factors are favourable.
The author used to extract one or two teeth on the
initial visit of the patient. If all postoperative effects
goes well and the patient is perceptive for multiple
extractions then it can be done.
After a week’s time when the sutures (if given) are
removed, and the patient feel bright, the teeth from
another quadrant are removed. Like wise in a months
period total extractions can be completed.
This combination of serial extractions and timings
can be altered as per decision of the dentist or opinion
of the patient.
Quadrant-wise, What should be the Order of
Extraction?
1. Because infiltration anesthesia is more effective and
thus extractions in that area will be comparatively
less painful, maxillary teeth are extracted first.
2. Because the hematoma, saliva etc. collects in the
posterior region of the mouth, the last tooth present
in that maxillary quadrant should be extracted first.
3. If we extract mandibular teeth first, the debris,
pieces of dislodged calculus, old silver fillings, bone
chips, etc. may get dislodged during extraction
of upper (maxillary) teeth and get entrapped/
lodged/lost in fresh/healing sockets of the mandi-
bular teeth and causes relative complications later.
4. If the teeth in the quadrant are relatively firm the
first molar and canine which are the pillars due to
presence of Atkinson’s key ridge and canine
eminence, a trajectory of force on respective tooth,
making the alveolar bone very thick and firm,
should be extracted last, so that enough space is
available in near by vicinity for making extraction
of these teeth bit easier.
5. If a root, however, breaks during serial extractions
from posterior to anterior region, i.e. third molar,
second molar, second premolar, first premolar,
second incisor, central incisor, first molar and
canine, the root should be extracted first and
further extractions should be stopped till the root
piece is taken out from the respective socket, for
the following reasons:
a. Better location, because of presence of landmark
of the mesial tooth still present in relation to
the broken root/roots. Hence location of the
root by relative anatomy is easier at this
juncture. If tooth mesial to, where the root has
broken is extracted first, it will be difficult to
locate the exact position of the socket where the
root piece was broken/left.
b. In locating, and removing the root may take
some time. If the tooth mesial to the one where
root was broken is extracted first then it will
unnecessary bleed for a longer duration and the
bleeding also cause obstruction regarding the
sight/view of the operator.
EIGHT
ANESTHESIA USED
FOR EXODONTIA
The following methods/types of anesthesia can be used
for extraction/exodontia purpose.
1. Infiltration/Local anesthesia (Lignocane hydro-
chloride injection, 2% solution with Adenaline1:
80000) (commonest)
2. Regional/Block or Local anesthesia. (commonest)
3. Local anesthetic solution, with sedation or supple-
mented with light general anesthetic agent.
4. General anesthesia, including either by intra-
venous route or by inhalation.
FACTORS ON WHICH CHOICE OF ANESTHESIA

DEPENDS
1. Age and physical status of the patient.
2. Infection.
3. Trismus.
4. Nature and expected time consumption of the
operation.
5. Depth of anesthesia required.
6. Amount of muscle relaxation required.
7. Emotional status of the patient.
8. Allergies.
9. Choice of the patient.
10. Availability of type of anesthesia and training of
the operator.
AGE AND PHYSICAL STATUS OF THE PATIENT

1. Very young patients, below the age of reasoning
are best managed under general anesthesia,
usually inhalation type or in combination with
Anesthesia used for Exodontia 111
small dosages of intravenous anesthetic agent like
barbiturates.
The geriatric patients metabolizes barbitu-
rates poorly, hence should be given in lesser dozes.
They are best managed with local anesthesia mixed
with judicial use of sedatives.
The older patients generally have systemic
diseases that complicates general anesthesia
administration, hence they are best managed
under local anesthesia.
2. When localized infection is present the local
anesthetic effect is not profound. If local anesthesia
is to be used in such case then best is to give a
nerve block in the area, which is away from the
infection site.
3. In no case local anesthesia should be injected/or
the needle should pass through the area of
cellulites. This act may result into spread of
infection through facial spaces/planes and cause
serious complications.
4. If the patient is toxic, dehydrated due to presence
of infection, these toxic conditions of, dehydration
and infection is controlled first and only then the
required surgery should be done under general
anesthesia.
5. Before removal of tooth in acute infective state,
adequate blood level of antibiotic should be
obtained to avoid postoperative infection compli-
cations.
6. In case of trismus where there is difficulty in
opening of the mouth of the patient, and the usual
route of injection is not available/possible, an
extra-oral block may be considered to reach the
mandibular foramen. When the effect of
local anesthesia has relieved the pain, the patient
can open the mouth to admit necessary surgery.
7. In cases of maxiofacial/fracture surgery, deep
anesthesia with muscular relaxation is required,
hence general anesthesia is preferred.
8. Some times ethyl chloride sprays over the muscle
in spasm may help to enable the patient to open
his/her mouth and allow the usual route to
administer the local anesthesia. Care should be
taken not to freeze the tissues with ethyl chloride
spray.
9. In case of marked trismus due to infection/
trauma, general anesthesia with deep muscle
relaxation may be very helpful in performing
smooth surgery on complete open mouth of the
patient.
10. In trauma case of life threatening emergency or
immediate need of surgery, some times tracheo-
tomy may be necessary, to induce general anes-
thesia to the patient and to maintain the airway
clear.
NATURE AND DURATION OF OPERATION

1. Generally those cases, which require surgical
operations of more than half an hour are best,
managed in local anesthesia with premedication.
2. For operations under general anesthesia, the patient
should be admitted to a hospital, where adequate
Fig. 8.1: Technique of injecting into mandibular foramen to block inferior

alveolar nerve. The index finger of the operator is placed to fit into the
mandibular notch, just at the base of ascending ramus, over the occlusal
level line of mandibular molar teeth. An imaginary line is drawn posteriorly
towards the throat, in line of the centre of the finger as shown in the
figure with black line. Now where this line intersects the “mandibular
fold” (shown in red line) that point determines the point of entry of the
needle. Now the syringe containing local anesthetic solution is brought
from second premolar of the opposite side of the mandible and the
needle enters the tissues at this point. The needle is advanced in the
tissues till it comes in contact with bone. The back suction is done in the
syringe to check, if the needle is not in a vessel. The local anesthetic
solution is injected slowly (about 1-2 cc), always keeping in mind
that the needle should be in contact with the bone. Then the
syringe is withdrawn a little, so that if the tip of the needle is engaged in
the bone it may not break, then it is brought parallel to the finger line
and advanced a little , then it is withdrawn while injecting the solution
to anesthetize long buccal and the lingual nerve while coming out. (See
Figs 8.5 and 8.6)
Fig. 8.2: Technique of injecting into mandibular foramen to block

inferior alveolar nerve. Zoom view of Fig. 8.1

inferior alveolar nerve. View from slightly posterior angle

alveolar nerve. Zoom view of 8.3 for better appreciation of the landmarks

alveolar nerve. Real actual view of the technique of finding out puncture
point for inferior alveolr nerve. Green line is the imaginar line drawn
from centre of the finger and the mandibualr fold is shown between
arrows. Centre of the white cross is the point of the entry of the needle

inferior alveolar nerve

alveolar nerve. Note another patient, receiving block anesthesia

alveolar nerve. Note the syringe is brought parallel to the finger of the
operator to block buccal and lingual nerves simultaneously
Fig. 8.9: Technique of injecting infiltration anesthesia. The needle is

inserted in the gums at approximately halfway between anatomical
neck of the tooth and expected root of the tooth, and after reaching
under the periosteam when the needle comes in contact with bone
1-2 cc soloution of anesthetic agent is deposited. The effect of
anesthesia is noted within 2-3 minutes and can be confirmed by pinching
with some sharp instrument like sterile probe, etc
Fig. 8.10: Mental nerve block at mental foramen
Fig. 8.11: Mental nerve canal block, from posterior inclined angle,
so that the needle goes deep into the canal
Fig. 8.12: Infraorbital block
Fig. 8.13: Greater palatine foramen block

recovery facilities are available. For longer duration
of general anesthesia, more recovery period shall
be required.
EMOTIONAL STATUS OF THE PATIENT

1. Some patients have phobia regarding injection to
be given in the mouth. Because of availability of
better facilities of general anesthesia in modern
times the patient may be operated under general
anesthesia, if he/she insists.
2. If apprehensive patient must be treated under local
anesthesia, then sedation may be necessary as per
protocol. Under no circumstances the patient under
sedation should be allowed to drive a vehicle. A
responsible adult escort must accompany him/her
to his/her house.
DRUG ALLERGY
1. All the patients must be asked regarding known
allergies to any drug or else.
2. Patients having allergy to “Procaine” (local
anesthesia) may not have allergy to “lidocaine”,
because of different compound. Lidocaine has
lesser allergic reactions percentage, but still some
patients have been reported to have allergy to it.
3. Barbiturates have lesser reaction cases of allergy.
Some times its normal reactions like nausea; vomit-
ing and psychic reactions, are taken as allergic
reaction.
4. The kit to treat any impending allergic reaction
should always be ready and properly checked in
advance just before the induction of the anesthetic
drug/drugs.
5. In the following Chinese technique there is no dan-
ger of any reaction. Cooling of dorsal web area of
hand (Hoku point) (see Figs 8.14 to 8.17) for seven
minutes by direct application of ice, seems to have
paresthetic effect on ipsilateral, i.e. same side of
TM Joint area. This helps to relieve discomfort, mild
pain, and muscle trismus in that area including in-
traoral structures, like teeth and gums.
Method of application of ice; ice cube or piece
should be kept on Hoku Point for first three and a
half minute. The pain is likely to be reduced in TMJ
area by about 30 to 50%. If the application is con-
tinued for another three and a half minutes the pain
is reduced to 60 to 100% (Total application of ice
should not exceed seven minutes in all, because
after this time ischemia in the tissues may occur).
The theory of “acupuncture” differs from western
theory of communication between organs through
circulatory, nervous and endocrine systems. The
acupuncture theory is based upon a different in-
visible system of communication between differ-
ent organs of the body, not known to the western
medicine.
The author used to extract loose teeth by using
this technique (even slight pinching on Hoku point
by the operator) was sufficient to elicit the response
of paresthesia and sufficient anesthetic effect for
extraction of very loose teeth. The patient always
fears the needle prick pain, and always fear pain
associated with extraction of tooth, hence this
psychology of patient made the author very popular
Figs 8.14 and 8.15: Hoku point, i.e. “Dorsal web area of hand” (L-4
Chinese technique). If this point is cooled by keeping ice on it for
7 minutes, it seems to relieve ipsilateral pain in TM Joint area, probably
supported by “Gate control Theory of pain”
Figs 8.16 and 17: Here location of the “Hoku” point is specified by
finger. Next the ice cube is kept over the “Hoku point”
as a “wizard of extraction of teeth” without injection

and without pain just by pinching on hand.
Transcutaneous neural stimulation (TNS); by
using intermittent low voltage current produced
by a small electronic portable machine with two
attached terminals, negative pole and the positive
pole attached to skin of the effected area at some
distance apart from each other, and the machine
worked for 15 to 20 minutes. This procedure also
produces paresthetic effect and muscle relaxation
effect. The readers are advised to have further
readings about these techniques.
NINE
FORCEP EXTRACTION
OF INDIVIDUAL TOOTH
UPPER/MAXILLARY CENTRAL
INCISOR (11 AND 21)
Single rooted tooth with almost straight roundish, root
having little or no distal bend as the apex is approached
(Fig. 9.20).
Position of the Operator

Right-handed operator will stand on right side front
of the patient, whereas the position of the assistant
will be left side front of the patient.In left-handed
operator the above-mentioned positions will be
reversed, i.e. the operator will be on the right side
rear of the patient and the assistant will stand on the
left side front of the patient. Retraction of the tissues,
the upper lip, etc will be done by left hand of the
operator (Figs 9.17 and 9.19).
The Forcep Used

Forcep No.1 (Fig. 9.18)
Holding of tooth; is done with one beak of the
forcep at the buccal/labial cemento-enamel junction
(anatomical neck of the tooth). The posterior beak will
be on the palatal side anatomical neck of the tooth
(Figs 9.17 and 9.19).
Extraction Movements
First movement: Will be to labial side.
Second movement: Towards palatal side.
Third movement: Rotary from labial to distal side
and back to initial position.
Forcep Extraction of Individual Tooth 125
Fourth movement: Rotary from labial to mesial side
and back to initial position.
Fifth movement: Downward movement in line of
side of the anatomical position of
the tooth along with mixture
above mentioned movements.
All movements described above will enlarge the
alveolar socket in all directions and break the
periodontal fibers. Outward movement will pull the
tooth out of the expanded socket. The described
movements are the mean of the commonest
movements for a beginner, but the operator in different
situations can apply any variation as and when
required as deemed appropriate.
THE RATIONALE/RESULT OF EXTRACTION

MOVEMENTS
A tent is held in position with the help of its supporting
ropes tied to it on one side and on the other side the
ropes are being tied to some fixed firm anchors.
Similarly the tooth is also held firmly in the alveolar
socket, due to millions of tied ropes between
cementum on one side and the socket bone on the other
side (anchor). These ropes are called the periodontal
fibers. They have one unique property that they can
be stretched to some extent without being damaged/
broken, because of their—
1. S-shape of fibers, which allows some lengthening
under stress, till this S-shape becomes straight.
2. Due to their formation by elastic tissue (Both of
these properties of giving margins of stretching are
developed by nature to combat absorb/neutralize
any sudden jerk without damage to the supporting
system of the tooth, during chewing process.). But
when these fibers are starched more than their
optimum capacity of starching they give way/
break.
So during forcep delivery of a tooth, the move-
ments exerted by the operator, through extraction
forcep the maximum stretching limit of the periodontal
fibers exceeds and as a result they break, thus loosing
the support to the tooth.
On the other hand when the lateral forceful
movements are given to the tooth the supporting
socket bone gets compressed on the pressure side,
under pressure created by moving root under
extraction movements (See Figs 9.20 to 9.22).
Similarly the bone will be compressed on the other
side when the exertion of force is shifted in the other
direction, thus resulting into widening of the socket
containing the tooth.
This two-fold action will result into:
1. Loosening of the tooth in its socket by breaking
most of the supporting periodontal fibers.
2. Widening of the socket containing the tooth.
Now when final outward pulling force is applied
in the line of original position of the tooth, already
loosened tooth, lying in an already widened socket
will deliver out of its socket. If the outward force is
applied and the tooth is not in its original anatomical
position, either the tooth will break/or crack at that
point of excessive pressure or the alveolar bone of
the socket will break, both of these conditions are
undesirable.
Figs 9.1 and 9.2: Forcep No. 1, right special

universal forcep for upper teeth
Figs 9.3 to 9.5: From left to right; English pattern lower incisors/
roots; lower premolar forcep; lower molar forcep
Figs 9.6 to 9.8: Left to right. Upper third molar forcep,

upper cow-horn forceps right and left
Figs 9.9 to 9.11: Left to right lower third molars. The convexity of the
beak protein will always remain on distal side for better hold and view
(German pattern)
Fig. 9.12: Lower third molar forceps “Ash” pattern
Figs 9.13 and 9.14: Zoom view of upper cow-horn forceps left. In
photo for right side teeth and right in photo is for left side use. The single
horn will always fit in the bifurcation of the buccal roots of the upper
molars
Fig. 9.15: Lower mandibular cow horn forcep
Fig. 9.16: Zoom view of lower cow-horn forcep. Note both horn like
beaks shall fit into bifurcation area of the mandibular molars
Fig. 9.17: Extraction of upper/superior/maxillary 11 (Permanent right

central incisor). Note position of the thumb, fingers of the operator and
also note position of extraction forcep No. 1, holding the tooth
Fig. 9.18: Forcep No. 1

Fig. 9.19: Extraction of upper/superior/maxillary 21 (Permanent left central

incisor). Note position of the thumb, fingers of the operator and also
note position of extraction forcep No. 1, holding the tooth
Extraction movements for extraction of maxillary

permanent central incisor tooth. Left side of figures
shows buccal side and right side shows the palatal side
Fig. 9.20: The anatomical position of the tooth.

Note that the forcep No. 1 is applied
Fig. 9.21: First movement is given Fig. 9.22: The second movement
to labial side. Note the root moving is applied in palatal direction.
to palatal side Note movement of the root in
opposite, i.e. labial direction
Fig. 9.23: Thirdly rotary movement from labial to distal and back to initial
position. Forthly rotary movement from labial to mesial direction and then
back to initial position. Finally the movement is given in outward direction
of the long axis of the tooth to deliver it
UPPER/SUPERIOR/MAXILLARY LATERAL INCISOR
(12 AND 22)
Anatomy
Single rooted tooth compressed mesiodistally and
flattened labio-palatally. Apical 1/3rd of the root has
a tendency to bend/incline towards distal side.
Position of the Operator and the Assistant

Right handed operator, to the right side in front
position of the patient and assistant on left front side
of the patient (See Figs 9.24 and 9.25). Position of the
left hand/fingers of the operator; index finger on labial
side of the tooth reflecting the lip and holding the
labial plate of the alveolar plate. Thumb; on the palatal

lateral incisor). Note position of the thumb, fingers of the operator and
also note position of extraction forcep No. 1, holding the tooth
Fig. 9.25: Extraction of upper/superior/maxillary 22 (Permanent left lateral

incisor). Note position of the thumb, fingers of the operator and also
side supporting the palatal alveolar plate. Forcep used;

forcep No. 1.
Movements of Extraction
1. First movement; towards palatal side the labial plate
will be felt broadening under index finger of the
operator.
2. Second movement; towards anterior/labial side.
The alveolar bone will be felt moving towards
thumb of the operator.
3. Third movement; downward movement in line of
the tooth in which it was originally present for
delivering the tooth. Rotatory movements are
avoided because distal inclination of the apical
1/3rd of the root is likely to break at that point by
this movement.
UPPER/SUPERIOR/MAXILLARY
CANINE; (13 AND 23)
Anatomy of the Tooth
Single rooted, strong and long root having tendency
to incline towards distal side as apical 1/3rd portion
of the root is approached.
Position of the Left Hand and

Fingers of the Operator
The pulp of the index finger of the left hand holding
the labial plate above the root of the canine to be
extracted, middle ½ of the same index finger reflecting
the lip.
The pulp of the thumb is placed on the palatal
alveolar plate of the canine to be extracted, simul-
taneously pressing the lower arch/mandibular teeth
through sterile dry gauze.
Forcep Used
Forcep No. 1.
Movements of the Forcep

Separate the gums (circular ligament) completely from
the tooth/canine, the forcep is applied to the anatomi-
cal neck of the tooth.
First movement; movement is first given towards
buccal side.
Second movement; is given towards palatal side.
Third movement; both labial and palatal move-
ments are applied more forcefully till loosening of the
tooth.
Fourth movement; downward movement to take
out the tooth in long axis of its original initial anatomi-
cal position till the tooth is delivered.
Rotational movements should be avoided simply
because of the distal inclination of the apical 1/3rd of
the root, from where it can break by rotational move-
ment.

canine). Note position of the thumb, fingers of the operator and also
Fig. 9.27: Extraction of upper/superior/maxillary 23 (Permanent left

canine). Note position of the thumb, fingers of the operator and also
Extraction movements used for extraction of maxillary

canine, left side is the buccal and the right side is
palatal side
Fig. 9.28: Forcep applied to the max canine.

Note the root lying in anatomical position
Fig. 9.29: The first moment of the forcep applied in labial direction.
Note the movement of the root in opposite direction, i.e. palatally
Fig. 9.30: Second movement applied is in palatal direction (Blue arrow).

Note root moving in opposite direction, i.e. labial. Also note widening
space created in the socket bone by previous palatal movement of the
root (Shown in yellow double arrow)
Fig. 9.31: The tooth is brought back in anatomical line of the tooth and
outward force is applied. Note partial delivery of the tooth
Fig. 9.32: Anatomy of teeth and trend of the roots is shown in this figure. On left extreme 8 maxillary premolars are
shown with their root trend/variation. In the middle variations of roots of 27 mandibular molars are shown. On right
extreme 6 maxillary molars are shown with variations in their roots
UPPER/SUPERIOR/MAXILLARY PREMOLARS
Anatomy of the Tooth
Maxillary premolars have two roots labial and palatal
with various combinations of trends of roots (Fig. 9.35).

Operator on the right front side position of the patient
and the assistant on the left front side position of the
patient.
Forcep Used
Forcep No.150. (Forcep No. 1 can also be employed
some times).
Position of the Left Hand and Fingers

Almost similar to the one as were described for canine.
After separating the gums (circular ligament)—
First; the forcep is applied to the anatomical neck
of the tooth. The tooth is held firmly between the beaks
of the forcep, with no slipping movement whatsoever.
If the beaks of the forcep do have some movements/
looseness on the tooth, it may be exchanged with forcep
No. 1 till firm fitting is achieved.
First movement; is given to the buccal side.
Second movement; is given to the palatal side. Great
care must be taken because the roots some times have
tendency to fan out from each other and may break
under these movements.
When the tooth become loose due to enough
required broading of the alveolar coverage start
downward movement in the long axis of the tooth in
its original anatomical position till it is delivered.
Note: Care and attention should be paid because
faned roots generally break at this juncture, because
of the roots so much apart that the outward pulling
movements may force the apical 1/3rd of the root to
break. If the tooth is not coming out with normal force
application, stop. Check, repeat the buccal and palatal
movements again, extending the movements a little
further coronally and then try downward movement
again. Repeating these downward movements/buccal
and palatal movements and simultaneously slipping
the beaks of the forcep more apically thus utilizing
more and better leverage advantage, and thus the tooth
may be extracted in one piece.
Hurried, non-judicial, unthoughtful movements as
to where the tooth is being engaged and is not coming
out by normal force application may result in breaking
of the tooth.
If the root tip do break it will be difficult to take it
out, because of the presence of maxillary sinus just
above it where the root may slip during its extraction.If
the root does break during the extraction the patient
will also get worried and shall loose his/her confidence
in the dentist for future.
Hence it is judicial to use tactful and thoughtful
attention during difficult extractions. The above
mentioned procedures may take a little more time for
ultimate safe extraction of the tooth, it is much better
than breaking the roots and creating more compli-
cations by hurried/fast movements on part of the
dentist and by this act the patient also looses his/her
confidence in the dentist.
Fig. 9.33: Upper/superior/maxillary left first premolar (24) extraction.

Note position of fingers and thumb of the operator and position of the
forcep No. 150
Fig. 9.34: Upper/superior/maxillary left second premolar (25) extraction.

Note position of fingers and thumb of the operator and position of the
forcep No. 150. Sometimes in sitting position by the side of the patient
some operators may find reverse position of thumb and fingers more
convenient as shown in this figure. The position of finger and the thumb
can vary as per convenience and need of the operator (Left handed
operator, etc.)
Fig. 9.35: Maxillary premolars.

Note the variations in the root anatomy of the teeth
Extraction movements for maxillary premolar. Left

side is the buccal, whereas right is the palatal
Fig. 9.36: Extraction movements for maxillary premolar. Forcep No. 150
or No. 1, is applied to the anatomical neck of the maxillary premolar
Fig. 9.37: Extraction movements for maxillary premolar. First movement

is given in buccal direction. Note movement of the roots in the opposite
direction, i.e. palatally
Fig. 9.38: Extraction movements for maxillary premolar. Second movement

is applied in palatal direction. Note the roots move to labial side
Fig. 9.39: Extraction movements for maxillary premolar. Downward

movement in anatomical position of the tooth. Note partial delivery of the
tooth
Fig. 9.40: Extraction movements for

maxillary premolar. Note empty socket
UPPER/SUPERIOR/MAXILLARY MOLARS
Upper molars have three roots, two on buccal side,
mesial and distal and one on palatal side. There is lot
of variations in their relative positions right from
fusion to much, much fanning/separating from each
other in different directions.The further complication
is that the trends of distal inclination/bend of apical
1/3rd of the root/roots, which may be of different
magnitude in all the three roots (Figs 9.42 and 9.43).
Thus making straight line (coronal) delivery of the
tooth difficult or impossible some times. These fanning
roots always have a tendency to break, when tried to
be pulled out in line of long axis of the tooth. Either
single, two or all the three apical 1/3rds of the roots
may break.The firmness/thickness of the buccal plate
due to presence of Atkinson’s key ridge a trajectory
of force on the buccal side of the first molar tooth may
further complicate the situation.The author advises the
operators to be confident. But never overconfident
during extraction of multirooted teeth. Pay 100%
attention to the operation in progress, paying no
attention to any movements/disturbances either by
patient or the attendants of the patient. Pin drop silence
in the room/surgery is desirable, because if the root/
roots do break the mild sound of the breaking root
should be audible to alarm the operator. Because root
generally first cracks and make a little crackling
sound, but is still attached to the rest of the stump
and if the operator is lucky enough he/she may
manipulate to deliver it completely along with the rest
of the tooth.

and the Assistant
Right side front position of the patient for the operator
and left side front position for the assistant.
Position of the Operator’s

Left Hand and its Fingers
For right side upper molars; retraction of the tissues
along with palpation of buccal alveolar plate is done
by radial side of the index finger of the operator. For
left side upper molars; retraction of the tissues/cheek,
etc. is done by index finger being placed on buccal
bony plate with pulp of finger touching the alveolar
bone. The thumb will rest on palatal side of the alveolar
plate.
Forcep Used
No. 10-S, or upper molar forcep right/or left side (the
upper right side forcep has a notch on the buccal side)
which fits into the buccal intra-radicular embrasure/
bifurcation, whereas the other plain beak shall remain
on the palatal side. The upper left side forcep will have
the notch on buccal side to fit into buccal notch and
the plain beak will remain on palatal root side of the
upper molar tooth.
Or upper cow-horn forceps right and left may be
used instead of regular upper molar forcep.
The gum from the tooth is separated as per protocol.
The forcep is applied properly at the anatomical neck
of the tooth. The buccal side notch of the forcep should
fit firmly between two mesial roots at diversion point.
The palatal curved side should fit firmly around single
palatal root.
The first movement is given in the buccal direction.
The second movement is given towards down-
wards and towards palatal side, but care should be
taken to stop this movement at original position of
the long axis of the tooth (Do not give body movement
to the tooth towards palatal side, because it may break
the roots, or break the palatal side alveolar plate, both
of these are undesirable).
Third movement is given again on the buccal side,
with a little more force to make more space for the
tooth to come out, then it is repeated, this results in
widening of the buccal plate of the alveolar bone.The
tooth is slowly moved out of the socket by judicial
repetition of the movements described above, while
taking out the tooth outward force should be applied
along the long axis of the original anatomy of the tooth.
Basically the molars are extracted on expense of
fulcrum of the buccal bone plate and never on the
expense of palatal bone plate.
Fig. 9.41: Upper/superior/maxillary left first molar (26) extraction. Note

position of fingers and thumb of the operator and position of the upper
molar forcep (Left side)
Fig. 9.42: Fanning of the roots in case of maxillary

molars is shown. Note variations
Fig. 9.43: Six maxillary molars are shown. Note the root trend
Extraction movements for maxillary molars. Left side
represents buccal side, whereas right side represents
palatal side
Fig. 9.44: Extraction movements for maxillary molars. Forcep is

applied to the anatomical neck of the tooth
Fig. 9.45: Extraction movements for maxillary molars. First movement to

buccal side. Note roots move to palatal side due to lever action fulcrum
being at the anatomical neck of the tooth
Fig. 9.46: Extraction movements for maxillary molars. Second movement

downwards and towards palatal side. Note root moving in opposite
direction, i.e. buccally
Fig. 9.47: Extraction movements for maxillary molars. Downward

movement in the line of the original position of the tooth will deliver the
tooth. Note partial delivered tooth
Fig. 9.48: Extraction movements for maxillary molars.

Empty socket after the tooth is delivered
LOWER INCISORS AND CANINES

Single rooted teeth, roundish in labio-lingual direction
and flattened in mesio-distal direction, having a trend
to incline distally as apical 1/3rd is approached.

(For 31, 32, 33) (Figs 9.49 and 9.50)
Right side front position of the patient, whereas the
assistant stands on the left side front position of the
patient. Index finger of left hand of the operator will
be on labial side of the teeth and the thumb will be on
the lingual side.
Position of the Left Hand and Fingers of the Operator

For the extraction of right side teeth, i.e. 41, 42, 43,
with “Ash” (English) pattern of the forceps, the
operator stands on a little right side of the patient
with his left arm coming around the head of the patient,
the index finger of the operator rests on the labial side
of the tooth, incisors, or canine retracting the lip also.
The thumb will rest on lingual alveolar plate and also
retracting the tongue and floor of the mouth and
keeping them out of the field of operation.The middle
finger of the left hand of the operator rests on the
chin of the patient so as to provide stability to the
mandible, during application of extraction forces,
which may be conveyed to and affect the tempro-
mandibular joint if the mandible is not properly
stabilized. By resting of the middle finger (as anchor)
the index and the thumb will also get stability and
force. For the extraction of the lower left side incisors
and the canine the position of the fingers and the
thumb will change. The thumb will rest on buccal plate;
the index finger will rest on the lingual side whereas
the middle finger will rest on chin of the patient
providing support to the mandible. The operator may
go a little more in front if deemed necessary. When
using American pattern forcep No. 151, the position
of the operator will change as follows; slightly back
right side position of the patient. The hand will come
from backside of the head of the patient and the index
finger will rest on buccal alveolar plate, retracting the
lip also.The thumb will go behind the incisors and
canine to rest on lingual alveolar plate also retracting
tongue and floor of the mouth. The middle finger will
rest on the chin supporting it as well as giving anchor
force to index finger and thumb.
After separating the gums as per protocol the forcep
is placed on the tooth taking care that beaks of the
forcep do not slip and touch the adjacent tooth in any
case, otherwise during application of extraction forces
some of the forces will be transmitted to the adjacent
tooth through these beaks and it will either become
loose or shall also come out along with the one being
extracted (original diseased tooth).
First movement is given towards labial side.
Second movement is given to the lingual side.
Third movement is given outward in the direction
of the long axis of the original anatomical position of
the tooth to deliver it.
Note: When labial and lingual movements are given
to the tooth the roots (apical 1/3 portion) will move in
the opposite direction of the force applied to widen/
compress alveolar bone. If we are not careful to bring
the tooth back in line of its anatomical position, when
outward force is applied, then we are likely to damage
either the buccal/lingual alveolar plates or may break
the roots of the tooth.
Figs 9.49 and 9.50: Extraction of lower/inferior/mandibular incisors

and canine (41, 42, 43) with Mead extraction forcep. Note the position
of the thumb on the lingular side and the index finger on the labial plate
and the middle finger supporting the chin
Fig. 9.51: Extraction of lower/inferior/mandibular left incisors and the

canine. Note the thumb is on buccal side whereas the index finger is on
lingual side
Fig. 9.52: Position of operator’s fingers and thumb, during forcep

extraction of mandibular right premolars and molars. Note that the position
of the operator is right backside of the patient
Fig. 9.53: During forcep extraction of the left mandibular premolars and
molars position of the operator is right front. Note position of operator’s
fingers and thumb which supports mandible below the chin (Note shown
in the figure)
Fig. 9.54: During extraction of mandibular left anteriors, i.e. 31, 32, 33.
Note position of finger and thumb of the operator. Middle finger supports
the chin of the patient
Fig. 9.55: During extraction of mandibular left anteriors, i.e. 41, 42, 43.
Note position of thumb and fingers. The operator’s position is right back
position and the hand of the operator comes around left face of the
patient
Extraction movements to extract mandibular central

incisor. Right side in the figure is buccal side and left
side is the lingual
Fig. 9.56: Note forcep applied to anatomical

neck of lower/mandibular central incisor
Fig. 9.57: First movement is towards buccal side. Note root moving in
opposite direction, i.e. lingual compressing the lingual bone of the socket
Fig. 9.58: Second movement is applied in lingual direction. Note root

compressing labial bone of the socket
Fig. 9.59: Final force is applied in the long axis of the original position
of the tooth. Note the tooth being delivered
LOWER/MANDIBULAR PREMOLARS
Single rooted, roundish roots that may rarely have
tendency to incline towards distal side.

For extraction of the left lower quadrant the operator
will stand in right front side position of the patient
and the assistant will stand on left front position
(Fig. 9.60).
Position of the Left Hand of the Operator

(Using Mead Forcep)
The thumb will support the chin/mandible of the
patient as well as act as anchor to provide force to the
other fingers of the operator.The index finger will be
in the buccal vestibule reflecting the cheek and tissues,
as well as for feeling the widening effect of the alveolar
bone by the inner side of the pulp of the finger during,
when the extraction movements are applied.The
middle finger will rest on the lingual side of the alveolar
process and help to retract the tongue and other soft
tissues like floor of mouth, etc. and also feel the
widening effect of the alveolar bone with mesial side
of the pulp of the middle finger.

For extraction of right side lower premolars, the
operator stands on right side back position of the
patient, whereas assistant will occupy left side front
position of the patient.
Position of the Left Hand and Fingers of the Operator,
for Right side Lower Premolars (44 and 45)
The left hand of the operator will come around the
face of the patient from behind and the index finger
will rest on buccal alveolar plate with its pulp portion.
(Fig. 9.65).
Using Mead Forcep

The body of the finger will reflect the cheek and lip of
the patient.The thumb will be held against lingual
alveolar plate reflecting tongue and floor of the mouth.
The middle finger will support the chin/mandible.
Using No. 151 Forcep

These positions will be reversed if forcep No.151
(American pattern) is used. In case of both right and
left extractions the operator will be on right side front
position of the patient.
Movements of the Forcep
Separation of the gums and the circular ligament is
done as per protocol. The beaks of the extraction forcep
are engaged properly and firmly on the anatomical
neck of the tooth, keeping the handle of the forcep
outwards (buccally). First movement is given towards
lingual side. The operator will, however, feel the
widening effect on the buccal side plate of the alveolar
plate. Second movement is given to the buccal side;
here the operator will feel the widening effect of
alveolar bone on the lingual side.Third movement
should be rotatory movement from mesial to distal
side and back to initial position. Fourth movement will
be rotatory movement from distal direction to mesial
direction and back to initial position. Finally with
upward movement in the line of original anatomy of
the long axis of the tooth, the tooth is delivered.
Fig. 9.60: Extraction of lower/inferior/mandibular premolars (34 and

35). Note the position of the thumb, fingers of the operator and his/her
right hand holding lower premolar extraction forcep
Extraction movements for extraction of lower/mandibular

premolars. Left side of the figure represents buccal side,
whereas right side represents lingual side of the tooth
Fig. 9.61: Extraction of movements for mandibular premolar. Forcep

applied to the anatomical neck of the tooth
Fig. 9.62: Extraction movements for mandibular premolar. First movement

is given towards lingual side. Note root moves to buccal side widening
the alveolar socket around the apical 1/3rd
Fig. 9.63: Extraction movements for mandibular premolar. Second

movement to buccal side, thus widening lingual side of the socket with
rotary movement from mesial to buccal side, then reverse rotatory
movement, i.e. from distal to buccal side
Fig. 9.64: Extraction movements for mandibular premolar. The tooth is

delivered in line of original position of the tooth. Note partial delivered
tooth
LOWER/INFERIOR/OR MANDIBULAR MOLARS

The lower molars have two roots, mesial and distal,
but variations from fused roots to most faned roots
may occur sometimes (Fig. 9.32).

Position for extraction of left lower quadrant molars,
i.e. 36, 37, and 38.
Right side front position whereas the assistant stands
on left side front position of the patient.
Position for Extraction of the Right Side Quadrant

Molars, i. e. 46, 47, and 48.
Right side rear position of the operator whereas the
assistant will occupy left side front position of the
patient.
Position of the Operator’s Left Hand and its Fingers
for Extraction of 36, 37, and 38
During left lower molars extraction, the middle finger
will rest on lingual alveolar bone plate and also
reflecting the tongue and floor of the mouth with its
outer side.The index finger with its mesial side, rests
on outer buccal alveolar bone plate, whereas it will
also reflect cheek and lip with its outer side.The thumb
will support the mandible; by resting on chin and
simultaneously provide anchor to the other fingers.
Position of the Operator’s Hand and its Fingers for

the Extraction of 46, 47 and 48
During extraction of the right side lower molars the
left hand of the operator will come from behind round
the face of the patient. The index finger will support
and rest on buccal alveolar bone plate, whereas the
pulp of the thumb rests on lingual bone plate, and also
reflecting the tongue and floor of mouth.The middle
finger of the operator’s left hand supports the mandible
by resting on the chin and also provides anchor to the
rest of the fingers (Figs 9.52 and 9.65).
Forceps to be Used for Extraction

Mead or cow-horn No.16 forcep.
Movements Given on the Forceps for Extraction

The gums and the circular ligament is separated
thoroughly and firmly as per protocol.The beaks of
the forcep are placed and fixed on the anatomical neck
of the tooth (Mead) or in the embrasure formed due
to separating roots mesial and distal, from the crown
of the tooth (bifurcation). First movement is given on
the lingual side. The operator will feel the root moving
under his/her finger/thumb as the case may be. Second
movement is given towards buccal side.Thirdly both
of these movements are repeated more forcefully.
Fourthly upward movement in the line of original
anatomical position of the tooth till it is delivered.
If cow-horn forcep is used then its beaks are,
however, fixed and set into the bifurcation of the roots
of the tooth.Now use squeezing force on handles of
the forcep along with using slight up and down
movements (The horns of the forcep as they catch into
the bifurcation, will elevate the tooth in the socket to
some extent). When the beaks of the forcep sets firmly
deep into the bifurcation, the only lingual and buccal
Fig. 9.65: Extraction of lower/inferior/mandibular molars (46, 47 and

48). Note the position of the thumb, fingers of the operator and his/her
right hand holding lower molar extraction forcep (English pattern)
Extraction movements for lower/mandibular molars.
The left side of the figure represents buccal side and
right side represents lingual side
Fig. 9.66: Extraction movements for extraction of mandibular molars.

Forcep is applied at anatomical neck of the tooth (Mead/or cow-horn
forcep)

First movement is applied towards lingual side. Note the root moving in
opposite direction
Fig. 9.68: Extraction movements for extraction of mandibular

molars.Second movement towards buccal side. The roots automatically
move in opposite direction. When using cow-horn forcep after application
of the forcep beaks the handles are squeezed as well as they are
moved up and down till they are set well into bifurcation firmly. After
setting the properly the above-mentioned movements are started

For delivery of the tooth final outward movement in direction of the line
of original position of the tooth is applied. Note partial delivery of the
tooth
Fig. 9.70: Old type dental chair, where the dentist used to stand by
the side of the chair/patient to do the dental surgery
Fig. 9.71: Modern (Physiological) dental chair, where the dentist sits on
stool by the side of the chair/patient to do the dental surgery (Unoccupied)
Fig. 9.72: Modern (Physiological) dental chair, where the dentist sits
on stool by the side of the chair/patient to do the dental surgery
(Occupied)
movements are started and finally the tooth is taken

out in its original line of anatomical position (Watch
movie of this extraction on CD slide show).
Note:
1. The positions of operator and assistant will change
to reverse position if using American pattern
forcep, which act by twist/torque movement of the
wrist of the operator.
2. All the positions of the operator and placement of
fingers, thumb, etc. may vary/change if physio-
logical chair is used. The above mentioned
techniques are basic/standard techniques, but they
may be modified by the operator as per his/her
convenience.
TEN
THE SURGICAL
FLAP
The surgical flap is a soft tissue flap that is retracted
after appropriate incisions are given, to expose the
underlying pathology for treatment.
The operations, which are performed without
raising a flap and removing the overlying alveolar bone
are categorized as closed reductions or closed
procedures.
The operations, which require raising of a flap, are
called open reductions/open procedures.
INDICATIONS FOR SURGICAL FLAP

1. Fundamentally, the flap is raised so that any
procedure done on the undersurface of the soft
tissue flap does not get traumatized. Once a flap
containing mucosa/periosteum, etc. is raised, the
field of operation is exposed to clear view for the
surgical procedures to be done.
2. If closed method/procedure fails, open reduction
by raising a flap enhances approach and visualiza-
tion of the area to be operated.
3. For removing root pieces lying deep inside the
socket. After raising a flap, alveolar bone can be
removed to expose the root piece and remove it
without any complications/difficulty.
4. Where there is hypercementosis of the roots of the
tooth to be removed or it has divergent roots/
curved roots that cannot be removed by forcep
alone.
5. Where overlying bone surrounding the tooth to be
removed is dense/thick and will not easily give
way under forces of the forcep.
The Surgical Flap 173
6. Where there are definitive indications/suggestions
of the breaking of the tooth due to excessive caries,
weakened crown due to large restorations,
previously done root canal treatment, which makes
the tooth more brittle, similarly old aged persons
where the tooth becomes more brittle.
7. If there is large pathology like a cyst, granuloma
etc. at the apex of the tooth that cannot be removed
through narrow socket.
Flap Designing Principles

The healing should be uneventful if design of the flap
is properly planed.
1. The free portion of the flap should be designed in
such a way that the base portion where the flap is
attached, is quite broad, so that more blood supply
shall be available to the free flap.
The vertical cuts should be at made at an angle
so that broader base flap will result. If the cuts are
planed in a reverse way so that they are narrower
at the base and broader at free end then lesser area
for blood supply will result in delayed healing,
more chances of infection, postoperative pain,
swelling, oedema, due to reduced blood supply of
the flap to the extreme complication of necrosis of
the free flap.
2. The deep incision should be made clearly in one-
shot up to bone. Half haphazard, incomplete inci-
sion will result in ragged margins, undue tension,
stretching, pulling, etc. during elevating/raising of
the flap, will favour ischemia and hampered blood
supply to the free flap.
3. The flap should be reflected/ raised from the base
bone containing all the structures covering the bone,
i.e. periosteum, sub-mucosa, mucosa etc. If different
layers of the tissues are reflected separately or by
tearing or in pieces then again the blood supply to
the free flap shall be hampered. Incision should
always be made upon bone as base, which is not
likely to be included in the operated area. Incisions
should always be made on healthy area of the bone
and the sutured area should always be supported
by healthy bone below.
4. The flap should be planed right at the beginning,
as regards its size, and not that during operation
the operator suddenly realize that he needs to
enlarge the size of the already reflected flap to
uncover the underlying pathology completely.
5. The flap should be planed wide enough to provide
adequate view and coverage of pathological area.
6. The flap should be lifted unbroken by sharp
instruments, i.e. curette or periosteal elevator, with
minimum trauma and stretching, pressure, etc.
7. All the time during operation the flap should remain
tension free and no stretching should ever be done,
also no pressure on the soft tissues over the flap
should ever be applied, so as to maintain a good
blood supply to the raised flap all the time.
8. The flap should be sutured back in place without
tension, stretching, etc. and care should be exercised
to leave no surgical dead space between sutured
flap and the underlying tissues, because these dead
spaces are potential sources of infection due to
collection of large size hematoma, resulting
hampered organization of clot during healing
process.
9. After the sutures are placed area above the flap
should be either covered with periodontal packs
or pressure gauze pieces, again to minimize the size
of the dead space.
Varieties of Flap
There are two types of intraoral flaps.
1. Envelope flap: The envelop flap is made by incision
around the necks of several teeth, anterior and
posterior to the area of operation and extending
the resultant labial or buccal flap away from the
bone. This flap is generally used for removing the
impacted teeth.
2. Vertical component flap: Here a vertical incision is
made in muco buccal/labial area and then extended
horizontally to cover around the necks of one tooth
anterior and one tooth posterior to the affected
tooth. Here the advantage is that less tissue and
more area for the blood supply to the raised flap is
available, thus the resultant healing is fast.
PROCEDURE
The choice of flap depends upon need, experience of
the operator and his/her decision in a particular case.
1. Basically incision is given by No.15 Bard-parker
blade around the buccal/labial gingival cuff
surrounding the tooth posterior to the one that
needs operation, and then it is angled upwards
towards muco buccal fold moving away from the
tooth to be operated. (Fig. 10.1)
2. The vertical area of the incision is raised first
because periosteal attachment is not very tight.
Then the periosteal elevator is worked around the
gingival cuff as well as posteriorly.
Fig. 10.1: Envelop flap. Incision for raising the flap. Note the
effected tooth position as compared to the incision
3. The thin periosteum must be included in the lifted

flap.
4. The periosteal elevator is also inserted in the op-
posite gingival area from where the flap was cut/
separated to free it from the bone below for plac-
ing suture later after the operation is completed.
Fig. 10.2: The flap is retracted and the labial bone is removed from the
tooth to maximum possible area. Note the corners of the flap, which lie
on alveolar bone support
Fig. 10.3: Vertical flap. Inverted incision in mandibular premolar area.

Note the proximity of mental foramen to the periapical lesion
5. The raised flap is held either with periosteal
elevator/retractor or a sterile gauze piece without
any pressure and very gently to avoid damage and
oedema.
6. The flap may be held tension free during completion
of the operation.
7. Variation in flap design is sometimes mandatory
in certain areas like mandibular premolar area to
protect mental foramen structures, when distal
vertical component may be used to avoid mental
foramen (Fig. 10.3).
ELEVEN
COMPLICATED
EXODONTICS
ALVEOLOPLASTY
Alveoloplasty or alveolectomy is the surgical removal
of the portion of alveolar bone/process.
During multiple extractions specially when total
extraction is done to be followed by full/partial denture
replacement, the residual ridge may have obvious
sharp edges, protuberances, and/or deep undercuts,
which will take lot of postoperative time to get
rounded, by natural process.
Alveoloplasty results in quick postoperative
U-shaped residual ridges, smooth, having no
undercuts, making dentures more comfortable to wear
in short adaptation time.
Older people, who have experienced bony spicules,
undercuts, etc. under a newly constructed denture,
will certainly very much appreciate this anticipated
operation of alveoloplasty done in advance.
As discussed in previous chapters the immediate
collapse of widened alveolar socket after extraction
of tooth/teeth by finger and the thumb is possibly the
first and the best procedure to collapse the socket,
almost to 1/3rd size. By doing so the patient will bleed
less, have lesser postoperative complications, and shall
need no suturing to close the socket.
Three weeks time is sufficient for the postoperative
alveolar bone’s primary trimming and healing by
natural process.
The dentist should not, however, be reluctant in
performing alveoloplasty if deemed necessary,
otherwise the patient will suffer the consequences for
years. Generally when three weeks of extraction are
Complicated Exodontics 181
completed, the operator will notice only few areas
requiring alveoloplasty, as most of the bony spicules,
etc. will get rounded by initial resorption of bone
during this period of three weeks.
Varieties of Alveoloplasty
1. Simple alveoloplasty.
2. Radial alveoloplasty.
3. Inter-radial alveoloplasty.
Simple Alveoloplasty
After multiple extractions interseptal bone and alveolar
plates are examined for protuberances, sharp edges,
undercuts, etc.
If alveoloplasty is indicated due to presence of
sharp-edges, etc. then the incisions are made across
the interseptal crests, because soft tissue around the
socket is already separated due to extraction of teeth.
OPERATION
1. The muco-periosteum is raised carefully using no.4
molt curette or periosteal elevator.
Initially the separating of mucoperiosteal flap
from the alveolar bone will be difficult, because it
is firmly attached to it, but care should be exercised
not to tear it or raise it too much (over 2/3rd way
between edge of empty socket and vestibular fold).
If this point is not taken care of and the mucobuccal
flap is raised upto vestibular fold, where it is quite
loosely attached, after the healing is completed
there will be considerable loss of vestibular height
and very little area in height will be left for side
flanges of the denture.
2. Once the flap is lifted it is separated from the
alveolar bone by a sterile gauze, placed between
flap and the bone.
3. A universal rongeur is placed sideways upto half
way up the empty socket and slowly the bony
alveolar plate is removed by resection, making a
uniform height in all the sockets (Figs 11.1).
4. The rongeur is now placed at 45 degree angle over
the interseptal crest of alveolar bone, keeping one
beak of Rongeur in each adjacent socket. Removal
of the buccal or labial interseptal crest is removed
uniformly in all the interseptal areas as well as equal
to buccal/labial alveolar bone, which was reduced
earlier in step three (Fig. 11.2).
5. After all the sockets and the areas are completed,
bleeding is checked by pressing with a small
burnisher/curette.
6. After the bleeding stops, the corners, edges, etc.
should be checked for smoothness by finger tip, if
sharp they should be rounded with the bone files
moving from one side of the operated area to the
other end of the operated area. If we do not file in
this order then the file will result in making ditches
in the alveolar plate, and the uniformity regarding
the height of the ridges will not be maintained
uniformly.
7. Any undercut must be paid special attention and
over burdenous bone should be removed with
Rongeur, rotating bone burs, or files.
Figs 11.1: Simple alveoloplasty. A universal Rongeur is placed sideways

upto half way up the empty socket and slowly the bony alveolar plate is
removed by resection (See the sketch diagrammatic view in the inset)
Fig. 11.2: Zoom view of figures of 11.1. The removal of interseptal bone
is shown in inset, when both interseptal and alveolar plate is cut, wound
cleaned and margins of sharp bone rounded, the flap is sutured back in
place
Fig. 11.3: Simple alveoloplasty continue.

Removal of interseptal protruding tip, as shown in side view
8. The flap which was raised should be cleansed of

any granulation tissue, adhering bony chips, etc.
and is replaced back and sutured by interrupted
or continuous sutures, without tension only over
the interseptal areas and not over the sockets.
Note: If we close the socket area with the sutures,
then we are likely to provide surgical dead spaces.
Large hematoma will be formed in these spaces.
The large hematoma is more likely to get infected.
This will result in undesirable postoperative
swelling, pain, pus formation, and delayed healing,
etc. Hence, it is wise to leave the sockets unsutured,
so that they heal faster.
Presuming that the socket area will heal in a
uniform leaner line, the operator is tempted to
suture over the socket with the available flap, but
this tendency should be avoided.
RADIAL ALVEOLOPLASTY
1. In Angle’s class-II Div-I, cases where discrepancy
of upper and lower residual ridges with excessive
over-jet, or in marked prominent undercut in
residual alveolar ridges of extremely prominent
anteriorly inclined incisors cases, the patient some
times will require complete removal of the labial
plate to achieve better prosthetic replacement
(Fig. 11.4).
2. For correcting such type of cases, the mucoperiosteal
flap is raised before the extraction of teeth is
started.
3. The labial plate of the alveolar ridge is first removed
upto level of the roots of the teeth leaving the
interseptal bone intact.
4. After removal of teeth the bone is trimmed with
the help of chisel, or rongeur in the desired and
required fashion,
5. Because cutting longitudinally shortens the vertical
length of the original alveolar bone, the remaining
left length of the flap will be longer for the new
size of the remaining ridge. The excess flap is now
cut and removed so that it fits the newly created
length of alveolar bone. Finally it is sutured by
interrupted or continuous sutures over the septas
only.
6. Sometimes the horizontal length of the flap also
needs shortening. This can be achieved by removal
of a wedge (inverted V-shaped) of tissue from the
flap in the premolar region so that the flap is
shortened horizontally to cover the reduced length
of alveolar plate. Great care must be taken to check
and maintain the vertical height of the flap upto
the vestibule. If that gets reduced it may ultimately
reduce the vertical length of the vestibule which is
not desirable, because there will be hardly any space
left for vertical flanges of the denture.
Fig. 11.4: Radial alveoloplasty. The muco-periosteal flap is raised. The

labial bone overlying the effected teeth is removed as shown in black
bracket (The teeth are already missing in this photo, hence interseptal
bone is also removed, but it is clear from sketch diagramme no.1 in the
inset, that how it would have looked if teeth were present). The cross-
section in the inset no.1 shows removed labial bone to expose the
teeth. Inset no. 2 shows cross-section showing removal of bone to
uncompress greatest width of tooth
Fig. 11.5: Zoom view of Fig. 11.4. The inset no. 3 shows position when
the teeth were removed and the septa contoured back to palatal plate
INTER-RADICULAR ALVEOLOPLASTY
1. The inter-radicular bone is removed with narrow
beak rongeur, with one beak in each adjacent
socket. There is, however, no need to raise a flap
or to remove the buccal/labial plates.
2. A notch is made in the premolar region with
rongeur by cutting alveolar plate in vertical
direction.
3. Now with the pressure of thumb and the finger
the alveolar bone plate is slowly pressed/collapsed
under pressure to the desired shape, without being
eradicated, just by collapsing. The vertical cuts
made in the premolar region will help to adjust the
reduced horizontal length of the alveolar plate.
Fig. 11.6: Intra-radicular alveoloplasty. The interalveolar septa are

removed without removing the alveolar plate or raising a flap (See inset
No. 1 for diagrammatic view)
Fig.11.7: Intra-radicular alveoloplasty continue. Weakly supported labial

plate is now collapsed with thumb to the desired/required place, keeping
in view that using too much force may break the unsupported alveolar
plate
4. This technique can be employed in cases where the
anterior proclination is not very much marked and
required reduction is less/not very much.
5. In this technique there is less resorption of bone
with less postoperative pain and associated
symptoms, because there is no need to raise a flap,
which after suturing shall lie on rough bone and
take time to heal completely and smoothly.
TWELVE
REMOVAL OF
BROKEN/CHIPPED/
RESIDUAL ROOTS OF
THE TEETH
Freshly broken roots of the tooth, if there is clear
chance of success in the mind of the operator, can be
tried for removal by close method/procedure. But if,
however, most experienced operator fails to extract it
by closed method within five minutes, open reduction
should be started. Otherwise more and more time will
be wasted in close try without any success.
MAXILLARY ROOTS
1. Roots that fracture near their anatomical neck can
be tried by anatomical forcep or root forcep and
delivered out.
2. For engaging the forcep on the alveolar portion of
the root the space is created by removing/
loosening the buccal/labial gingival cuff with the
help of a sharp curette.
The buccal beak of the forcep is now placed and
fixed on the buccal bony plate over the root portion.
The palatal/lingual beak is placed on the other
side of the alveolar socket and a sharp, definitive
squeezing pressure is exerted on the handles of the
extraction forcep.
The beaks of the forcep will bite through alveolar
bone and hold the neck portion of the root, which
may be delivered along with cut alveolar plate
around its neck (Fig. 12.1).
Sometimes the squeezing pressure may break a
bigger portion of the alveolar plate, thus loosening
the root completely. Now the grip is loosened on
the forcep and in second attempt the neck portion
of the root is grasped and removed, leaving broken
Removal of Broken/Chipped/Residual Roots 193
alveolar plate/bone in its original place, where with
time it will heal.
This technique will be failure if there is thick
alveolar plate or where palatal edge of the root
cannot be grasped in the forcep.
3. A straight shank elevator is used for removing the
root tips broken just below the alveolar margin
especially in the maxilla.
4. If root is fractured halfway in the socket, root
elevators are employed. These are delicate
instruments and can break if used non-judiciously.
Some times direct pressure on the root may force
the fragment to slip into maxillary sinus/antrum,
mandibular canal or the surrounding soft tissues.
A clean and dry socket, good view in proper
lighting condition is the prerequisite of fractured
root extraction removals.
It is wise to excavate the thickest portion of the
socket wall to obtain a good catch to engage the
tip of the elevator rather than to apply direct
pressure on the broken portion of the root fragment
itself.
5. The broken roots in maxillary third molar region
are best seen by a mirror (indirect view). Buccal
roots of upper molars may be curved and difficult
to deliver, whereas palatal root is large and
surrounded by non-breakable socket bone walls,
no direct pressure should ever be used on these
root fragments, because of its proximity to the
maxillary sinus/antrum and may be it slips into
antrum with surprising suddenness.
The alveolar bone around these root fragments
should be removed to gain space and root should
be delivered on expense of alveolar bone as
fulcrum. If needed this step may be repeated on
buccal side of a curved root till it is free from
surrounding embedding bone and then, it can be
delivered out.
6. Maxillary first premolars are small, thin and
delicate. The buccal root may easily be pushed
between periosteum and the buccal bone during
extraction try. Hence, a finger placed over the
buccal plate may prevent it or locate it for removal
from under the periosteum on the buccal bone.
Fig. 12.1: Removal of superficial root. The labial soft tissues have been
reflected, and one of the beak of maxillary incisor forcep is positioned
on alveolar margin of the bone, under which lies the broken piece of the
root. The other beak of the forcep if placed on the palatal alveolar
margin, under which lies the palatal side of the root. Force is applied to
the handles of the forcep to crush the alveolar bone and grip the root
firmly, which is delivered with the usual moments of the forcep
Fig. 12.2: Zoom view to show the grip of the beaks

of the forcep more clearly
Fig. 12.3: Removal of residual root of maxillary canine with straight

shank elevator. Note position of elevator between interseptal bone (used
as fulcrum) and broken piece of the root
Fig. 12.4: Zoom view of the Figure 12.3
Fig. 12.5: Mandibular root is extracted with the help of “Winter” elevator.
The mesial root was already delivered, then the intra-radicular septa
was removed by engaging the beak of the elevator on the septa and
upward motion of the beak/edge will break the septa and deliver it out.
After removal of the septa, in first turn the second distal portion of the
root is extracted by engaging it with beak of “Winter” elevator and turn
of the elevator upward, using alveolar plate as fulcrum, the root is
delivered out
Fig. 12.6: Zoom view of figure 12.5. Red arrows show body and
position of the elevator, whereas black arrow indicates the direction in
which the root shall be delivered out by rotating the elevator beak, on its
fulcrum, in outward direction
The palatal root, however, can be delivered out

on expense of intervening septum between buccal
and palatal roots.
MANDIBULAR ROOTS
1. If the roots of molars are broken superficially near
the neck of the socket, they should be separated
from each other first, for their removal
individually. Separation can be done by chisel,
elevator or bur. The first root is removed with
winter crier short elevator No.11. The purchase is
made on side of the root and the other root is used
as fulcrum to deliver the first root.
Another approach may be interdental area
(Fig 12.5), once first half piece of the root is
extracted the same elevator may be used to deliver
the second root on expense of interradicular
fulcrum. Or long Winter elevator No.14 is placed
in the depth of the just emptied socket by
delivering the first root and tip of the elevator
turned upwards engaged in the septum and deliver
the second root along with broken septum or broken
septum in the first attempt and roots in the second
attempt. Care must be taken that heel portion of
the elevator should not damage the root of the
abutment.
By this technique broken roots of all the
mandibular molars can be extracted.
Mandibular roots of anteriors and premolars are
extracted with exolevers elevators.
OPEN REDUCTION PROCEDURE

When fragile socket walls (thin plates), curved root
tips, inadequate visibility make fractured roots
removal difficult by closed method an open reduction
option should be chosen without loss of time.
1. Standard flap raising process is adopted for buccal
root extractions.
2. Labial/buccal alveolar bone can now be removed
from over the broken root by rongeur, bur, or
chisel. The broken root tip/chip will be in view
soon after the overlying alveolar bone is cleared.
3. It can now be removed as deemed convenient.
4. Some surgeons prefer to give incision as is used
for apicectomy. The bone is removed and when
root chip is in the view it can be removed from the
window prepared in the alveolar bone. But in this
technique the operator needs more orientation and
experience.
5. In palatal roots standard flap raising, removal of
buccal alveolar bone, and then the inter-radicular
septum is cut and removed. Great care must be
taken in premolars and molars area because the
antrum is lowest in septal area, hence too deep
cutting of septum may expose the antrum. The septa
is removed and the root taken out from this vent.
This procedure of cutting the septa and
delivering of the roots piece through this area is
done, simply because roots of adjacent teeth are in
great approximation to the buccal roots of
premolars and molars.
In palatal root there is no chance of close
approximation of adjacent tooth root, hence alveolar
Fig. 12.7: Open reduction. The left maxillary canine (23) has been
exposed by ossisection
Fig. 12.8: Zoom view of figure 12.7
Fig. 12.9: Open reduction. The broken root of 23 (Left maxillary canine)
is shown as it lie in side the socket. (This is the imaginary view of the
root)
Fig. 12.10: Zoom view of figure 12.9
bone can be removed from mesial or distal side of

residual stumps of root without much of danger.
6. During extraction of palatal roots, if it suddenly
disappears upwards, there is every possibility that
it has been pushed into maxillary antrum. In such
case the patient should be asked to close his/her
nostrils and blow forcefully through closed nostrils.
Some times luckily if the root piece is delivered it
should be removed with great care, because it may
not be pushed back into the antrum again as the
path is already made for it.
7. But if the root piece does not come out by blowing
with closed nostrils, then Cald well-Luc operation
is indicated. Sometimes the small root piece get
wedged between membrane and bone of the
antrum and is not found lying free in the antrum.
In certain cases roots of maxillary molars break, or
chip horizontally through the pulp chamber, low
enough to be held by forcep. In this type of case a flap
should be raised, bone over the buccal side of the root
is removed and the buccal roots are separated with
bur, chisel or elevator. The buccal root separated so is
now removed with the help of elevator. If the other
buccal root is still attached to the palatal root, they
both may be removed together or separated and taken
out individually.
1. The bleeding is excessive in incisal flap areas.
Presence of mental foramen and heavy buccal bone
further strengthen by external oblique ridge should
always be kept in mind.
RESIDUAL ROOTS
1. The roots that are present for quite sometime after
they have been left by inexperienced operators are
considered to be infected. When they are deep,
painless and symptom free, judgment should be
made to leave them as such or remove them before
a denture is being constructed.
Most of the dentists do not construct a denture
over residual roots and most of the physicians
advice these infected roots to be removed for
specific systemic diseases (Sub acute bacterial
endocarditis “SBE” etc.).
2. An other perplexing situation is diagnosis of
differentiation between osteosclerosis and root
remnant on a radiograph.
If the osteosclerosis occurs near the socket or
between the two nutrient canals it is very difficult
situation to differentiate it from the root remnant.
3. Exact location of the residual root in an edentulous
mouth is another difficult situation. If there are no
anatomical landmarks present then a suturing
needle is placed in the close proximity of root piece
in anesthetized gums.
X-rays are made in two planes, bucco-lingual/
palatal and occlusal view. The exact location of the
residual root can be ascertained in comparison to
the needle, and root residual piece is removed
accordingly.
After a flap is raised, bur holes are made around
the expected location of the root, then they are
joined by chisel or bur and the cortical plate of the
bone is removed. Now the spongeosa is removed
slowly with a sharp curette, the root piece is lo-
cated and removed. If the window made is not
enough wide to anchor the buried root, it can be
extended in the expected line/direction of the root
remnant.
After completion of the job, the flap is sutured
back in place.
THIRTEEN
PRINCIPLES OF
ELEVATORS
Basically two types of forces are used in raising an
object from the base using a fulcrum. This depends on
the location of the fulcrum in relation to the object to
be raised. A push and pull force will dislodge the
object upwards (class 1 and class 2 leavers).
During extraction of third molars when forcep
cannot be applied the principle of elevator helps the
operator.
1. A thin elevator is placed between the second and
the third molar.
2. The bottom-rounded edge (heal) takes fulcrum on
the septal bone.
3. The top edge of the elevator does the lifting
(Fig. 13.6).
4. If the fulcrum is shifted towards the top edge of
the elevator, the bottom edge will do the lifting.
5. When the bottom edge of an elevator is used to
contact the third molar to be removed, the top edge
and back of the elevator form a fulcrum at the place
of its contact with second molar (Fig. 13.8).
6. The third molar is scooped out when sufficient space
is made by distal lodgment of the third molar.
7. When top edge of the elevator is in contact with
third molar the fulcrum automatically shifts to the
bottom edge of the elevator, which takes anchorage
from septal bone. Now the top edge is leaned
backwards to anchorage on anatomical neck of the
third molar. By means of up and down motion on
the elevator handle, the third molar is dislodged
straight upwards so that the anterior ramus of the
mandible does not interfere its path outwards
(Fig. 13.10).
Principles of Elevators 207
8. As the tooth leaves the socket it shifts distally also
and it looses contact with the elevator. The fulcrum
may now be reshifted to the bottom edge of the
elevator and it will scoop the tooth out of the socket.
The top edge of elevator will, however, be in
contact with septal bone rather than on second
molar (Fig. 13.10).
USING OF STRAIGHT ELEVATOR

1. Straight shank elevator (No.34) is used in two ways.
In first type it is placed between the long axis of
the root between socket’s inner wall and root
stump’s outer wall.
Now it is worked apically. The strongest portion
of the socket should be used as fulcrum so that it
does not break and the root is delivered.
Older method is to place the elevator between
root of the tooth to be removed and adjacent tooth
at right angles to the long axis of the root and to
rotate it slightly to deliver the root.
This method is sometimes used to loose an
entire/complete (unbroken) tooth before forcep
extraction.
2. The long Winter elevators (No.14-R and 14-L) are
designed to deliver roots of lower molars. They
are sometimes used exceptionally in third molars.
They generate lot of power and can even fracture
the mandible, hence great care must be exercised
while using them.
The elevator is used by placing it in the empty
socket of the root, which has already being
extracted, with the tip of the elevator towards the
remaining root to be extracted; the intra-radicular
septum is engaged into its tip from near the apex
of the socket. The handle/shank of the elevator is
always kept on the buccal side. The back of the
elevator (heal) should not rest on adjacent tooth,
but on the buccal bone, because it may generate lot
of force to damage the adjacent tooth.
Now a rotary motion to uplift the septum
engaged in it should be applied. The tip of the
elevator will sink into the septal bone break it, and
take it out.
The elevator is again set in the same position
this time engaging the remaining broken root. The
rotatory motion of the elevator will deliver the root
this time.
3. The Winter elevator No.14 can also be used to
deliver a partially luxated/ mobilized third molar.
Here the tip of the elevator is engaged in the
bifurcation of the buccal side of the tooth. By using
buccal plate as fulcrum the tooth is elevated by
rotatory motion of the elevator.
4. Short Winter elevators (No.11R and 11L) can be
used in many situations where fractured roots can
be engaged in its tip and keeping the heel of the
elevator on available firm fulcrum the root can easily
be lifted.
5. In many other situations like extraction of lower
first premolar where forcep application is difficult,
because of the crown of first premolar being inclined
lingually, the short Winter elevator can be applied
Fig. 13.1: Elevators. Top-straight elevator, second row left—“Winter”

short elevators left, and right. Second row right—root elevators, right
and left. Bottom Molt curet
Fig. 13.2: Use of straight elevator. Note insertion of beak of elevator

between residual root and the socket wall. The strongest wall of the
socket is chosen, here it is the distal interdental socket wall, which is
used as fulcrum to deliver the root
Fig. 13.3: Use of “Winter” elevator, for delivering

distal root of second molar tooth
Fig. 13.4: Mandibular root is extracted with the help of “winter” elevator.
The mesial root was already delivered, then the intra-radicular septa
was removed by engaging the beak of the elevator on the septa and
upward motion of the beak of the elevator will break and deliver the
septa. After removal of the septa, in second attempt distal root is extracted
by engaging it with beak of “Winter” elevator and rotation of the elevator
upward, using alveolar plate as fulcrum, the root is delivered out this
time as indicated by black arrow
Fig. 13.5: Zoom view of figure 13.4. Red arrows show body and
position of the elevator, whereas black arrow indicates the direction in
which the root shall be delivered out by rotating the elevator beak, on its
fulcrum, in outward direction
Fig. 13.6: Use of straight elevator in elevating the third molar. The fulcrum
(shown in white dot) is established on the septum by bottom edge of the
elevator, whereas the top edge engages the tooth for straight upward
movement (yellow arrow)
Fig. 13.7: Use of straight elevator in elevating the third molar.

Zoom view of figure 13.6
Fig. 13.8: Use of straight elevator in elevating the third molar. Here the
fulcrum lies near top edge of the elevator; the bottom edge engages the
tooth for elevating by “scoop” action
Fig. 13.9: Use of straight elevator in elevating the third molar.

Zoom view of figure 13.8
Fig. 13.10: Use of straight elevator in elevating the third molar. Best use
of “scooping” motion is taken when the tooth is elevated partially. Yellow
arrow and white round indicates fulcrum and generation of force. Black
arrow shows conveying of force to the tooth through elevator, and red
arrow shows final delivery force to the tooth
on mesial side of the tooth and it can be lifted or
loosened by using lingual alveolar ring as fulcrum.
6. Because the tip of the Winter elevators engages in
the object to be removed it should always be kept
quite sharp. Frequent maintenance and sharpening
of these elevators is mandatory.
Note:
It is difficult for a beginner to understand the above
mentioned text. Hence the students/beginners are
advised to fix freshly extracted teeth in a row in a
plaster of paris block and then try practically the above
mentioned techniques/movements of elevators.
Repeated practice and collaborating it with the
theory mentioned in this chapter will make the
budding dentist perfect as far as use of the theoretical
mechanisms of the elevators and their practical uses
in different situations are concerned.
FOURTEEN
IMPACTIONS
With the evolutionary changes, the size of human
brain/skull is increasing in size on expense of the size
of the jaws. The pre-pituitary line that used to slope
forward receded from forehead to protrude jaws in
older times (in pre-human form), has become almost
vertical in modern era human.
Modern soft diet, which needs lesser use of jaws
further, helps to reduce the size of the jaws. This results
into third molars, lateral incisors and canines in order
of merit to become vestigial. These being the major
reasons of increase in eruption complications, and
resultant impactions of the third molars in the recent
era.
The rationale for removal of all impacted teeth
before constructing a denture is that, if the impaction
is not giving any sign, symptoms and is not likely to
interfere with denture construction and use by the
patient, it may be left as such till it starts giving
problems under the dentures, due to being brought
superficial with time, due to resorption of alveolar
bone between the denture and the impaction.
This step of leaving the impaction under the
denture is advantageous in the point that the height
of the alveolar ridge/tuberosity is better maintained
for a longer time.
COVER OF ANTIBIOTICS
1. A cover of antibiotics (in proper dozes) is started a
night before the operation or it may be given an
hour before the surgery, as the case may be. The
injectable antibiotics may be given fifteen to thirty
minutes before the operation.
Impactions 217
2. If pericoronitis is present, it should be treated first,
before the operation is executed, because the
infection may be carried into deep areas (facial
planes) of the neck, and result into serious
complications.
3. Sometimes if during the operation roots of the
impacted tooth breaks, it is safe to leave them as
such till the pericoronal infection ceases completely.
After the infection is over the residual roots left at
that time may safely be removed in second
installment operation.
Premedication and Preparations

1. Premedication is administered if the operation is
done under local anesthesia.
2. 0.1.G pentobarbital sodium may be given orally/
or
3. 1 to 2 ml of pentobarbital sodium is given intra-
venously.
4. After the operation is over the patient can walk,
but needs someone to help him/her. Driving is
prohibited.
5. Gargles with mouth wash, and proper mechanical
cleaning of pockets around the neck of the tooth
should be done thoroughly because that is the most
potential area harbouring maximum strains of
bacteria.
PREPARATION OF THE PATIENT AND THE

OPERATOR
1. The sterile towel around the field of operation,
eyes of the patient, not only provide sterile field
for the operation, but also help in reducing fear
of the patient by covering his/her eyes.
2. The sterile towel is kept on back of the head of
the patient and brought forward covering base
of nose, eyes head (hairs), ears, side of ramus of
mandible, etc. It is brought forward and fastened
by sterile towel clips or safety pins.
3. The exposed portion of the face of the patient is
washed with antiseptic solution and then the chest
of the patient is covered with another sterile
towel.
4. Now a sterile towel is clipped on chest of the
operator.
5. The operator may put on the sterile hand gloves.
6. These precautions will help to avoid “Dry-socket”
condition in third molar socket after the tooth is
removed surgically and development of post-
operative infection in other intra-oral operations.
7. The position of the dental chair should be low
enough to provide relaxed position of the
operator’s hands/arms.
8. Sterile sponges (7.6 × 7.6 cms) should be placed
with one end near incisors and the other under
the tongue. The sponge will provide dry field of
operation (by absorbing the saliva) and avoid
eliminated bony chips to slip and lodge in lingual
vestibule or the throat. These sponges may be
changed from time to time, when they become
wet with ropy, heavy saliva produced due to
“sympathetic nervous system” stimulation.
9. The retractors should be placed properly to isolate
the area of operation and should be held with
Impactions 219
soft hands. No pull or stretching force should be
applied on retractors. Another assistant may
control the suction tip, if the suction machine is
employed during the operation.
10. The sterile instruments should be properly
arranged on Mayo-stand in serial order, as they
shall be required during the operation.
Classification of mandibular third molar
Impaction.
1. Mesio-angular (Fig. 14-1)
2. Horizontal (Fig. 14-2)
3. Vertical (Fig. 14-3)
4. Disto-angular (Fig. 14-4)
5. Bucco-version (Fig. 14-8)
6. Lingo-version (Fig. 14-7)
7. Low-level (Fig. 14-5)
8. High-level (Superficial) (Fig. 14-6)
Fig. 14.1: Mandibular mesio-angular impaction

Fig. 14.2: Mandibular horizontal impaction
Fig. 14.3: Mandibular vertical impaction
Fig. 14.4: Mandibular disto-angular impaction

Impactions 221
Fig. 14.5: Mandibular low-level impaction
Fig. 14.6: Mandibular high-level impaction
Fig. 14.7: Mandibula mpaction’s lingo-version position

Fig. 14.8: Mandibular impaction’s bucco-version position
GENERAL CRITERIA
a. The teeth nearer to the surface (superficial) are
easier to remove than deep (low-level) ones.
b. A tooth displaced buccally is easier to remove than
nearer to lingual plate or just behind second molar
position (where there is no space between second
and third molar)
c. A tooth may be blocked by bone above its crown
(bone block) or it may be blocked by adjacent tooth
(tooth block) or both.
d. Horizontal impactions are difficult to extract.
e. Deep disto-angular impactions are also difficult to
extract.
Impactions 223
Technique of Ossisection / Bone Removal from
Around the Impacted Tooth
Bur technique; the recent high-speed surgical pneumatic
drill, which does not give liquid spray and forced air,
is widely used for removal of impacted teeth
Advantages
1. The patient is usually familiar with the experience
of dental drills, being used by dentists, in the
patient’s mouth as compared to rare use of chisel
and mallet. So the patient cooperates better, while
quite conscious under local anesthesia.
2. The sound and the thrushes and the blows and the
pressure, etc. of the mallet and chisel are all
eliminated.
3. There is no need of an assistant to give blows on
the mallet, the required amount of force on the
mallet changes from place to place, but the assistant,
blowing the mallet, may not regulate the blow
power as per changing requirement of the operating
surgeon and damage the tissues like thin separating
bone between the socket and the maxillary sinus.
4. When bur technique is used the field of operation
is to be continuously washed with saline/or distilled
water to cool the heat generated by friction
between bone and the drill. The field of operation
automatically gets washed and remains free of any
bony fragments, blood, saliva and other debris etc.
5. When using bur the alveolar bone from around the
tooth/roots can be removed in much controlled,
delicate and desired manner as compared to chisel
technique. This feature of cutting with bur is of
great advantage while working on maxillary/
mandibular root tips, lying in close proximity of
antrum or mandibular canal. Sometimes blow of
the chisel break the thin remaining bone separating
the root from the antrum/mandibular canal and
may result into traumatic opening into either the
sinus/or the mandibular canal.
The bur can also make a desired notch more
efficiently on the residual root piece to engage an
elevator/curet etc into it without any chance of slipping,
for the safe and atraumatic removal of the root piece.
Which technique is preferred? Odentectomy (cutting
of tooth into pieces) or ossisection (cutting of the
surrounding alveolar bone)?
This question is generally asked while removing
the impactions as to which of the two technique is
better?
1. Breaking the impacted tooth into several pieces and
remove them one by one (odentectomy) without
cutting and removing much of bone.
2. Removing much of bone by ossisection with
minimum damage to the tooth and thus removing
the impacted tooth intact/or with minimum pieces.
The answer to this question is as far as possible
preserve the bone because it has to remain as residual
ridges. Hence the tooth may be sectioned into as many
pieces as required/needed because once it is extracted
it is to be discarded and it hardly matters whether it
is discarded in one piece or in several pieces.
1. Nowadays with the introduction of autoclaveable
air turbine hand piece and drills with rotating speed
of 300000 to 400000 (3-4 lakhs) rpm has become the
method of choice.
Impactions 225
2. The air turbine hand piece is easily autoclaveable,
and because infection may result into dry socket
or spread into facial planes, which are dangerous
complications, this quality has made these hand
pieces very useful.
3. Constant irrigation with copious coolant drip by
IV drip type equipment with mild antiseptic
solutions may help not only to keep the field of
operation clear of bony debris, tooth pieces/
fragments, blood, etc. but also avoid bone
necrosis/charring, etc. by cooling as well as keep
the wound clear of bacteria and clear view for the
operator.
4. The chisel technique has its own advantages and
disadvantages. It is a wise choice of a good
operating surgeon to combine merits of both bur
and chisel techniques and avoid disadvantages of
each technique.
The fundamental points of merit of each technique
and their best combinations are given below.
1. Heavy/dense bone is removed best by bur
technique, whereas chisel is used best for removal
of thin layers of relatively softer bone. This combi-
nation is mostly used in removal of maxillary third
molars.
2. The chisel is used for dividing and splitting of tooth
along natural cleavage lines. Small sectioning
especially of dentine part are better done with high
speed burs.
3. Dense bone in close vicinity of crown is eliminated
with the help of chisel not only to facilitate to clear
the path for its removal, but also to gain space
enough to split the tooth with chisel.
CRITERIA IN REMOVAL OF MANDIBULAR THIRD

MOLARS
The following criteria are of general consideration in
removal of mandibular third molars:
1. Clearance of overlying bone.
2. Removal of bone in anterior border of ascending
ramus.
3. Clearance of adjacent second molar.
4. Unfavorable root formation.
Problems that may be encountered are:
a. Proximity of inferior alveolar nerve.
b. Thin lingual plate.
c. Restricted access.
d. Abnormal bone formation.
e. Lack of visibility.
f. Any other surgical/anatomical problem.
MANDIBULAR MESIO-ANGULAR IMPACTION

The bone removal is done in a similar fashion as
described in vertical impaction.
a. The ditch/trough in the bone is made around the
crown in a similar fashion as described for the
vertical impaction (Fig. 14.12).
b. The depth of ossisection around the tooth is
increased.
c. At this point one of the many options to remove
the impaction is chosen.
Impactions 227
Option-1: Distal Crown Split Technique
1. The distal cusp is cut starting from buccal groove
to anatomical neck of the tooth.
2. This separated distal cusp is removed.
3. Now if the available space allows the rest of the
remaining portion of the tooth, i.e. mesial crown
attached to both mesial and distal roots is delivered
in single piece.
Option-2: Two Halves Technique

a. The impaction is divided into two halves mesial
and distal (Starting from buccal groove to
bifurcation of the roots).
b. The distal (superiorly lying piece) is taken out first,
followed by mesial half.
Option-3: Three Piece Technique

1. If the mesial root is embedded tightly under the
second molar, then it will not come out attached
together with the mesial crown portion.
2. In such situation the root is separated from the
crown by cutting it with bur and separated it with
the help of explorer/chisel.
3. Now when the mesial crown is separated from the
root, it is delivered, and lastly the embedded root
below the second molar is delivered.
The above-mentioned techniques are standard
commonly used techniques. Any changes may have to
be made in the mentioned techniques, here and there,
as per need of individual case and the choice of the
operator. As such there is no fixed rule applicable
uniformly to all the cases.
Fig. 14.9: For removal of mandibular mesio-angular impaction the incision

is started in the base of ascending ramus, then passing through the
tissue covering the impaction and then brought upto buccal cusp of the
second molar, then it is turned towards buccal vestibule and carried
towards first molar at an angle of 45 degrees (Diagrammatic occlusal
view)
Fig. 14.10: Diagrammatic buccal view of the incision for raising the flap
for mandibular mesio-angular impaction. Starting from base of ascending
ramus of mandible, passing from over the impaction over the middle of
the ridge, upto mesio-buccal cusp of first molar. The flap is raised along
with the periosteum, exposing the bone covering the impaction
Impactions 229
Fig. 14.11: The flap is raised as shown by red lines (imaginary). The
ossisection is done to expose the crown of impacted third molar along
with exposure of enough bone to allow entry of an elevator on buccal
side both anterior and posterior to the just exposed crown of the impacted
tooth
Fig. 14.12: Note the “ditch” made in the buccal side of the impacted
tooth, where the bone is cut at an angle of 45 degrees, down vertically,
between alveolar plate and the tooth without reducing the horizontal
level of the buccal plate
Fig. 14.13: Zoom view of Figure 14.12

Fig. 14.14: Odentectomy operation for removal of mesio-angular

impaction. In schematic diagramme, the raised flap as shown in red,
(mind it is the crown only that comes to view as shown in Fig. 14-11, but
here for simplification of what is actually happening inside under the
covered portion of the cortical plate of buccal bone of the body of
mandible, this diagramme is given here with the request to the reader to
use his/her imagination, because this will not be the visual picture.).
Now in step two, the tooth is cut either with chisel or preferably with
bur. The first cut that is given to the distal cusp, is shown in black line,
and the cut portion of the cusp is removed, if there is space to rotate the
tooth and deliver it out, it can be done now. But if the space on mesial
side is less, then the second cut to the tooth is given on mesial cusp as
shown in blue line, and the slices of the mesial crown is separated and
removed as shown by green arrows. Lastly the remaining portion of
the tooth along with the roots is removed as described in the text
Impactions 231
Fig. 14.15: Mandibular mesio-angular impaction. The operation of

odentectomy for removal of impaction is shown inthe following photos.
The reader is requested to use his/her imagination because it is only
imaginary demonstration work, but certainly exactly like real operation
as if done on the patient
Fig. 14.16: Zoom/enlarged view of Fig. 14.15
Fig. 14.17: Mesio-angular impaction. Odenctomy operation steps. The

first cut is given on the superiorly lying distal cusp almost at buccal
groove level
Fig. 14.18: Zoom view of Fig. 14.17
Fig. 14.19: Mesio-angular impaction. Odenctomy operation steps.

The cut is deepened with the help of high speed bur
Impactions 233
Fig. 14.21: Mesio-angular impaction. Odenctomy operation steps.

The cut distal cusp is separated with the help of single beveled chisel,
keeping the bevel of the chisel towards to be separated portion of the
crown. If we use bi-beveled chisel or use even single beveled chisel
keeping the bevel towards bulk of the tooth, the sudden blow on chisel
will give a reverse jerk on the tooth and may damage the already
weakened mandible or even fracture it at the angle of mandible. Now
finally the tooth is delivered as described in the text. If the space to
rotate and deliver the radicular portion of the impaction is less, then an
additional cut may be given as shown in blue line (Fig. 14.14) to separate
and remove the mesial cusp, the inset sketch shows use of elevator to
lift the radicular portion of the impacted tooth
Fig. 14.22: Zoom view of the Fig. 14.21
MANDIBULAR VERTICAL IMPACTIONS

1. Bone removal is started at muco-buccal line angle
of the third molar. First the bone is cut vertically
down to expose the convexity of the tooth (occlusal
to anatomical neck direction as well as anterior-
posteriorly direction).
2. Cutting is continued towards disto-buccal angle
at the same depth and continued on distal side
and then turned to cover around the lingual surface
of the tooth.
3. This cutting will result in a trough/ditch like
gutter made all around the tooth. The advantage
of this trough making is to expose the tooth
without reducing the vertical height of the socket.
4. This cutting should be enough to expose the tooth
sufficiently for sectioning, which should be started
now by sectioning distal 1/3rd of the crown of
the impaction.
Impactions 235
5. Now if the cutting of the bone is insufficient it
can be extended as and where required. If
insufficient then the groove should be made still
deeper in the bifurcation area of the impaction.
6. The main obstruction in this type of impaction is
by distal part of the impaction, hence sufficient
bone is removed from the distal side of the
impaction.
7. Distal crown split technique: A long vertical split is
made starting from the buccal groove, covering
the distal crown portion, upto below the
anatomical neck of the impaction. This cut distal
slice is removed.
8. Now a thin spear point elevator is forcefully
inserted between the impaction and the second
molar and the impaction is elevated. If access is
not possible between impaction and the second
molar then no.14 elevator may be employed by
engaging the beak of it into the buccal side
bifurcation area of the impaction. A force straight
upwards is now applied to lift the impaction.
9. Root division technique: If the impaction is not
delivered by distal crown split method, then a
bur is employed to increase the depth of
ossisection at bifurcation level. Next starting at
bifurcation a deep groove is cut to separate both
the roots. The distal root is left there as such.
10. Now the mesial portion of the crown along with
attached mesial root is delivered as single unit.
11. At last the remaining embedded distal root is
delivered.
Fig. 14.23: Odentectomy operation of mandibular vertical impaction.

The flap is raised as shown in red line. First cut on the tooth is given as
shown in black line, and the disto-buccal portion of the crown is sliced
and removed first as shown by violet colour arrow. Now there is enough
space for removal of rest of the portion of the tooth by elevating it
distally and removed as shown in blue line and taken out as piece no. 2
in the diagramme
Fig. 14.24: Mandibular vertical impaction.

Odentectomy operation steps. The vertical impaction
Impactions 237
Fig. 14.26: Mandibular vertical impaction. Odentectomy operation

steps. First the distal cusp is separated with a deep groove by bur
Fig. 14.28: Mandibular vertical impaction. Odentectomy operation steps.

The cut portion of the distal cusp is separated and removed. The rest of
the tooth is elevated as described in the text
Impactions 239
MANDIBULAR HORIZONTAL IMPACTION

1. The complete anatomical portion of the impacted
tooth is exposed of the overlying bone by surgical
bur as described earlier.
2. The bur is used to further expose the buccal side
bone to expose labial surface of the crown. This is,
however, done without reducing height of buccal
plate, but by making a ‘ditch’ between the bone
and buccal side of the crown.
FIVE PIECES SPLIT TECHNIQUE

Step 1
The distal 1/3rd portion of the crown (lying superfi-
cially) is cut with the help of a chisel/bur, and removed
to expose the pulp of the impaction.
Step 2
Second cut is made to separate the mesial cusp, by
starting the cut from the buccal groove to the
anatomical neck of the impaction. The mesial cusp is
separated and left as such embedded under the rest
of the bulk of impaction.
Step 3
Third cut is made at anatomical neck portion of the
impaction, and this portion of the crown from which
distal and mesial cusps were separated, is removed
now. (Triangular piece see Fig. 14.30, piece No.2)
Step 4
A cut is now made with bur at the bifurcation level to
separate both mesial and distal roots. These two roots
are delivered separately one by one (If space allows
these roots can be delivered joint together).
Step 5
The embedded mesial crown portion is now free from
all the obstructions and can be delivered (The above-
mentioned technique can be changed as per
requirement at any step as needed by the operator.)
An other method to deliver this type of impaction
is to divide the crown of the impaction from the roots
with the help of bur or chisel. The crown can now be
removed. If deemed necessary both mesial and distal
roots are separated from each other and delivered
separately one by one or joint together as one unit.
Impactions 241
Fig. 14.30: Mandibular horizontal impaction operation (kindly use

imagination). The reflection of flap is shown by red line. After exposing
the crown portion of the impacted tooth, first cut is given to superiorly
lying distal cusp by bur as shown by yellow line, and the cut disto-
buccal cusp is removed (Slice No.1). Second cut is given as shown in
light blue colour line to underlying mesial cusp, which is separated from
the tooth bulk, but is left as slice no 4 as embedded below the bulk of the
tooth, it is to be removed in the last. If the space to remove the roots and
the bulk of the tooth (Slice No.2 and 3) is enough, it may be removed in
one piece. If enough space is not present then another cut is made as
shown in green colour line at the anatomical neck portion of the tooth.
Now the triangular Slice No. 2, is separated and removed. After removal
of Portion No.2, there will be sufficient space to remove Portion No.3,
i.e. the roots of the tooth, which should be removed now. Lastly the
embedded Portion No. 4, i.e. mesial cusp portion is removed. The cleaning
of the wound, rounding of alveolar bone etc is completed and the flap is
sutured back in place
Fig. 14.31: Mandibular horizontal impaction operation steps. Mandibular

impacted third molar tooth in horizontal position. Imaginary diagrammatic
view of actual operational steps performed during odentectomy of
horizontally impacted third molar is shown in coming figures. Though
they are on model, yet do not differ from the real operation, but the
reader has to use his/her imagination

Impactions 243
Fig. 14.33: Mandibular horizontal impaction operation steps. First step is

to cut superiorly lying distal cusp. A deep groove is made starting from
buccal groove to the anatomical neck of the tooth. This is separated
with chisel and removed

Fig. 14.35: Mandibular horizontal impaction operation steps. The

second step is that the distal cusp is removed as shown in the Figure
Fig. 14.37: Mandibular horizontal impaction operation steps. Now the

inferiorly lying mesial cusp is cut with a deep groove
Impactions 245
Fig. 14.39: Mandibular horizontal impaction operation steps. The mesial

cusp is separated, but it may be left in place, bcause it is buried under
the remaining bulk of the impaction and cannot be removed at present
Fig. 14.41: Mandibular horizontal impaction operation steps. The

separated mesial cusp which was buried, is left and rest of the tooth
portion along with the roots is extracted. The roots may be delivered
joint together if there is space available or they may be separated and
removed individually, one by one
Impactions 247
Fig. 14.43: Mandibular horizontal impaction operation steps. Now at last

the inferiorly buried mesial cusp is delivered. Note the empty socket
after odentectomy and delivery of the tooth, are completed
Fig. 14.45: Mandibular horizontal impaction operation steps. All the pieces
of the removed impaction by odentectomy are assembled for display to
the readers
Impactions 249
MANDIBULAR DISTO-ANGULAR IMPACTION
Four Split / Piece Technique
1. The main obstruction to the removal of this type of
impaction is the vertical ascending part of the ramus
of the mandible.
2. After removing the buccal bone to expose the height
of contour of the impacted tooth, the bur is used
for removing the distal bone.
Fig. 14.46: Odentectomy operation for removal of mandibular disto-

angular impaction (Diagrammatic representation). Raised flap is shown
as red line. First cut on the tooth is given to distal cusp as shown in
black line starting at buccal groove upto anatomical neck of the tooth
and it is separated. Now a second cut is given on the anatomical neck
of the tooth and the crown portion is separated from the root portion of
the tooth, and the mesial crown portion, which gets separated, is
removed as shown in green arrow at no.1. The already cut distal cusp
is now removed as shown by yellow (Slice no. 2) arrow. Lastly remaining
root portion is removed as one piece or the roots are separated at point
marked by light blue line, at bifurcation of the roots and removed
individually one by one as shown by gray and violet arrows, as nos. 3
and 4 slices
Fig. 14.47: Mandibular disto-angular impaction

Impactions 251
Fig. 14.49: Mandibular disto-angular impaction operation steps. First

step is to cut distal cusp, give a deep cut starting from buccal groove to
distal anatomical neck portion of the impaction

Fig. 14.51: Mandibular disto-angular impaction operation steps. The

cut distal cusp is separated and removed (If space allows) see text

Impactions 253

second step is to cut the impaction at anatomical neck portion. The
cuspal portion is separated and removed

Fig. 14.55: Mandibular disto-angular impaction operation steps.

Third cut is given to separate both the roots

Impactions 255
Fig. 14.57: Mandibular disto-angular impaction operation steps. Both

the roots are separated with the help of chisel. The mesial root is
delivered


finally remaining distal root is delivered at last

Impactions 257
Fig. 14.61: Mandibular disto-angular impaction operation steps.

Note the empty socket


pieces of the impaction, which were removed by odentectomy, are
assembled for display to the readers
3. The distal 1/3rd portion of the crown or the

impacted tooth is divided into distal and mesial
halves by splitting it at bifurcation level.
4. Two split halves are now removed separately.
5. Alternate approach includes, division of the tooth
at crown-root level. The crown portion is removed
first, the remaining mesial and distal roots are
sectioned separate and removed one by one or both
together as the circumstances allow.
Impactions 259
Extraction of impacted mandibular left third molar
(38), bucco-version, low level, actual operation done
in the patients mouth
Fig. 14.64: Initial position/situation
Fig. 14.65: Incision given

Fig. 14.66: Note the exposed crown of the impaction
Fig. 14.67: Tooth being removed

Impactions 261
Fig. 14.68: Empty socket, after the removal of impaction
Fig. 14.69: Wound closed by sutures

MAXILLARY MESIO-ANGULAR IMPACTION
1. Cover of antibiotic/premedication/draping/intra
oral sponges and other preparations are comple-
ted. Local anesthesia is injected by infiltration
around the maxillary third molar impaction.
2. After checking the effect of local anesthesia an
incision is made over the crest of the ridge starting
from the tuberosity to cover impacted tooth and
being extended to second molar, then the incision
is extended upwards into the muco buccal fold of
the second molar (Fig. 14.70).
3. The muco-periosteal flap is raised with the help
of curet No.4 (Molt)
4. If chisel technique is used, a sharp chisel is used
to give, a vertical cut in the bone almost parallel
to distal root of second molar. The soft spengeosa
will be cut easily with light malletting strokes,
and soon the enamel crown of the impacted molar
will be visible/felt. The buccal plate may be
slightly raised/or removed completely in case of
heavy/deep impaction, on the buccal side of the
tooth.
5. In bur technique the bone around the impaction
is removed rapidly. Now with a small curet it is
ascertained whether there is any space available
between second molar and the impaction,
generally it does not exist.
6. The point of a sharp elevator can be tried to enter
into the interdental space. If much pressure is
applied between these two teeth, then chances of
fracture of tuberosity increases. In such cases bone
Impactions 263
should be first removed from distal side of the
impacted tooth, so that there is enough space for
the tooth to move distally without much pressure
being conveyed to tuberosity.
7. The tooth is removed with the help of a spear
point elevator, a no.34 elevator, or a no.14 elevator.
The point of elevator is inserted forcefully in
between the teeth, where ossisection was done,
straight, downward and buccally directed force
is applied to the impacted tooth. The point and
inferior edge of the elevator are in contact with
anatomical neck of the tooth and elevate it
downwards and outwards, if the space on distal
side is not enough wide to deliver the tooth, then
the distal cusp is removed after slicing the tooth
from the centre of the occlusal surface of the tooth
to distal anatomical neck of the tooth. But any
damage to the tuberosity should be avoided.
8. After delivery of the tooth, the socket and the cut
bone area is cleansed of extraneous hard and soft
tissue and the bony edges of the socket are
smoothened with a curet or a bone file.
9. A suture is placed across the cut on the ridge and
a second suture is placed over vertical incision.
10. After removing all sponges, curtain sponge, etc. a
sterile sponge with moistened centre with distilled
water is placed over the wound especially on the
buccal side and the patient is asked to bite on it
with pressure.
11. After few minutes when the hematoma would
have formed a post operative X-ray is made.
Another sterile sponge is placed over the wound
with the instructions to the patient to keep it
pressed for half an hour. The patient is asked to
return to his/her house with the instructions to
place ice bag from outside on the ipsilateral cheek
on the operated side for 10 minutes on and 10
minutes off for about 10-12 hours.
12. Proper analgesic is administered after about half
an hour of the operation so that the pain relieving
effect is attained before the effect of anesthesia
disappears.
Fig. 14.70: Maxillary mesio-angular impaction. Red line indicates the

incision, white circle indicates the position of the elevator, and finally the
tooth is removed in the direction indicated by black arrow. If there is
difficulty in delivery of the tooth, more bone can be removed on distal side
by bur without damage to the tuberosity, or distal cusp may be sliced with
bur as shown by blue line and the separated slice may be removed
(Shown as No.1) to make enough room for delivery of the rest of the tooth
Impactions 265
MAXILLARY VERTICAL IMPACTION (FIG. 14.71)
If there is no space between the second and the
impacted third molar, then following technique should
be used.
1. A vertical cut is made parallel to the mesial edge of
the impacted tooth. Then the bone on the buccal
side is removed carefully. Now the space is created
by careful cutting of distal surface bone, so that
any distal/or backward movement of impacted
tooth may not break the tuberosity.
2. A thin bladed elevator is now introduced between
the second and the third molar teeth. Sometimes
when sufficient space is not available for the
elevator to enter into this place between these two
teeth, enough force may be required to insert point
of the elevator into this space. That is why the bone
has already being removed from the distal side of
the impacted tooth in advance, so that this piercing/
separating force may not be conveyed to tuberosity
and break it.
3. Sometimes the impacted tooth is suddenly
delivered into the mouth of the patient and the
patient may reflexly swallow or aspirate it. That is
why a curtain of gauze is mandatory/necessary on
the distal side of the area of third molar.
4. If the tooth does not come out by this mentioned
technique a bur hole is made on the buccal side of
the tooth and it can be delivered with the help of
sharp point of elevator using buccal bone plate as
fulcrum moving the tooth downwards and
backwards.
5. If enough portion of the crown is exposed, the tooth
may be held in third molar forcep and delivered.
Fig. 14.71: Maxillary vertical impaction. Incision to expose the impaction

is sown in red. The crown of the impaction is exposed after removal of
bone and making “ditch” inthe alveolar bone as shown in the figure. The
final delivery of the tooth is done by forcep/or elevator or both as
described in the text
MAXILLARY DISTO-ANGULAR IMPACTION

This type of impaction is rare, and requires a larger
size of flap raising and extensive removal of
surrounding bone.
1. A mid crest incision is given extending from the
distal of the second molar to the curvature of the
tuberosity. Now two vertical extantions to buccal
Impactions 267
and palatal side are made just distal to second
molar. The flap is raised to expose the complete
tuberosity region (see Fig.14.72).
2. A vertical bone cut incision is given distal to second
molar upto apex. Buccal and alveolar crest bone is
removed. The bone in area distal to impaction is
removed completely using a high-speed bur
without using much of pressure.
Fig. 14.72: Modified incsion for removal of maxillary disto-angular

impaction. Note midcrest incision from curvature of the tuberosity to
distal side of the second molar, which now is divided into buccal and
palatal components and these are extended upto first molar. This type
of flap will expose the tuberosity completely along with the impaction
Fig. 14.73: Maxillary disto-angular impaction (Side view). Red line

indicates the incision, after exposure of the bone ossisection is done to
expose the impaction as shown in the figure. And finally the tooth is
removed in the direction indicated by black arrow with the help of
elevator placed on mesial side of the impaction as shown by white
circle
3. The tooth is elevated on the mesial side purchase

of elevator as high apically as possible on the
impacted tooth, because the tooth can easily be
pushed into maxillary sinus/antrum upwards and
backwards.
4. It is a good policy to use another instrument like
No.5 molt curet, simultaneously on the distal side
of the impacted tooth to guide it downwards and
do not let it slip upwards or backwards.
5. Another technique that may be employed is to use
a no.14 elevator on distal side of the impacted tooth
to bring it downwards and to mesial/forward side.
Impactions 269
6. If space allows the tooth can be held firmly in an
extraction forcep and pulled downwards and
removed (if required some more bone can be
removed with the help of bur).
7. After the tooth is delivered the wound is cleaned
and alveolar bone edges rounded with bone file,
and now the wound is stitched with multiple
interrupted sutures.
MAXILLARY CANINE IMPACTIONS

The canine impactions can be classified as:
1. Labial.
2. Palatal.
3. Intermediate.
The classification must be done properly, with the
help of occlusal and regular X-rays (Clark’s rule, buccal
object rule) because all the three categories are
operated with completely different approach, and have
almost different operations from each other. Palpation
and other clinical tests like bulge on buccal aspect may
not be sufficient, because of labially displaced roots of
incisor/or premolars due to impacted canine growth
may lead to wrong categorization. Hence the roll of
diagnostic quality X-rays in occlusal view, labio-
lingual/palatal view and extra-oral X-rays shall be
more dependable for correct classification of the
impacted canine tooth.
Palatal Canine Impaction/Position

This is the commonest among three verities of the
impacted canine.
Fig. 14.74: Palatal canine impaction. After confirmation of position of the

tooth, the incision is given to expose the palatal mucoperiosteal flap as
shown in red line. (The expected imaginary position of the canine is also
shown for facilitation of understanding of the reader)
Fig. 14.75: A window is opened in the palatal bone over middle 1/3rd
of the embedded canine as marked in black bracket
Impactions 271
Fig. 14.76: After reflecting the flap only a window is made in the middle
1/3rd of embedded canine by removing overlying bone with bur, as
indicated by yellow brackets. Now the exposed middle 1/3rd portion of
the impaction is cut at two places with bur as shown by red lines. After
separating middle 1/3rd portion of the root of the impaction, this middle
1/3rd portion of the root is taken out first, as shown in black arrow.
Secondly the crown portion is pulled into this empty window, which
was previously occupied by middle 1/3rd portion of the impacted canine.
This crown portion is removed on no.2, as indicated. Lastly on no 3, the
apical 1/3rd. portion of the root is pulled into the empty window, and is
also removed through the same window. By this technique of dividing
the tooth (Odenctomy), though the complete tooth is removed in three
sections, but the amount of bone loss is saved as compared to, if the
tooth would have been removed in one piece, where amount of over
lying bone emoval would have been three times more
1. The incision is started on the palatal inter-dental
space side in the premolar region of one side (left
or right) extended around the palatal free gingival
fibers and inter-dental spaces to the premolar of
the other side. (See Fig.14.74)
2. The thick mucoperiosteal flap is raised from the
palatal bone with No.4 Molt curet. The nerve and
vessels that comes out of incisive foramen are cut
by knife blade, at the point of their entrance into
the raised flap.
3. The palatal bone removal is started with chisel in
a square block fashion just at the back of the
incisor, which is nearest to the impacted canine,
as confirmed by radiographs. If a definite
protuberance of the impacted canine is present,
the bone should be removed from above it.
4. When the impacted tooth is located, the middle
1/3rd portion of it is exposed like a small window,
in the overlying bone. (Leaving coronal and
radicular 1/3rds undisturbed/unexposed).
5. Next a split/cut is made at the anatomical neck of
the just exposed impacted canine. If the crown of
the impacted canine lies just closed to or under
the incisor, an other cut/split is made at a distance
of about 3 mm or so apical to the first cut/split at
the anatomical neck of the tooth.
6. The small separated piece between the two cuts
is removed. Next the crown, which is lying in the
undercut below the crown of the incisor, is pulled
backward into this created space and is removed
through the same window. Now the residual
Impactions 273
portion of the impacted canine is displaced with
the help of a curet or a No. 34 elevator into the
already made space due to removal of coronal
portion of the impaction and is removed through
the same small window (See the movie on
accompanying CD).
7. Maxillary canines can be removed by bur
technique also. The bur is made to swing to and
fro (wiping motion) till a portion of impacted tooth
is located.
8. Further removal of bone is done by creating
grooves around the impacted tooth till it is
exposed.
9. The bur is ideal for sectioning the body of the
impacted canine tooth, because the gap produced
between two cut pieces by bur has some space,
facilitating removal of piece No.1 (small rounded
cut piece) because bur creates space enough for
manipulation for the removal of the cut piece of
the impacted tooth.
10. The rest of the canine cut parts (crown and root)
are removed as described and the bone chips/
debris, etc. in the wound is cleaned and the bony
socket edges are rounded with the help of curet/
bone file.
11. The wound is sutured by giving sutures in the
interdental spaces and tied on the labial side.
12. A large piece of gauze is kept over the wound,
pressed properly for 15 to 20 minutes.
13. Some operators use a prefabricated clear acrylic
plate to cover the palate including the wound
portion.
14. Some other surgeons prefer to put a stab incision
in the mucoperiosteal flap layer over the wound
and put a rubber drain to avoid formation of
dependant hematoma.
LABIAL IMPACTED CANINE (FIGS 14.77 AND 14.78)

1. The impaction is located with the help of X-rays,
clinical findings, etc.
2. A large semi lunar incision is given extending from
the labial frenum to the premolar region, with the
curvature towards the gingival margin.
3. The flap is raised as already described earlier and
bone over the impaction is also slowly removed
until the impaction is located. It may be lying high
on the facial side of the maxilla.
Fig. 14.77: Labial/buccal canine impaction position. The black bracket

indicates expected position of the impaction. Red line shows position of
incision
Impactions 275
Fig. 14.78: After reflecting the flap and ossisection to expose the
impaction, the tooth is removed by elevating it with suitable instrument
as shown by green arrow
4. Sufficient bone may have to be removed to expose

the impacted canine, when exposed, then it may be
removed with suitable elevator, curet, etc.
INTERMEDIATE CANINE IMPACTION

(FIGS 14.79 TO 14.81)
1. The usual position of impaction in this category is
that the crown of the canine lies on the palatal side,
whereas the root lies on the apices of the premolars,
near the buccal cortex (Figs 14.79 and 14.80).
2. The palate is exposed by reflecting a palatal muco-
periosteal flap; bone over the crown of the impacted
canine is removed. The exposed crown is now cut
from rest of the root portion and is removed.
3. Another separate flap is raised on the buccal side
over the pre-diagnosed position of the location of
the root portion, which was established with the
help of clinical findings and radiographs, above and
between the roots of the ipsilateral (same side)
premolars (See the movie film of operation on
accompanying video CD).
4. The bone over the root tip portion of the impacted
canine is now removed completely and the root tip
portion of the impacted tooth exposed.
5. This root tip portion is now pushed from the facial
side window into the empty space made by
removed crown of the impaction on the palatal side,
Fig. 14.79: Expected position of intermediate canine impaction as shown

in black bracket. Red line indicate the position of the incision to expose
the palatal bone, under which lies the expected impaction
Impactions 277
Fig. 14.80: The expected (Imaginary) position of the impacted canine
Fig. 14.81: Position of incision is shown in red line. Exposed crown

portion of the intermediate impacted canine. The crown portion of the
tooth is cut and removed from the exposed window as shown inthe
figure. Now a separate window is made on the ipsilateral buccal side
and careful bone removal will expose the root tip portion of the impaction,
which generally lies above and between premolars. Now the remaining
portion of the impaction is pushed from the buccal side into the palatal
wound, which was emptied by removal of crown portion of the impaction.
This portion is now removed from the palatal wound. Both the wounds
are now closed separately
and it is also removed from the palatal side wound,
and not from the buccal side.
6. Sutures now close the two separate sites
individually, after cleaning and rounding of the cut
alveolar bone.
IMPACTION OF SUPERNUMERARY TEETH

Though supernumerary teeth may be found impacted
anywhere in any region of the alveolar ridge, but the
most common site is the anterior region of the maxilla.
They may occur as single mesiodens, between the
central incisors or mesiodentes (two).
Ordinarily these mesiodens are not operated for
removal till apical foramen of permanent incisors is
closed (i.e. 10 years of age of the patient), because of
the impending danger of damage to the growing
mesenchymal portion of the tooth.
If the incisor does not erupt due to obstruction by
supernumerary teeth, they should be removed earlier,
after careful identification and location without any
danger to erupting permanent teeth.
1. Normally the maxillary supernumerary teeth are
removed through palatal approach, when the loca-
tion of the supernumerary teeth cannot be ascer-
tained by X-rays as to whether they are placed
anteriorly or posteriorly to the normal teeth,
generally only few are located on anterior side
position.
2. The technique used for their removal resembles with
the technique of removal of palatally impacted
canine.
Impactions 279
Fig. 14.82: Expected location of the maxillary supernumerary teeth,

which may be present anterior or posterior to permanent central incisors.
They can be located by reflecting a palatal flap, the incision is shown in
red line. If protuberance is present that will confirm the location/position
of the supernumerary, but other wise if no protuberance is seen then
ossisection is started just behind the incisors just on back of incisive
foramen. Ossisection is extended upward and backward till enamel of
the impaction is seen. A collar of bone should be left around the
permanent central incisor
Fig. 14.83: Palatally placed supernumerary teeth

situated posterior to permanent central incisors
Fig. 14.84: Complete (Along with roots) tooth

location of the supernumerary
Fig. 14.85: Expected site for locating the anteriorly placed supernumerary
teeth (Black bracket). The red line indicates placing of the incision
Impactions 281
Fig. 14.86: Crowns of the supernumerary teeth that are

exposed by ossisection on anterior labial/buccal plate
Fig. 14.87: Complete (Along with roots) supernumerary teeth

present anterior to the permanent central incisors
3. An incision is made around the necks of the teeth
on palatal side from premolar to premolar and the
palatal flap is raised (Figs14.82, 14.83).
4. If no bony protuberance is noticed confirming the
location of the supernumerary, then bone cutting
is started behind the permanent central incisor, just
behind the incisive foramen. The dissection is
carried out in upward and backward direction till
the enamel crown of the supernumerary is
encountered.
5. The supernumerary should be identified and
differentiated well from the permanent incisors
before being extracted. Enough bone may have to
be removed to deliver the supernumerary tooth.
6. If bilateral impaction is present, the second
supernumerary shall be a little easier to locate as
the first one has already been located and removed
and the second one is generally present in close
vicinity of the first one (See movie film for complete
operation on accompanying audio-visual CD slide
show).
7. The wound is cleaned/bony edges smoothened and
finally the wound is closed in the usual manner.
IMPACTED MANDIBULAR SUPERNUMERARY

PREMOLARS
a. Mandibular impacted supernumerary premolars are
difficult to remove, because of the compact
surrounding bone and presence of vital organs like
mental foramen structures, on the labial side and
salivary glands and neurovascular structures on the
lingual side.
Impactions 283
Fig. 14.88: Supernumerary premolar (erupted) on lingual side between

35 and 36. The caries developed in 35 and 36 due to non-cleansing area
and stagnation of food. 36 was, however, was exposed, hence RCT
was advised and done
b. The occlusal X-ray should be consulted for ascer-

taining the position of the mandibular super-
numerary premolar, which may be:
A. On the buccal side.
B. On the lingual side.
C. Intermediate between buccal and lingual plates.
(Most frequent).
1. A double flap is made by two vertical components
of an incision at some distance and connected by
incisions around the necks of the teeth in between
the vertical components of the cut.
2. If the tooth lies embedded inside the lingual plate
it is very difficult and hazardous to locate it and
dissect to reach it. If it lies enough erupted on
lingual side it presents no much problem.
3. If the supernumerary tooth is not developed
completely, then it may be difficult to remove it,
because of narrow access. In such case a small thin
instrument can be placed between the teeth to
engage the impacted supernumerary premolar and
tap softly with a mallet and separate and deliver
the impacted tooth. A bur hole on the surface of
the impacted tooth may help to engage it more
firmly and avoid it’s slipping under the instrument’s
hold.
4. After the delivery of the supernumerary the wound
is cleaned of bony debris, the margins of the bone
are rounded and the flap sutured in place.
MOLAR SUPERNUMERARY TEETH

Because they occur on distal side of the molar series,
hence they are removed as impacted third molars.
FIFTEEN
REMOVAL OF
DECIDUOUS TEETH
As far as possible extractions in children should be
avoided/postponed, till permanent teeth erupts, but
if it is a must the following considerations should be
considered.
1. The age of the child.
2. His or her maturity.
3. Any dental treatment taken by the child in the past,
which may change his/her present attitude towards
the present dental problem.
4. Physique of the child, whether healthy or compro-
mised.
5. The expected time the operation is likely to take
and how much work is to be done during the
present surgery.
ANESTHESIA
Younger children who are innocent and do not
understand reasoning are generally operated best
under general anesthesia.
Indications for General Anesthesia

1. In younger children who do not understand
reasoning and are quite innocent.
2. The presence of pain, fear, sight, smell, surgical
atmosphere, pressure exerted by operator during
surgery, noise due to instrumentation, will always
be associated with psychology of the child shall
turn him/her anxious and rebellious.
3. Slight discomfort is always associated with local
anesthesia.
Removal of Deciduous Teeth 287
4. Some surgeons give a push/pressure on shoulder
of the child and then explain that the child is likely
to feel pressure of the instruments, something like
this, during the extraction movements etc, but
certainly it is not the pain.
5. The child should be appreciated after the surgery
for his/her brave attitude and cooperation during
the surgery.
6. In case of child patient, he/she should not be made
to wait in clinic or outer office or waiting room.
He/she should be taken for surgery immediately
and the job to be done is completed as soon as
possible. This quickness will give the child no time
to develop and accumulate the feeling of fear,
apprehension, etc.
7. Premedication in case of apprehended child
patient will help him/her to be calm and quite
and more cooperative, children become restless
if more time is consumed during surgery.
8. The child in no case should see the instruments/
syringe/needles etc. used for surgery and
anesthesia. These should come from behind the
patient from a mayo stand, which should have
been well covered with sterile surgical towels,
when the child was taken to the dental chair.
9. Because there is resorption of the roots of the
deciduous teeth due to formation and eruption
of permanent teeth below them, hence the
extraction of deciduous teeth is not difficult as
far as firmness of the tooth in the socket is
concerned. Another criteria that help is that the
spongiosa of the developing bone is soft, which
gives way under much less force of extraction as
compared to fully developed dense bone of adults.
10. Cow horn forcep (no.16) is not used for extraction
of deciduous teeth, because the penetrating beaks
of the forcep in bifurcation area may damage the
developing permanent premolar tooth, which lies
just between the much-divided roots of the
deciduous molars.
11. The six anteriors (both maxillary and mandibular)
are removed with movements first towards labial
side, followed by mesial rotation and then
pressure in the line of removal, because of presence
of developing permanent incisors, which are
situated just on the lingual side and has already
resorbed the bone and could be damaged if
sudden slip force results as discrepancy of force
applied by the operator and unexpected/
unpredicted movement of the tooth under that
force.
12. The maxillary or mandibular molars are luxated
to buccal or lingual area and taken out from mesial
or distal side, because of root curvature in mesio-
distal direction.
13. The preoperative X-ray for deciduous tooth to be
removed is very essential, because the roots of
the deciduous may resorb unequally/or unusually.
Very thin roots may be present and may break at
the time of extraction of the tooth. In such case
very careful use of small elevator or curet may be
done to remove it, because of the presence of
permanent tooth just below it.
Removal of Deciduous Teeth 289
14. If the broken root tip is locked under developing
permanent tooth, then the permanent tooth is
likely to be injured during removal of root tip of
deciduous tooth locked below it. It is better to
leave the root tip of deciduous tooth, because it
will get resorbed or shall be pushed up by
developing permanent tooth and can be removed
conveniently and harmlessly at that time.
15. Sometimes the growth of developing permanent
premolar may be completely wedged tightly
between the bell shaped roots of the deciduous
molar. Great care must be taken, that this
developing permanent tooth bud may not be
extracted along with deciduous tooth, being
caught between the vice like roots of deciduous
tooth.
Fig. 15.1: Removing the retained 61. For complete procedure watch
accompanying CD, movie slide no. 66
In such case where the permanent tooth bud has
been locked in between the roots of deciduous molar
(pre-diagnosed by X-rays prior to decision of
extraction of deciduous molar tooth), the deciduous
tooth is divided into mesial and distal portions and
extracted one by one leaving the permanent tooth bud
in situ.
If by chance the developing bud of the permanent
premolar is extracted attached along with deciduous
tooth the bud should be replaced back into the socket
(replantation), without any trauma/tackling, keeping
in mind about maintaining it’s anatomical position that
the buccal side on buccal and lingual side on lingual
side of the alveolus. A suture to close the socket will
keep the bud in situ.
SIXTEEN
EMERGENCIES IN
DENTAL CLINIC:
SYNCOPE (FAINTING)
EMERGENCIES IN DENTAL CLINIC: SYNCOPE
(FAINTING)
It is probably the commonest emergency usually
associated with administration of local anesthetic
agent. The etiology is inadequate blood supply to the
brain (hypoxia), resulting from the disturbance in
control mechanism of normal blood pressure. Dilata-
tion of splanchnic vessels causes fall of blood pressure
and thus there is decrease in cerebral blood flow.
The start of syncope is characterized by the follow-
ing symptoms:
1. Pallor, dizziness, light-headedness, clammy skin,
nausea, and sometimes loss of consciousness. The
treatment consists in placing the patient in supine
position, with the head lowered than the rest of
the body. (Tilting of the chair backwards and raising
the feet of the patient).
2. Airway is maintained and oxygen started.
3. Patient is made to smell mild respiratory stimulants
such as spirit of ammonia. Analeptics are more
potent but are only used if specifically indicated.
4. The law of prevention is better than cure, should
be utilized and syncope should be better avoided
than to render any treatment for it. Psychic behavior
of the patient should be noted before the adminis-
tration of local anesthetic agent. Measures should
be taken to eradicate/remove the apprehension.
Emergencies in Dental Clinic 293
DELAYED REACTIONS
1. Delayed or less severe reactions may include
swelling at the site of injection, angio-nurotic
oedema, pruritus and urticaria.
2. The treatment consists in administration of
antihistamines and palliative care of the patient.
Toxic reactions, of local anesthetic agent and other
drugs like penicillin, sulfonamides and other antibiotics
commonly used by dentists, is characterized by initial
excitement phase followed by deep depression phase.
The patient may become talkative, anxious and nausea
and vomiting may occur in excitement phase. This
initial short phase may be followed by convulsions
and then into marked depression.
1. The piston of the syringe should always be sucked
back to check suction of blood into the syringe,
before the local anesthetic solution is injected into
the tissues. If the blood is being sucked, then the
position of the tip of the needle should be changed,
again suck the piston back and check, till there is
no blood whatsoever into the syringe. Now the
solution should be injected very slowly into the
tissue (Local anesthetic solution should never be
injected into a blood vessel).
It is always a good policy to inject a very small
quantity of local anesthetic solution into the tissue
and wait, after some lapse of time another small
doze is injected again. If there is no untoward
reaction then the rest amount of local anesthetic
solution may be injected slowly. If during any time
any untoward reaction occurs the needle should
be withdrawn immediately.
Worth mentioning here that all the time while
injecting local anesthetic solution into the tissue for
mandibular block anesthesia the point of the needle
should always be in contact with the bone. This
will avoid injection being deposited into the parotid
gland and development of facial paralysis for over
two months, if the needle is too long and the point
of the needle looses contact with the bone and
patient opening his mouth too wide, the needle may
pass through in between coronoid and condiloid
processes and reach into parotid gland through
which passes the facial nerve situated just superficial
to that area. Some times the injection may be
deposited into mastoid artery/or posterior
auricular artery and cause ischemia (of the vessels
supplying the seventh nerve) resulting into transient
facial paresis.
3. Most of the toxic reactions of the anesthetic agent
are of minor nature and requires palliative care
treatment. If convulsions do occur and become
intense, in that case to control them, a short acting
barbiturate or diazepam should be given by intra-
venous injection. Oxygen should be started
immediately to ensure adequate oxygen supply to
the vital organs. If the stimulation phase is of short
duration or of mild nature, no sedatives are given
but only oxygen is given and steps are immediately
taken to maintain adequate blood circulation.
4. If the reaction is of grievous nature involving
central nervous system, stimulation or depression
or involving cardiovascular system collapse,
immediate expert professional help should be called
for. This step does not indicate inefficiency on part
of the dentist, but proves good judgment on his/
her part (From medicolegal aspect also).
5. To avoid any reaction to any drug, a careful
exploring history should be taken prior to use of
the drug, especially the local anesthetic agents.
6. The allergic reactions may be quick developing, i.e.
anaphylactic reaction. Here the patient feels extre-
mely apprehensive, intense itching occurs and
asthmatic breathing occurs. Urticaria may develop
rapidly, the blood pressure falls and the pulse may
be week or absent. The patient may go into
unconscious state with or without convulsions.
Death may occur immediately or after few hours.
7. The treatment of anaphylactic reaction is as follows:
a. Epinephrine is the drug of choice because it is
bronchodilator, vasopressor and has antihista-
minic effect.
b. The dosage in an adult ranges from 0.3 to 1.0
mg. (0.3 to 1.0 ml. of a 1:1,000 solution), sub-
cutaneously, intramuscularly or intravenously
or may be in along with intravenous drip. The
intravenous drip should be started immediately
to maintain fluid balance. (If intravenous route
is selected to administer epinephrine it should
be injected slowly, although the total doze will
remain the same)
c. Antihistaminic drugs such as diphenhydramine
50 mg is given intramuscularly or intravenously
d. Corticosteroids such as hydrocortisone 100 mg
intravenous or intramuscularly are given to
maintain peripheral vascular effect.
e. Oxygen under positive pressure with assisted
respiration should be also given immediately
to the patient.
f. Professional aid should be made available as
soon as possible. If symptoms continue, further
administration of epinephrine or histamine or
both may be continued.
8. Dentist and his team (assistants) should be trained
to meet the emergencies, though rare in occurrence,
but can result in grievous results if the team is not
prepared well in advance.
9. Teeth displaced to oropharynx:
a. This condition presents no problem provided
they are recovered before they go into the
deeper structures.
b. When an extracted tooth is displaced to
oropharynx in a patient under local anesthesia
effect, he/she is instructed not to breathe or
swallow till the tooth is recovered.
c. If it occurs during general anesthesia, every
thing stops/stand still till the tooth is retrived.
Assistant should make no movements in suction
tip/retractors, etc. because any movement can
cause the loss of tooth into the larynx or eso-
phagus.
d. When the extracted tooth slips into the posterior
pharynx, the normal reflex of the patient is either
swallow or cough; in many cases the patient will
swallow the tooth. Regardless of reaction of the
patient, the exact location of the swallowed
tooth should be determined by radiographs. If
the tooth is located in the gastrointestinal tract.
The patient should be given high bulk diet, so
that it will come out with the fesses. The patient
should collect the fesses and it should be
thoroughly checked for confirmed removal of
the tooth. (Generally the tooth passes out
without any symptoms/incidence)
e. If the tooth is lodged in the respiratory tract,
during coughing the patient may cough out the
foreign body (tooth), or it will be lodged into
the pharynx or aspirated into tracheobronchial
tree. For dislodging larger objects abdominal
thrust procedure should be used.
f. If the tooth is launched in the larynx, laryngeal
spasm may precipitate, blocking the exchange
of air by the lungs. The tooth may be removed
with laryngoscope or McGill forcep. If the tooth
can not be removed quickly, the air way must
be established immediately by performing crico-
thyroidotomy.
This can be done by locating triangular shaped
cricothyroid membrane beneath the thyroid cartilage
(Adam’s apple), which is the largest tracheal cartilage,
and the cricoid cartilage, which is the next inferior
tracheal cartilage. The cricothyroidotomy is done
through this triangular shaped membrane.
Oxygen should be given through this established
airway until laryngeal spasm is over.
g. The displaced teeth in tracheobronchial tree
present great problems. A specialist, specially
trained in methods of bronchoscope, can only
do the removal of this foreign body. The patient
may cough continuously and become cyanosed.
The patient in such cases should be shifted to
hospital, where the tooth should be located and
removed by direct bronchoscopy by experts.
The tooth or debris aspirated into the lungs may
result in lung abscess formation.
h. Radiographs should be taken to confirm the
removal of the foreign body from elementary
tract or air way
i. Needless to stress, “prevention is better than
cure”. Hence the very occurrence of such
conditions should be avoided by taking proper
prophylactic measures like screens of gauze/
throat packs, etc. before the operation is started.
REMOVAL OF THE TEETH UNDER GENERAL

ANESTHESIA
1. The team for using general anesthesia should be
well organized, disciplined, and should work as a
team. It generally comprises of surgeon, anesthetics,
and assistants for running/operating the suction
apparatus/retraction of tissue/instrument nurse,
providing instruments to the surgeon or to help
wield the mallet, if chisel technique is employed.
2. In inducing general anesthesia to the patient the
following combinations may be used:
a. Inhalation alone.
b. Barbiturates alone.
c. Barbiturates + oxygen + nitrous oxide gas, in
combination with more potent halothane gas.
d. In addition local anesthetic agent is sometimes
used for local vasoconstriction action and to
reduce the quantity of barbiturates used in
lengthy procedures.
3. Mouth prop are inserted immediately prior to
induction of anesthesia. Two types of mouth props
are generally used, solid rubber bite block type or
ratchet type. After induction of the anesthesia the
prop is adjusted to the degree of the opening
required.
4. The mouth packing is done now. The pack is placed
so as to hold the tongue and the soft tissues of the
floor of the mouth but not so posteriorly to
stimulate the oropharynx.
If inhalation anesthesia is used airtight pack is
essential to maintain anesthesia through nasal mask
only. Extra sponges may be needed to check exce-
ssive bleeding, because of lack of vasoconstrictive
agents in general anesthesia.
5. The surgical team should waste no time after
induction of anesthesia, and start the operation
straight away. After removal of the tooth all the
mouth packs are removed and the suction of the
mouth completed, the socket is collapsed and
covered with gauze pack. The mouth prop is closed,
but lefts in place till the patient respond. The patient
is finally shifted to recovery room.
6. During longer procedures the gauze sponge is kept
over mouthpiece and changed frequently. A careful,
unhurried, efficient technique should be developed
using powerful suction, which should be kept in
most dependent part of the mouth and not
necessarily into the socket itself.
7. The suction apparatus should be powerful and all
blood, saliva, debris, bone chips, etc. should be
cleaned out, and the mouth should remain free of
any debris, so that this debris may not irritate the
larynx of the patient under operation. The
neurosurgical suction tip is more appropriate for
use in oral surgery because it can enter even into a
socket, than using of a “tonsil suction” tip which
sucks liquids better because of its larger head.
8. The technique of exodontia does not lie in force,
but lies in tact and intelligence. Because the patient
under anesthesia feels no pain and all his/her
guards against pain are dulled, hence tendency to
apply more force on the elevator or rough retraction
of the soft tissues will not be protected by reflexes
of the patient during operation and may result
adversely.
9. The fundamental rule of surgery is “lesser the
trauma, lesser are the post operative complications
and better is the sequlae/result”.
Which Patients Need Hospitalization for Exodontia

1. If the patient is having a medical management
problem along with extraction of a tooth, the patient
should be admitted to a hospital and the tooth
should be extracted when all the medical problems
are under control, strictly under the supervision of
experts/physian, etc.
2. If the patient is to be operated under general
anesthesia he/she should be admitted to a hospital,
where facilities of operation theater, anesthetist,
recovery room and trained staff is available to meet
any emergency that may arise during or after the
surgery.
3. The routine electrocardiogram (ECG), bleeding
time (BT), coagulation time (CT), hemoglobin (Hb)
and other essential tests as required in individual
case like blood sugar estimation in diabetic case
etc should be done prior to surgery.
4. In hospital better facilities for sterilization are
available. The mouth and face of the patient should
be cleaned as per protocol.
5. Proper equipment, trained staff of the hospital
provides better postoperative facilities, especially
during recovery stage. (Nausea, vomiting, etc.)
6. The patient should be discharged from the hospital,
when all the parameters are normal and the patient
feels healthy enough to leave for his/her house.
MANAGEMENT OF ACUTE INFECTED CASE

1. Acutely infected cases may be operated when the
infection is under control; the infection (pus) is
localized due to antibiotic therapy, etc.
2. The blood level of the antibiotic should be
maintained as soon as possible, to avoid spread of
infection to adjacent tissues. Toxemia, bacteremia,
pyaemia, septicemia, should be avoided by proper
coverage of antibiotics (operating under umbrella
of antibiotics).
3. The antibiotic should be continued for three more
days after the extraction of the tooth, when all the
symptoms of infection are over.
SEVENTEEN
COMPLICATIONS OF
EXODONTIA
1. The complications arise from wrong judgment in
diagnosis, improper use of instruments, lack of
visibility, application of wrong and strong forces
by the operator, etc.
2. In extraction of upper premolars special care must
be taken not to open into maxillary sinus/antrum.
3. All upper molars extraction, including tuberosity
region should be paid due care, because of close
proximity of maxillary sinus/antrum. Bone
removal, root removal etc, any upward force
application, and the use of elevator should be done
very carefully, not to push root stump/piece into
the sinus.
4. If the maxillary sinus does open inspite of all the
precautions, it should be closed properly at that
time only. The patient should be warned not to
blow through the nose or mouth.
5. After the tooth is delivered the spicules of bone
and bony projections on sides of the socket should
be properly rounded with rongeur or curet, and if
the flap was raised it should be replaced and
sutured properly in its place.
6. Sometimes buccal roots of maxillary premolars are
pushed laterally through the wall of the maxilla
and lie above the attachment of buccinator muscle.
While using any elevator on these root pieces, the
operator should keep the finger of the left hand
over the buccal plate so that he/she can feel any
movement of the root, if it is pushed into that
direction. If the root is pushed up into this area, a
Complications of Exodontia 305
small incision is made over the root lying above
the attachment of buccinator muscle and it is picked
up by hemostat, etc.
7. The infratemporal space is situated posterior and
superior to maxillary tuberosity. This space contains
many important neurovascular structures. During
extraction of maxillary third molars, the root
remnants, or supernumerary teeth in that region,
great care must be taken not to dislodge them
posteriorly into this space. If at all any thing is
pushed into this space and requires removal, it
should not be done by just trying to grasp it blindly,
because this act may damage a vessel or a nerve,
resulting into massive hemorrhage or nerve
damage.
8. In the lower third molar region, the lingual plate
curves laterally near the root apices. Sometimes
when the lingual plate is fractured during extraction
of lower third molar tooth and the root tip is
broken, it may slip inferiorly into this space. A
finger should be kept in the mouth posterior and
inferior to the root tip so that it may not slip further
deep into this space and the free root piece may
remain stabilized. Access to it is obtained by an
incision on lingual plate to raise a mucoperiosteal
flap and the stabilized piece of the root is delivered
through this incision window.
9. In case the broken root tip of lower third molar is
pushed into mandibular canal, it is very difficult to
remove it, because to reach it from base of the
socket is difficult due to lack of visibility (light)
and depth of the wound. In such case access should
be made through a window cut in the buccal plate,
locate and remove the root tip, without injury to
inferior alveolar nerve or vessels passing through
the canal. If the vessel is injured, the hemorrhage
is controlled with gauze pieces soaked in adrenaline,
packed tightly into the wound for ten minutes or
so. If the hemorrhage still persist the vessel should
be severed completely and allowed to retract into
the canal.
POST EXTRACTION COMPLICATIONS

Hemorrhage
1. Postoperative hemorrhage is the commonest
complication after extraction of tooth.
2. The patient may inform the surgeon that the
bleeding has started again, after he/she has reached
home after the surgery is over. In such case the
patient should be instructed to clean his/her mouth
with a gauze piece if available or by rinsing the
mouth with warm saline water, leaving the clot
intact in the socket. If a sterile gauze piece is
available it should be placed over the socket and
pressed by teeth of the opposite jaw for fifteen
minutes to half an hour. If gauze piece is not
available a tea bag may be used instead. If the
bleeding does not stop in half an hour the patient
should report back to the clinic.
3. At clinic a sterile gauze piece, gel foam, topical
thrombin, oxidized cellulose or avitene may help
to check the bleeding.
4. If the hemorrhage is, however, not controlled by
these measures, the patient is injected with local
anesthesia with adrenaline. The clot formed in the
socket is removed. The bleeder is located and
crushed with a sterile ballpoint burnisher point. If
the bleeding still persists, the socket may be packed
with gel foam soaked in thrombin and a pressure
suture may be applied over it. The usual gauze plug
is placed over the stitched socket and kept under
pressure of opposite teeth for half an hour. If the
bleeding is from the surrounding soft tissues a
tension suture should be placed to apply pressure
in the surrounding tissues.
INFECTION
Can be treated with the judicial use of appropriate
antibiotics.
Dry Socket (Localized Osteitis)

It is very perplexing, extremely painful condition. The
exact cause of the condition is not known, but the
following factors are considered to be contributory
factors.
a. Excessive trauma.
b. Infection.
c. Decreased blood supply of the surrounding bone
of the socket.
d. General systemic conditions.
Treatment
1. Minimum trauma to the tissues should be given
during extraction of simple or impaction tooth.
2. Careful cleaning of the wound from bony chips,
hemorrhage clots, soft and unhealthy granulation
tissue should be ensured, and bone spicules of the
socket should be rounded, the socket should be
collapsed by pressure of the finger and thumb of
the surgeon.
3. All the time high standards of sterilization should
be maintained.
4. Dense osteosclerotic bone or the teeth having
osteosclerotic alveolar walls, because of chronic
infection are the predisposing causes of dry socket.
5. Dry socket generally develops on third or fourth
day of the operation and is diagnosed by presence
of severe continuous pain in the socket and presence
of typical necrotic odor from the mouth of the
patient. Clinically the hematoma formed in the
socket of the tooth which was extracted few days
back, gets necrosed. This necrosed clot along with
other debris should be removed with warm water
irrigation of the socket curetting is contraindicated.
Because this denuded bone is severely/extremely
painful, hence potent analgesic packs/dressings
should be applied locally into the socket. A light
dressing of quarter of an inch of plain gauze
saturated with a paste of equal parts of thymol
iodide powder and benzocaine crystals dissolved
in eugenol may be packed into the socket. Systemic
administration of analgesics or narcotics will help
to relieve the pain. Antibiotics seem to have no roll
unless systemic signs of infection are present. The
socket takes quite some time (two to three weeks)
to heal, so till then the dressings may have to be
changed daily or on alternate days.
Index
A Antibiotics 52
antibiotic therapy 53
Analgesics and antipyretics 88
ampicillin (extended
aminophenol derivatives
89 spectrum group)
actions 89 56
uses 89 erythromycin 65
NSAIDs (nonsteroid anti- penicillin 54
inflammatory drugs) penicillin-V 56
90 indications and
effect 90 contraindications of
highest risk 93 antibiotic therapy
intermediate risk 93 74
lowest risk 93 use of prophylactic
warning 93 antibiotic 74
salicylates 88
action 88 B
contraindications 89
uses 88 Bacteria 50
trigeminal neuralgia; aerobic strains 50
carbamazepine 90 anaerobic stains 50
dozes 90
Anesthesia used for C
exodontia 109
age and physical status of Celphalosporin group 65
the patient 110 Chloramphenicol 66
drug allergy 120 Choice of antibiotic 69
emotional status of the Complicated exodontics 179
patient 120 alveoloplasty 180
nature and duration of inter-radicular
operation 112 alveoloplasty 187
radial alveoloplasty pregnancy 10
185 psychosis and
simple alveoloplasty neurosis 11
185 pyrexia of unknown
Complications of exodontia origin 10
303 senility 11
infection 307
dry socket (localized F
osteitis) 307 Forceps used for
treatment 308 upper/superior/
post extraction maxillary molars
complications 306 148
hemorrhage 306
G
D
General outlines for
Delayed reactions exodontia 99
of syncope 293 after extraction of the
tooth 104
E anesthesia 100
extraction by forcep 102
Extraction of teeth 6 position of the hands of
clinic and equipment 11 the operator 102
oxygen cylinder 12 position of the patient in
radiograph viewer 12 the chair 100
sterilized tray/basin 11 preparation and draping
contraindications 8 101
acute infection 9
acute pericronitis 8 I
addisonian crisis 8 Impactions 215
indications 6 impacted mandibular
systemic conditions 9 supernumerary
Addison’s disease 10 premolars 282
blood dyscrasias 10 impaction of
cardiac diseases 9 supernumerary teeth
nephritis 10 278
Index 313
intermediate canine L
impaction 275
Lower incisors and canines 153
labial impacted canine 274
extraction movements 154
mandibular disto-angular
position of the left hand
impaction 249
and fingers of the
four split/piece
operator 153
technique 249
position of the operator
mandibular horizontal
and the assistant 153
impaction 239
Lower/inferior/or
five pieces split
mandibular molars 164
technique 239
forceps to be used for
mandibular mesio-
extraction 165
angular impaction 226
movements given on the
distal crown split
forceps for extraction
technique 227
165
three piece technique
position for extraction of
227
the right side quadrant
two halves technique
molars 164
227
mandibular vertical
impactions 234
position of the operator’s
maxillary canine
hand and its fingers
impactions 269
for the extraction 165
palatal canine
position of the operator’s
impaction/position
left hand and its
269 fingers for
maxillary disto-angular extraction 165
impaction 266 Lower/mandibular
maxillary mesio-angular premolars 160
impaction 262 movements of the forcep
maxillary vertical 161
impaction 265 position of the left hand
Infective organism and and fingers of the
antibiotic sensitivity 77 operator 161
Isolation of the patient from position of the left hand
the operating team 46 of the operator 160
position of the operator maxillary roots 192
and the assistant 160 residual roots 202
position of the operator Removal of deciduous teeth
and the assistant 160 285
using mead forcep 161 anesthesia 286
indications for general
M anesthesia 286
Removal of the teeth under
Management of acute
general anesthesia 298
infected case 301
Molar supernumerary teeth
S
284
Scrubbing 42
N Sterilization 28
boiling water sterilization
Narrow spectrum antibiotics 32
70 chemical sterilization 33
Nystatin 67 benzalkonium
chloride 33
O glutaraldehyde 33
Operation room decorum 42 hexachlorophenes 33
chemical vapor
P sterilization 34
dry heat sterilization 32
Patient need hospitalization
gas sterilization 34
for exodontia 300
ethylene oxide 34
Principles of elevators 205
Sterilization and care of
using of straight elevator
instruments 24
207
Sterilization on bulk level 35
Subacute bacterial
R endocarditis (SBE) 82
Radiation sources 36 sequences 82
Removal of broken/chipped/ first set of 82
residual roots of the second set of 83
teeth 191 third set of 83
mandibular roots 197 Surgical flap 171
open reduction indications 172
procedure 198 procedure 175
Index 315
Surgical instruments 18 position of the left hands
Allis forcep 24 and fingers of the
chisel 18 operator 136
curets 18 Upper/superior/maxillary
hemostats 24 lateral incisor 134
high speed motor, anatomy 134
handpiece, and bone movements of extraction
burs 18 135
needle holder 24 position of the operator
Rongeur forcep 18 and the assistant 134
single tooth forcep 24 Upper/superior/maxillary
suturing needle 24 molars 146
Syncope (fainting) 292 extraction movements 148
delayed reactions 293 forcep used 148
T position of the operator’s
Transient bacteremia 81 left hand and its
fingers 147
U Upper/superior/maxillary
premolars 141
Upper/maxillary central
anatomy of the tooth 141
incisor 124
extraction movements 141
forcep used 124
forcep used 141
position of the left hand
124
rationale/result of and fingers 141
extraction movements position of the operator
125 141
Upper/superior/maxillary Use of therapeutic antibiotics
canine 136 67
anatomy of the tooth 136
forcep used 136 V
movements of the forcep Viral conditions (Hepatitis B)
136 85

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Step by Step®

Pramod Bansi Mathur

Sanjay Bansi Mathur

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

First Edition: 2008

If making of the denture is the butter for the dentist

Pramod Bansi Mathur

Index ...................................................................... 311

RECORDING OF BLOOD PRESSURE

INDICATIONS FOR EXTRACTION

CLINIC AND EQUIPMENT REQUIRED FOR ORAL

Fig. 2.7: Chisels and the mallet

Fig. 2.8: Zoom view of the cutting edge

Fig. 2.9: Front view of chisels shown in Fig. 2.8

Fig. 2.12: From left to right; Rongeur, Gum separator, Periosteal

Fig. 2.13: Zoom view of bone cutting bur.

Fig. 2.14: Top; Multi-doze 30 ml bottle of 2% lignocane hydrochloride

Fig. 2.15: Needles, needle holder and suture cutting scissors

Russian forceps: V Mueller Co. 15 cm. For grasping tooth.

STERILIZATION AND CARE OF INSTRUMENTS

The timings and pressure maintenance will depend

Fig. 3.1: Vertical, autoclave

Fig. 3.2: Vertical, autoclave Fig. 3.3: Latest autoclave to be

Fig. 3.4: Modern autoclave to be kept on tabletop

Fig. 3.5: Electric “boiling water” sterilizer

Boiling Water Sterilization

Dry Heat Sterilization

Chemical Vapor Sterilization

STERILIZATION ON BULK LEVEL

GENERAL OBSERVATIONS REGARDING

Method Temperature Time Comments

Recent studies shows that gram-negative bacteria

Fig. 5.1: Kirby-Bauer method for testing

SOME FACTS ABOUT ANTIBIOTIC THERAPY

Narrow Spectrum Antibiotic

Ampicillin (Extended spectrum group)

for 30-40 min in

Oral-250-500 mg odontogenic 4-6 times a day penicillin. penicillin.

Tetracycline 250- Exacerbations of Adults—1-2 gm daily Pregnancy, Tooth discoloration,

Use of Therapeutic Antibiotics

Use Least Adverse Reaction Causing Drugs

Use of Prophylactic Antibiotic

Prevention of Wound Infection

Increased Rate of Infection due to

Infective Organism and Antibiotic Sensitivity

Timing of the Antibiotic Administration

The Dozes of Antibiotics during/after Surgery

Last Doze Immediately after Surgery

Table 5.2: Prophylaxis of wound infection

Table 5.2A: Oral regimen

Prevention of Metastatic Infection

Subacute Bacterial Endocarditis (SBE)

First Set of Sequences (In the heart)

THIRD SET OF SEQUENCES

Table 5.3: Recommended SBE prophylaxis regimen:

Viral Conditions (Hepatitis-B)

Analgesics (Pain killers) 91

Name of drug Action/Effect Doze Contraindications Side effect

Analgesics (Pain killers) 95

Name of drug Action/Effect Doze Contraindications Side effect

control pain for

Analgesics (Pain killers) 97

POSITION OF THE PATIENT IN THE CHAIR