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Full text of "Contemporary Oral and Maxillofacial Surgery,4th Ed Part II Principle of Exodontia"

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Principles of Uncomplicated 
Exodontia 



Larry j. Peterson 



Chapter outline 



CHAPTER 



PAIN AND ANXIETY CONTROL 

Local Anesthesia 

Sedation 
PRESURGICAL MEDICAL ASSESSMENT 
INDICATIONS FOR REMOVAL OF TEETH 

Severe Caries 

Pulpal Necrosis 

Severe Periodontal Disease 

Orthodontic Reasons 

Malopposed Teeth 

Cracked Teeth 

Preprosthetic Extractions 

Impacted Teeth 

Supernumerary Teeth 

Teeth Associated with Pathologic Lesions 

Preradiation Therapy 

Teeth Involved in Jaw Fractures 

Esthetics 

Economics 
CONTRAINDICATIONS FOR THE REMOVAL OF TEETH 

Systemic Contraindications 

Local Contraindications 
CLINICAL EVALUATION OF TEETH FOR REMOVAL 

Access to Tooth 

Mobility of Tooth 

Condition of Crown 



RADIOGRAPHIC EXAMINATION OF TOOTH FOR 
REMOVAL 

Relationship of Associated Vital Structures 

Configuration of Roots 

Condition of Surrounding Bone Summary 

PATIENT AND SURGEON PREPARATION 
CHAIR POSITION FOR FORCEPS EXTRACTION 
MECHANICAL PRINCIPLES INVOLVED IN TOOTH 

EXTRACTION 
PRINCIPLES OF FORCEPS USE 
PROCEDURE FOR CLOSED EXTRACTION 
Role of Opposite Hand Role of Assistant 
During Extraction 
SPECIFIC TECHNIQUES FOR REMOVAL OF EACH TOOTH 

Maxillary Teeth 

Maxillary Incisor Teeth 

Maxillary Canine Maxillary 

First Premolar Maxillary 

Second Premolar Maxillary 

Molar Mandibular Teeth 
Mandibular Anterior Teeth 
Mandibular Premolars 
Mandibular Molars 

Modifications for Extraction of Primary Teeth 
POSTEXTRACTION CARE OF TOOTH SOCKET 



113 



PART II 



Principles of'Exodontia 



Extracrion of teeth is a procedure that incorporates 
the principles of surgery and many principles from 
physics and mechanics. When these principles are 
applied correctly, a tooth can probably be removed intact 
from the alveolar process without untoward sequelae. 
This chapter presents the principles of surgery and 
mechanics for uncomplicated tooth extraction. In addi- 
tion to a discussion of the fundamental underlying prin- 
ciples, there is also a detailed description of techniques 
for removal of specific teeth with specific instruments. 

At the outset it is important to remember that removal 
of a tooth does not require a large amount of brute force 
but rather can he accomplished with finesse and con- 
trolled force in such a manner that the tooth is not pulled 
from the hone but instead is lifted gently from the alveo- 
lar process. During the preoperative period the degree of 
difficulty that is anticipated for removing a particular 
tooth is assessed. If the preoperative assessment leads the 
surgeon to believe that the degree of difficulty will be 
high and the initial attempts at tooth removal confirm 
this, a deliberate surgical approach — not an application 
of excessive force — should be taken. Excessive force may 
injure local tissues and destroy surrounding bone and 
teeth. Moreover, excessive force heightens the intraoper- 
ative discomfort and anxiety of the patient. The most 
efficient way to remove a tooth is slowly. 

PAIN AND ANXIETY CONTROL 

The removal of a tooth is a challenge to the dentist. This 
is because profound local anesthesia is required to pre- 
vent pain during the extraction, and control of the 
patient's anxiety is necessary to prevent psychologic dis- 
tress. Local anesthesia must be absolutely profound to 
eliminate sensation from the pulp, perindontal ligament, 
and buccolingual soft tissues. 

It is equally important for the dentist to recognize the 
anxiety that invariably exists in patients about to under- 
go tooth extraction. Few patients face this procedure with 
tranquility, and even patients with no overt signs of anx- 
iety are likely to have internal feelings of distress. 



Local Anesthesia 

Profound anesthesia is needed if the tooth is to be 
removed without pain for the patient; therefore it is 
essential that the surgeon remember the precise innerva- 
tions of all teeth and surrounding soft tissue and the 
kinds of injection necessary to anesthetize those nerves 
totally. Table 7-1 summarizes the sensory in nervation of 
the teeth and surrounding tissue. It is important to 
remember that, in areas of nerve transition, some overlap 
exists. For example, in the region of the mandibular sec- 
ond premolar, the buccal soft tissues are Innervated pri- 
marily by the mental branch of the inferior alveolar nerve 
but also by terminal branches of the long buccal nerve. 
Therefore it may be necessary to supplement the inferior 
alveolar nerve block with a long buccal nerve block to 
achieve adequate anesthesia of the buccal soft tissue 
when extracting this particular tooth. 

When anesthetizing a maxillary tooth for extraction, 
the surgeon should anesthetize the adjacent teeth as well. 
During the extraction process the adjacent teeth are usu- 
ally subjected to certain amounts of pressure, which may 
be sufficient to cause the patient pain. This is also true for 
mandibular extractions, but the mandibular-block anes- 
thetic usually produces sufficient anesthesia. 

Profound local anesthesia results in the loss of all pain, 
temperature, and touch sensations, but it does not anes- 
thetize the proprioceptive fibers of the involved nerves. 
Thus the patient feels a sensation of pressure, especially 
when the force is intense. The surgeon must therefore 
remember that the patient will need to distinguish between 
sharp pain and the dull, albeit intense, feeling of pressure. 

In spite of profound soft tissue anesthesia and appar- 
ent pulpal anesthesia, the patient may continue to have 
sharp pain as the tooth is luxated. This is especially like- 
ly when the teeth have a pulpitis or the surrounding soft 
and hard tissues are inflamed or infected. A technique 
that should be employed in these situations is the peri- 
odontal ligament injection. When this injection is deliv- 
ered properly and the local anesthetic solution injected 
under pressure, immediate profound local anesthesia 
occurs in almost all situations. The. anesthesia is relative- 



% TABLE 7-1 ■ 


Sensory Innervation of Jaws 


Nerve 


Teeth 


Soft Tissue 


Inferior alveolar nerve 


All mandibular teeth 


Buccal soft tissue of premolars, canine, 
and incisors 


Lingual nerve 


None 


Ungual soft tissue of all teeth 


Long buccal nerve 


None 


Buccal soft tissue of molars 


Anterior superior alveolar nerve 


Maxillary incisors and canine tooth 


Buccal soft tissue of incisors and canine 


Middle superior alveolar nerve 


Maxillary premolars and portion of first 
molar tooth 


Buccal soft tissue of premolars 


Posterior superior alveolar nerve 


Maxillary molars except for portion of 
first molar tooth 


Buccal soft tissue of molars 


AnLerior palatine nerve 


None 


Lingual soft tissue of molars and premolar; 


Nasopalatine nerve 


None 


Lingual soft tissue of incisors and canine 



Mnciples of Uttcuffiplkated Exodonliu 



CHAPTER 7 



11 



ly short-lived, so the surgical procedure should be one 
that can be accomplished within 15 or 20 minutes. 
Intraosseous injections may be used where standard and 
periodontal ligament injections have failed. The 
Stabident System is useful for the intraosseous injection. 

It is important to keep in mind the pharmacology of 
the various local anesthetic solutions that are used so that 
they can be employed properly. Table 7-2 summarizes the 
commonly used local anesthetics and the amount of time 
they can be expected to provide profound anesthesia. The 
dentist must remember that pulpal anesthesia of maxil- 
lary teeth after local infiltration lasts a much shorter time 
than does pulpal anesthesia of mandibular teeth after 
block anesthesia. In addition, pulpal anesthesia disap- 
pears 60 to 90 minutes before soft tissue anesthesia docs. 
Therefore it is quite possible that a patient may still have 
lip anesthesia after having lost pulpal anesthesia and may 
be experiencing pain. 

Only a certain amount of local anesthetic can be safe- 
ly used in a given patient. To provide profound anesthe- 
sia for multiple tooth extractions, it may be necessary to 



'ABLE 7-2 



Duration of Anesthesia 











Local 
Anesthetic 


Maxillary 
Teeth 


Mandibular 
Teeth 


Soft Tissue 


Croup 1* 
Croup 2* 
Croup 3* 


10-20 min 
50-60 min 
60-90 min 


40-60 min 
90-100 min 
3 hr 


2-3 hr 
3-4 hr 

4-9 hr 



*Group 1 : Local anesthetics without vasoconstrictors. 
Mepivacainp 3%. 
Prilocaine 4%. 

+Group 2: Local anesthetics with vasoconstrictors. 
Lidocaine 2% with 1 :50,000 or 1 : 100,000 epinephrine. 
Mepivacaine 2% with 1 :20,000 levonordefrin, 
Prilocaine 4% with 1 :400,000 epinephrine. 
Articaine 4% with 1:100,000 epinephrine. 
+Group 3 : Long-acting local anesthetics. 
Bupivacaine 0.5% with 1 :?00,000 epinpphrine. 
Etidocaine 1 .5% with 1 :200,000 epinephrine. 



inject multiple cartridges of local anesthetic. Thus it is 
important to know how many cartridges of a given local 
anesthetic solution can be administered safely. Table 7-3 
summarizes (in two different ways) the maximal amounts 
of local anesthetic that can be used. First, each local anes- 
ihelic has a recommended maximal dose based on mil- 
ligrams per kilogram. The second column in Table 7-3 
indicates the number of cartridges that can safely be used 
on a Healthy 154 pound (70 kg) adult. It is rarely neces- 
sary to exceed this dose, even in patients larger than 154 
pounds. Patients who are smaller, especially children, 
should be given proportionally less local anesthetic. The 
most likely victim of overdose is the small child to whom 
3% mepivacaine (Carbncaine) is administered. For a 
patient who weighs 44 pounds (20 kg), the recommended 
maximal amount of mepivacaine is 100 mg. If the child 
is given two cartridges of 1.8 ml each, the dose totals 
108 mg. Therefore a third cartridge of 3% mepiva-caine 
should be avoided. It is wise to remember that the 
smallest amount of local anesthetic solution sufficient to 
provide profound anesthesia is the proper amount. 

Although it is self-evident that local anesthesia is nec- 
essary for intraoperative pain control, the surgeon should 
also acknowledge its role in postoperative pain control. 
For routine extractions where mild-to-moderate anal- 
gesics only will be necessary, usually no additional local 
anesthetic is necessary. After procedures that have been 
more traumatic (e.g., the removal of impacted teeth) and 
where stronger analgesics arc likely to be necessary, many 
surgeons use a long-lasting local anesthetic (e.g., 
etiodocaine), instead of or in addition to their usual local 
anesthetic. By doing this the clinician provides the 
patient with 4 to 6 hours of local anesthetic with no pain. 
This method also allows adequate time for the patient to 
take the required analgesics and for the analgesics to take 
effect before the discomfort begins. 

Sedation 

Management of patient anxiety must be a major consider- 
ation in oral surgical procedures. Anxiety is a more impor- 
tant factor in oral surgical procedures than in other areas 
of dentistry. Patients are frequently already in pain and 
may be agitated and fatigued, both of which lower the 



TABLE 7-3 



Recommended Maximal Local Anesthetic Doses 




Lidocaine 2% with 1 :1 00,000 epinephrine 
Mepivacaine 2% with 1 :20,000 levonordefrin 
Mepivacaine 3% (no vasoconstrictor) 
Prilocaine 4% with 1 ;200,000 epinephrine 
Articaine 4% with 1 :1 00,000 epinephrine 
Bupivacaine 0.5% with 1 :200,000 epinephrine 
Etidocaine 1.5% with 1:200,000 epinephrine 



Maximal Number 


Number of Cartridges 


Number of Cartridges 


of mg/kg 


for 70 kg (1S4 


lb) 


Adult 


for 20 kg (44 lb) Child 


5.0 


10 


3.0 


5.0 


10 






3.0 


5.0 


6 






2.0 


5.0 


6 






2.0 


7.0 


6 






1.5 


1.5 


10 






3.0 


8.0 


15 






5.0 



116 PART II 



I'rmtipkb of ExotUmLiu 



Patient's ability to deal with pain or pain-producing situa- 
tions. Patients who are to have extractions may have 
predetermined concepts of how painful such a procedure 
will be; they have seen other patients, including family 
members, who have reported how painful it is to have a 
tooth extraction. They arc thus convinced that the 
procedure they are about to undergo will be 
uncomfortable. In addition, patients may experience 
certain psychologic complications when surgical 
procedures are being performed. The removal of teeth 
causes a variety of reactions; a patient may mourn tor 
lost body parts or perceive the extraction as a 
confirmation that youth has passed. In such situations, 
patients would like to avoid the extraction; because they 
cannot avoid it, they become doubly agitated. 

Finally, anxiety is likely to be higher because the 
procedure is truly uncomfortable. As noted 
previously, although the sharp pain is eliminated by 
local anesthetic, a considerable amount of pressure 
sensation still exists. Other noxious stimuli are 
present during an extraction procedure, such as the 
cracking of bone and clicking of instruments. For these 
reasons, prudent dentists use a prospective planned 
method of anxiety control to prepare themselves and 
their patients for the anxiety associated with tooth 
extraction. 

Anxiety control may sometimes consist of a proper 
explanation of the planned procedure, including assur- 
ance that there will be no sharp pain and an 
expression of concern, caring, and empathy from the 
dentist. For the mildly anxious patient with a caring 
dentist, no pharma-cologic assistance is necessary. 

As patient anxiety increases, it becomes necessary to 
employ pharmacologic assistance. Fundamental to all 
anxiety-control techniques are a thorough explanation 
of the procedure and an expression of concern. These 
are augmented with drugs given in a variety of ways. 
Preop-erative orally administered drugs, such as 
diazepam, may provide a patient with rest the night 
before the surgery and some relief of anxiety in the 
morning. However, orally administered drugs are 
usually not profound enough to control moderate-to- 
severe anxiety once the patient enters the operative 
suite. 

Sedation by inhalation of nitrous oxide and oxygen 
is frequently the technique of choice and may be the 
sole technique required for many patients who have 
mild-to-moderate anxiety. If the dentist is skilled in 
the use of nitrous oxide and the patient requires a 
routine, uncomplicated surgical procedure, nitrous 
oxide sedation is frequently sufficient. 

An extremely anxious patient who is to have several 
uncomplicated extractions may require parenteral seda- 
tion, usually by the intravenous (IV) route. IV sedation 
with anxiolytic drugs, such as diazepam or midazolam 
with or without a narcotic, allows patients with 
moderate anxiety to undergo surgical procedures with 
minimal psychologic stress. If the dentist is not skilled 
at using this modality, the patient should be referred 
to a dentist or oral maxillofacial surgeon who can 
provide it. 

Further discussion of the techniques of oral, inhala- 



tion, or IV sedation is beyond the scope of this text. 
PRESURGICAL MEDICAL ASSESSMENT 

When evaluating a patient preoperatively, it is critical 
that the surgeon examine the patient's medical status, 
Patients may have a variety of maladies that require treat- 
ment modification before the required surgery can be 
performed safely. Special measures may be needed to con- 
trol bleeding, prevent infection, and prevent worsening 
of the patient's preexisting disease state. This information 
is discussed in detail in Chapter 1 . The reader should refer 
to that chapter for information regarding the specifics of 
altering treatment for medical management reasons. 

INDICATIONS FOR REMOVAL OF TEETH 

Teeth are removed from the mouth for a variety of reasons. 
Although the position of modern dentistry is that all pos- 
sible measures should be taken to preserve and maintain 
teeth in the oral cavity, it is still necessary to remove some 
of them. This section discusses a variety of general indica- 
tions for removing teeth. It must be remembered that these 
indications are recommendations and not absolute rules, 



Severe Caries 

Perhaps the most common and widely accepted reason to 
remove a tooth is that it is so severely carious that it can- 
not be restored. The extent to which the tooth is carious 
and is considered to be nonrestorable is a judgment call 
to be made between the dentist and the patient. 



Pulpal Necrosis 

A second, closely aligned rationale for removing a tooth 
is the presence of pulp necrosis or irreversible pulpitis 
that is not amenable to endodontics. This may he the 
result of a patient declining endodontic treatment or of a 
root canal that is tortuous, calcified, and untreatable by 
standard endodontic techniques. Also included in this 
general indication category is the endodontic failure. In 
this situation, endodontic treatment has been done but 
has failed to relieve pain or provide drainage. 

Severe Periodontal Disease 

A common reason for tooth removal is severe and exten- 
sive periodontal disease. If severe adult periodontitis has 
existed for some time, excessive bone loss and irreversible 
tooth mobility will be found. In these situations the 
hypermobile teeth should be extracted. 

Orthodontic Reasons 

Patients who are about to undergo orthodontic correc- 
tion of crowded dentition frequently require the extrac- 
tion of teeth to provide space for tooth alignment. The 
most commonly extracted teeth arc the maxillary and 
mandibular first premolars, but second premolars or a 
mandibular incisor may occasionally require extraction 
for this same reason. 



Principles of Uncomplicated Exodordiu 



CHAPTF.R 7 



IP 



Malopposed Teeth 

Teeth that are malopposed or malpositinned may be indi- 
cated for removal in several situations. If they traumatize 
soft tissue and cannot be repositioned by orthodontic 
treatment, they should be extracted. A common example 
of this is the maxillary third molar, which erupts in severe 
buccal version and causes ulceration and soft tissue trau- 
ma in the check. Another example is malopposed teeth 
that arc hypererupted because of the loss of teeth in the 
opposing arch. If prosthetic rehabilitation is to be carried 
out in the opposing arch, the hynererupted teeth may 
interfere with construction of an adequate prosthesis. In 
this situation the malopposed teeth should be considered 
for extraction. 

Cracked Teeth 

A clear but uncommon indication for extraction of teeth 
is a tooth that is cracked or has a fractured root. The 
cracked tooth can be painful and is unmanageable by a 
more conservative technique. Even endodontic and com- 
plex restorative procedures cannot relieve the pain of a 
Clacked tooth. 

Preprosthetic Extractions 

Occasionally, teeth interfere with the design and proper 
placement of prosthetic appliances, that is, full dentures, 
partial dentures, or fixed partial dentures. When this hap- 
pens, preprosthetic extractions are necessary. 

Impacted Teeth 

Impacted teeth should be considered for removal. If it 
is clear that a partially impacted tooth is unable to 
erupt into a functional occlusion because of inadequate 
space, interference from adjacent teeth, or some other 
reason, it should be scheduled for surgical removal. 
However, it removing the impacted tooth is contraindi- 
cated, such as in cases of medical compromise, full 
bony impaction in a patient who is over the age of 35, 
or in a patient with advanced age, then the tooth may 
be retained. See Chapter 9 for a more thorough discus- 
sion of this topic. 

Supernumerary Teeth 

Supernumerary teeth are usually impacted and should be 
removed. A supernumerary tooth may interfere with 
eruption of succedaneous teeth and has the potential for 
causing their resorption and displacement. 

Teeth Associated with Pathologic Lesions 

Teeth that are involved in pathologic lesions may require 
removal- In some situations the teeth can be retained and 
endodontic therapy performed, however, if maintaining 
the tooth compromises the complete surgical removal of 
the lesion, the tooth should be removed. 



Preradiation Therapy 

Patients who are to receive radiation therapy for a 
variety of oral tumors should have serious consideration 
given to removing teeth in the line of radiation therapy. 
See Chapter 18 for a more thorough discussion of the 
effects of radiation therapy on the teeth and jaws. 

Teeth Involved in Jaw Fractures 

Patients who sustain fractures of the mandible or the 
alveolar process occasionally must have teeth 
removed. In a majority of situations the tooth involved 
in the line of fracture can be maintained, but if the 
tooth is injured or severely luxated from the 
surrounding bony tissue, its removal may be necessary 
to prevent infection. 

Esthetics 

Occasionally, a patient requires removal of teeth for 
esthetic reasons. In these situations teeth may be 
severely stained, as with tetracycline staining or 
fluorosis, or they may be severely malopposed and 
usually protruding. Although other techniques, such as 
bonding, can be employed to relieve the staining 
problem, and orthodontic or osteotomy procedures can 
be used to correct severe protrusion, the patient may 
choose to have extraction and prosthetic 
reconstruction. 

Economics 

A final indication for removal of teeth is economic. All 
of the indications for extraction already mentioned 
may become stronger if the patient is unwilling or 
unable financially to support the decision to maintain 
the tooth. The inability of the patient either to pay for 
the procedure or to lake enough time from work to 
allow it to be performed may require that the tooth be 
removed. 



CONTRAINDICATIONS FOR THE REMOVAL 

liven if a given tooth meets one of the requirements for 
removal, in some situations the tooth should not be 
removed because of other factors or contraindications 
to extraction. These factors, like the indications, are 
relative in their strength. In some situations the 
contraindication can be modified by the use of 
additional care or treatment, and the indicated 
extraction can be performed. In other situations, 
however, the contraindication may be so significant 
that the tooth should not he removed until the 
severity of the problem has been resolved. Generally 
the contraindications are divided into two groups: (1) 
systemic and (2) local. 

Systemic Contraindications 

Systemic contraindications preclude extraction 
because the patient's systemic health is such that the 
ability to withstand the surgical insult may be 
compromised (see 



118 PART II 



Principles ofExodontia 



Chapter 1). One systemic contraindication is a group of 
conditions called severe uncontrolled metabolic diseases. 
Brittle diabetes and end-stage renal disease with severe 
uremia are part of this group. Patients with mild diabetes 
or well-controlled severe diabetes can be treated as rea- 
sonably normal patients. It is only when the disease 
process becomes uncontrolled that the patient should 
not have a tooth removed. 

Patients who have uncontrolled leukemias and lym- 
phomas should not have teeth removed until the 
leukemias can be brought under control. The potential 
complications are infection as a result of nonfunctioning 
white cells and excessive bleeding as a result of an inade- 
quate number of platelets. Patients with any of a variety 
of severe uncontrolled cardiac diseases should also have 
their extractions deferred until the disease can be brought 
under control. Patients with severe myocardial ischemia, 
such as unstable angina pectoris, and patients who have 
had a recent myocardial infarction (MI) should not have 
a tooth extracted. Patients who have severe uncontrolled 
hypertension should also have extractions deferred, 
because persistent bleeding, acute myocardial insufficien- 
cy, and cerebrovascular accidents are more likely to occur 
as a result of stress caused by the extraction. Patients who 
have severe, uncontrolled cardiac dysrhythmias should 
have their extraction procedures deferred as well. 

Pregnancy is a relative contraindication; patients who 
are in the first or last trimester should have their extrac- 
tions deferred if possible. The latter part of the first 
trimester and the first month of the last trimester may be 
as safe as the middle trimester for a routine uncomplicat- 
ed extraction, but more extensive surgical procedures 
should be deferred until after the child has been delivered. 

Patients who have a severe bleeding diathesis, such as 
hemophilia, or severe platelet disorders should not have 
teeth extracted until the coagulopathy has been correct- 
ed. Most severe bleeding disorders can be controlled by 
the administration of coagulation factors or platelet 
transfusions. Close coordination with the patient's hema- 
tologist can result in an uncomplicated recovery from the 
extraction procedure in most situations. Similarly, 
patients who take anticoagulants can have routine 
extractions performed when care is taken to manage the 
patient appropriately. 

Finally, patients who take or have taken a variety of 
medications should have surgery performed with cau- 
tion. Drugs to watch for include corticosteroids, immuno- 
suppressives, and cancer chemotherapeutic agents. 

Local Contraindications 

Extractions of indicated teeth have several local con- 
traindications. The most important and most critical is a 
history of therapeutic radiation for cancer. Extractions 
performed in an area of radiation may result in osteora- 
dionecrosis and therefore must be done with extreme 
caution. Chapter 19 discusses this in detail. 

Teeth that are located within an area of tumor, espe- 
cially a malignant tumor, should not be extracted. The 
surgical procedure for extraction could disseminate cells 
and thereby hasten the metastatic process. 



Patients who have severe pericoronitis around an 
impacted mandibular third molar should not have the 
tooth extracted until the pericoronitis has been treated. 
Nonsurgical treatment should include irrigations, antibi- 
otics, and removal of the maxillary third molar to relieve 
impingement on the edematous soft tissue overlying the 
mandibular impaction. If the mandibular third molar is 
removed in the face of severe pericoronitis, the incidence 
of complications increases. If the pericoronitis is mild 
and the tooth can be removed easily, then immediate 
extraction may be performed. 

Finally, the acute dentoalveolar abscess must be men- 
tioned. It is abundantly clear from many prospective 
studies that the most rapid resolution of an infection sec- 
ondary to pulpal necrosis is obtained when the tooth is 
removed as early as possible. Therefore acute infection i 
not a contraindication to extraction. However, it maybe 
difficult to extract such a tooth because the patient may 
not be able to open the mouth sufficiently wide, or it may 
be difficult to reach a state of adequate local anesthesia, 
If access and anesthesia considerations can be met, the 
tooth should be removed as early as possible. 

CLINICAL EVALUATION OF TEETH FOR 



In the preoperative assessment period the tooth to be 
extracted should be examined carefully to assess the diffi- 
culty of the extraction. A variety of factors must be specif- 
ically examined to make the appropriate assessment. 

Access to Tooth 

The first factor to be examined in preoperative assess- 
ment is the extent to which the patient can open 
the mouth. Any limitation of opening may compromise 
the ability of the surgeon to do a routine 
uncomplicated extraction. If the patient's opening is 
substantially com-promised, the surgeon should 
plan for a surgical approach to the tooth instead of a 
forceps extraction Additionally the surgeon should look 
for the cause of the reduction of opening. The most 
likely causes are trismu; associated with infection, 
temporomandibular join (TMJ) dysfunction (especially 
internal joint derangemert with displacement of the 
disk without reduction), and muscle fibrosis. 

The location and position of the tooth to be extracted 
within a dental arch should be examined. A properlly 
aligned tooth has a normal access for placement of eleva- 
tors and forceps. However, crowded or otherwise malop- 
posed teeth may present difficulty in positioning the 
proper forceps onto the tooth for extraction. When access 
is a problem, a compromise forceps must be chosen or 
surgical approach may be indicated. 

Mobility of Tooth 

The mobility of the tooth to be extracted should to 
assessed preoperatively. Greater-than-normal mobility is 
frequently seen with severe periodontal disease. If 
teeth are excessively mobile, an uncomplicated 
tooth 



Principles of Uncomplicated Exodontia ■ CHAPTER 7 




FIG. 7-1 A, Tooth with severe periodontal disease with bone loss and wide periodontal ligament 
space. This kind of tooth is easy to remove. B, Retained mandibular second primary molar with an 
absent succedaneous tooth. It is submerged, and likelihood for ankylosed roots is high. 




FIG. 7-2 Teeth with large carious lesions are likely to fracture during extraction, making 
extraction more difficult. 



removal should be expected, and there should be more 
involved and complicated soft tissue management after 
the extraction (Fig. 7-1, A). 

Teeth that have less-than-normal mobility should be 
carefully assessed for the presence of hypercementosis 
or ankylosis of the roots. Ankylosis is often seen with 
primary molars that are retained and have become sub- 
merged (Fig. 7-1, B); in addition, it is seen occasionally 
in nonvital teeth that have had endodontic therapy 
many years before the extraction. If the clinician 
believes that the tooth is ankylosed, it is wise to plan for 
a surgical removal of the tooth as opposed to a forceps 
extraction. 



Condition of Crown 

The assessment of the crown of the tooth before the 
extraction should be related to the presence of large caries 
or restorations in the crown. If large portions of the 
crown have been destroyed by caries, the likelihood of 
crushing the crown during the extraction is increased; 
thus causing more difficulty in removing the tooth (Fig. 
7-2). Similarly, the presence of large amalgam restorations 
will produce a weakness in the crown, and the restoration 
will probably fracture during the extraction process (Fig. 
7-3). In these two situations it is critical that the forceps 
be applied as far apically as possible so as to grasp the root 
portion of the tooth instead of the crown. 



120 PART II 



Principles ofExodontia 



If the tooth to be extracted has a large accumulation of 
calculus, the gross accumulation should be removed with 
a scaler or ultrasonic cleaner before extraction. The rea- 
sons for this are that calculus interferes with the place- 
ment of the forceps in the appropriate fashion, and frac- 
tured calculus may contaminate the empty tooth socket 
once the tooth is extracted. 

The surgeon should also assess the condition of the 
adjacent teeth. If the adjacent teeth have large amalgams 
or crowns or have had endodontic therapy, it is impor- 
tant to keep this in mind when elevators and forceps are 
used to mobilize and remove the indicated tooth. If the 
adjacent teeth have large restorations, the surgeon should 
use elevators with extreme caution, because fracture of 
the restorations may occur (Fig. 7-4). The patient should 
be informed before the surgical procedure about possible 
damage to these restorations. 




FIG. 7-3 Teeth with large amalgam restorations. These are likely to 
be fragile and to fracture when extraction forces are applied. 








RADIOGRAPHIC EXAMINATION OF TOOTH 

It is essential that proper radiographs be taken of the tooth 
to be removed. In general, periapical radiographs provide 
the most accurate and detailed information 
concerning the tooth, its roots, and the surrounding 
tissue. Panoramic radiographs are used frequently, but 
their greatest useful-ness is for impacted teeth as 
opposed to erupted teeth. 

For radiographs to have their maximal value 
they must meet certain criteria. First of all, they must be 
prop erly exposed, with adequate penetration and good 
con trast. The radiographic film should have been 
proper positioned, so that it shows all portions of the 
crown and roots of the tooth under consideration without 
distortion (Fig. 7-5). The radiograph must be properly 
processed, with good fixation, drying, and mounting. 
The mounting should be labeled with the patient's 
name and the date on which the film was exposed. The 
radiograph should be mounted in the American Dental 
Association stan-dardized method, which is to view 
the radiograph as if looking at the patient; the raised dot 
on the film faces the observer. The radiograph should be 
reasonably current; as to depict the presently existing 
situation. Radiograph: older than 1 year should 
probably be retaken before sur-gery. Finally, the 
radiograph must be mounted on a view box that is 
visible to the surgeon during the operation, 
Radiographs that are taken but not available during sur- 
gery are of no value. 

The relationship of the tooth to be extracted to adjacent 
erupted and unerupted teeth should be noted. If it is a pri 
mary tooth, the relationship of its roots to the underlying 
succedaneous tooth should be carefully noted. It is possi- 
ble that the extraction of the primary teeth can injure or 
dislodge the underlying tooth. If surgical removal of a 
root or part of a root is necessary, the relationship of the 
root structures of adjacent teeth must be known. Bone 
removal should be performed judiciously whenever it is 
necessary, but it is particularly important to be careful 
if adjacent roots are close to the root being removed. 





■ 



FIG. 7-4 Mandibular first molar. If it is to be removed, surgeon must take care not to fracture 
amalgam in second premolar with elevators or forceps. 



Principles of Uncomplicated Bxodoutki 



CHAPTER 7 



121 



Relationship of Associated Vital Structures 

When performing extractions of the maxillary molars, it is 
essential to be aware of the proximity of the molars' roots 
to the floor of the maxillary sinus. If only a thin layer of 
bone exists between the sinus and the roots of the molar 
teeth, the potential for perforation of the maxillary sinus 
during the extraction increases. Thus the surgical treat- 
ment plan may be altered to an open surgical technique, 
with division of the maxillary molar roots into individual 
roots before the extraction proceeds (Fig. 7-6). 

The inferior alveolar canal may approximate the roots 
of the mandibular molars. Although the removal of an 
erupted tooth rarely impinges on the inferior alveolar 
canal, if an impacted tooth is to be removed, it is impor- 
tant that the relationship between the molar roots and 
the canal be assessed. Such an extraction may lead to 
injury to the canal and cause consequent anesthesia of 
the inferior alveolar nerve (Fig. 7-7). 




FIG. 7-5 Properly exposed radiographs for extraction of mandibu- 
lar first molar. 



A periapical radiograph taken before the removal of 
mandibular premolar teeth should include the mental 
foramen. Should a surgical flap be required to retrieve a 
premolar root, it is essential that the surgeon know where 
the mental foramen is to avoid injuring the mental nerve 
during flap development (see Fig. 7-3; Fig. 7-8). 

Configuration of Roots 

Radiographic assessment of the tooth to be extracted 
probably contributes most to the determination of diffi- 
culty of the extraction. The first factor to evaluate is the 
number of roots on the tooth to be extracted. Most teeth 
have the typical number of roots, in which case the sur- 
gical plan can be carried out in the usual fashion, but 
many teeth do have an abnormal number of roots. If the 
number of roots is known before the tooth is extracted, 
an alteration in the plan can be made to prevent fracture 
of the additional roots (Fig. 7-9). 

The surgeon must know both the curvature of the 
roots and the degree of root divergence to plan the 
extraction procedure. Roots of the usual number and of 
average size may still diverge substantially and thus make 
the total root width so wide that it prevents extraction 
with normal forceps. In situations of excess curvature 
with wide divergence, surgical extraction may be required 
(Fig. 7-10). 

The shape of the individual root must be taken into 
consideration. Roots may have short, conic shapes that 
make them very easy to remove. However, long roots 
with severe and abrupt curves or hooks at their apical end 
are more difficult to remove. The surgeon must have 
knowledge of the roots' shapes before surgery to allow an 
adequate plan to be made (Fig. 7-1 1). 

The size of the root must be assessed. Teeth with short 
roots are easier to remove than teeth with long roots. A 
long root that is bulbous as a result of hypercementosis is 
even more difficult to remove. The periapical radiographs 
of older patients should be examined carefully for evi- 




FIG. 7-6 Maxillary molar teeth immediately adjacent to sinus present increased dan- 
ger of sinus exposure. 



122 PART H ■ Principles of Exudotitia 








FIG. 7-7 Mandibular molar teeth that are close to inferior alveolar canal. Third molar removal is 
procedure most likely to result in injury to nerve. 






FIG. 7-8 Before premolar extractions that require a surgical flap are performed, it is essential 
to know relationship of mental foramen to root apices. Note radiolucent area at apex of second 
premolar, which represents mental foramen. 



dence of hypercementosis, because this process seems to 
be a result of aging (Fig. 7-12). 

The surgeon should look for evidence of caries extend- 
ing into the roots. Root caries may substantially weaken 
the root and make it more liable to fracture when the 
force of the forceps is applied (Fig. 7-13). 

Root resorption, either internal or external, should be 
assessed on examination of the radiograph. Like root 
caries, root resorption weakens the root structure and 
renders it more likely to be fractured. Surgical extraction 
may be considered in situations of extensive root resorp- 
tion (Fig. 7-14). 



The tooth should be evaluated for previous endodon- 
tic therapy. If there was endodontic therapy many years 
before the extraction process, there may be ankylosis or 
the tooth root may be more brittle. In both of these situ- 
ations, surgical extraction may be indicated (Fig. 7-15). 

Condition of Surrounding Bone 

Careful examination of the periapical radiograph indi- 
cates the density of the bone surrounding the tooth to be 
extracted. Bone that is more radiolucent is likely to be less 
dense, which makes the extraction easier. On the other 



Principles, of Uncomplicated Exodvniki 



CHAPTER 7 



123 



hand, if the bone appears to be radiographically opaque 
(indicating increased density) with evidence of condens- 
ing osteitis or other sclerosis-like processes, it will be 
more difficult to extract. 

The surrounding bone should also be examined care- 
fully for evidence of apical pathology. Teeth that have 
nonvital pulps may have periapical radiolucencies that 
represent granulomas or cysts. It is important to be aware 
of the presence of such lesions, because they should be 
removed at the time of surgery (Fig. 7-16). 




Summary 

Presurgical assessment of the patient includes evaluation of 
the level of anxiety, determination of health status and any 
necessary modifications of routine procedures, evaluation of 
the clinical presentation of the tooth to be removed, and 
radiographic evaluation of the tooth root and bone. All four 
of these major factors must be weighed when estimating the 
difficulty of the extraction. If any factor or combination of 
factors presents a level of difficulty that seems too great, the 
dentist should refer the patient to an oral and maxillofacial 
surgeon. 





FIG. 7-11 Curvature of roots of this tooth is unexpected. 
Preoperative radiographs allow surgeon to plan extraction more 
carefully. 



F1C. 7-9 Mandibular canine tooth with two roots. Knowledge of this fact 
preoperatively may result in less traumatic extraction. 





FIG. 7-10 Widely divergent roots of this maxillary first molar make 
extraction more difficult. 



FIG. 7-12 Hypercementosis increases difficulty of these extrac- 
tions, because roots are larger at apical end than at cervical end. 

Surgical extraction will probably be required. 



124 PAET II ■ Principles ofExodontia 





FIG. 7-13 Root caries in first premolar tooth make extraction 
more difficult, because fracture of tooth is likely. Note 
hypercementosis of second premolar. 



FIG. 7-1 4 Internal resorption of root makes closed 
extraction almost impossible because fracture of root will almost 
surely occur. 




FIG. 7-1 5 Tooth made brittle by previous endodontic therapy. It is thus more difficult to 
remove. 



iYmriptesofUncoinpikaledExadontia ■ CHAPTER 7 125. : 




FIG. 7-16 A, Periapical radiolucency. Surgeon must be aware of this before extraction so that prop- 
er management can be delivered. B, Periapical radiolucency around mandibular premolar represents 
mental foramen. Surgeon must be aware that this is not pathologic condition. Intact lamina dura is 
noted in B but not in A. 



PATIENT AND SURGEON PREPARATION 

Surgeons must prevent inadvertent injury or transmis- 
sion of infection to their patients or to themselves. The 
concept of universal precautions states that all patients 
must be viewed as having blood-borne diseases that can 
be transmitted to the surgical team. To prevent this trans- 
mission, surgical gloves, surgical mask, and eyewear with 
side shields are required- (See Chapter 5 for a detailed dis- 
cussion of this topic.) Additionally most authorities rec- 
ommend that the surgical team wear long-sleeved gowns 
that can be changed when they become visibly soiled 
(Fig. 7-17). 

If the surgeon has long hair, it is essential that the hair 
be held in position with barrettes or other holding 
devices or be covered with a surgical cap. It is a major 
breach in aseptic technique to allow the surgeon's hair to 
hang over the patient's face and mouth (Fig. 7-18). 

Before the patient undergoes the surgical procedure, a 
minimal amount of draping is necessary. A sterile drape 
should be put across the patient's chest to decrease the 
risk of contamination (see Fig. 7-17). 

Before the extraction, patients should vigorously rinse 
their mouths with an antiseptic mouth rinse, such as 
chlorhexidine. This reduces the gross bacterial contami- 
nation in the patient's mouth, which helps to reduce the 
incidence of postoperative infection. 

To prevent teeth or fragments of teeth from falling 
into the mouth and potentially being swallowed or 
aspirated into the lungs, many surgeons prefer to place 
a 4 X 4 inch gauze loosely into the back of the mouth 
(Fig. 7-19). This oral partition serves as a barrier so that, 
should a tooth slip from the forceps or shatter under 
the pressure of the forceps, it will be caught in the 
gauze rather than be swallowed or aspirated. The sur- 




FIG. 7-17 Surgeon, prepared by wearing protective eyeglasses, 
mask, and gloves. Surgeons should have short or pinned-back hair 
and should wear long-sleeved smocks that are changed daily or 
sooner if they become soiled. Patient should have full, waterproof 
drape. 



geon must take care that the gauze is not positioned so far 
posteriorly that it makes the patient gag. The surgeon 
should explain the purpose of the partition to gain the 
patient's acceptance and cooperation for allowing the 
gauze to be placed. 



m 



126 I'AR'l M 



Mneip fes of Extidon tia 





FIG. 7-18 A, If dentist's hair is long, it should be tied so that it stays 
in place and does not drape into surgical field. B, As an alternative, 
dentist's hair can be placed under surgical cap. C, Long and uncon- 
trolled hair that drapes into surgical field is unacceptable. 



FIG. 7-19 A gauze partition can be placed in the mouth to help 
guard against loss of tooth or tooth fragments into the oral pharynx. 



CHAIR POSITION FOR FORCEPS EXTRACTION 

The positions of the patient, chair, and operator are criti- 
cal for successful completion of the extraction. The best 
position is one that is comfortable for both the patient 
and surgeon and allows the surgeon to have maximal 
control of the force that is being delivered to the patient's 
tooth through the forceps. The correct position allows 
the surgeon to keep the arms close to the body and pro- 
vides stability and support; it also allows the surgeon to 
keep the wrists straight enough to deliver the force with 
the arm and shoulder and not with the hand. The force 
delivered can thus be controlled in the face of sudden loss 
of resistance from a root or bone fracture. 

Dentists usually stand during extractions, so the posi- 
tions for a standing surgeon will be described first. Mod- 
ifications that are necessary to operate in a seated posi- 
tion will be presented later. 

For a maxillary extraction the chair should be tipped 
backward so that the maxillary occlusal plane is at an angle 
of about 60 degrees to the floor. The height of the chair 
should be such that the height of the patient's mouth is at 
or slightly below the operator's elbow level (Fig. 7-20). Dur- 
ing an operation on the maxillary right quadrant, the 
patient's head should be turned substantially toward the 
operator, so that adequate access and visualization can be 
achieved (Fig. 7-21). For extraction of teeth in the maxillary 
anterior portion of the arch, the patient should be looking 
straight ahead (Fig. 7-22). The position for the maxillary left 
portion of the arch is similar, except that the patient's head 
is turned slightly toward the operator (Fig. 7-23). 

For the extraction of mandibular teeth, the patient 
should be positioned in a more upright position so that 
when the mouth is opened widely, the occlusal plane is 
parallel to the floor. A bite block should be used to stabi- 
lize the mandible when the extraction forceps is used. 
Even though the surgeon will support the jaw, the addi- 
tional support provided by the bite block will result in 
less stress being transmitted to the jaws. The chair should 
be lower than for extraction of maxillary teeth, and 
the 



Principles of Uncomplicated Exodontia ■ CHAPTER 7 127 




FIG. 7-20 Patient positioned for maxillary extraction: tilted back so 
that maxillary occlusal plane is at about 60-degree angle to floor. 
Height of chair should put patient's mouth slightly below surgeon's 
elbow. 




2 Extraction of anterior maxillary teeth. Patient looks 
straight ahead. 







FIG. 7-21 Extraction of teeth in maxillary right quadrant. Note 
that surgeon turns patient's head toward self. 



FIG. 7-23 Patient with head turned slightly toward surgeon for 
extraction of maxillary left posterior teeth. 



surgeon's arm is inclined downward to approximately a 
120-degree angle at the elbow (Fig. 7-24), which provides 
a comfortable, stable position that is more controllable 
than the higher position. During removal of the 
mandibular right posterior teeth the patient's head 
should be turned severely toward the surgeon to allow 
adequate access to the jaw, and the surgeon should main- 



tain the proper arm and hand position (Fig. 7-25). When 
removing teeth in the anterior region of the mandible, 
the surgeon should rotate around to the side of the 
patient (Figs. 7-26 and 7-27). When operating on the left 
posterior mandibular region, the surgeon should stand in 
front of the patient, but the patient's head should not 
turn quite so severely toward the surgeon (Fig. 7-28). 



PART II 



Principles of'Exodtmtia 




FIG. 7-24 For mandibular extractions, patient is more upright so 
that mandibular occlusal plane of opened mouth is parallel to floor. 
Height of chair is also lower to allow operator's arm to be straighten 





-■<> 



*1 

1 



- 



FIG. 7-26 For extraction of mandibular anterior teeth, surgeon 
stands at side of patient, who looks straight ahead. 





FIG. 7-25 Patient with head turned toward surgeon for removal of 
mandibular right teeth. 



FIG. 7-27 When English style of forceps is used for anterior 
mandibular teeth, patient's head is positioned straight. 



Some surgeons prefer to approach the mandibular 
teeth from a posterior position. This allows the left 
hand of the surgeon to support the jaw better, but it 
requires that the forceps be held opposite the usual 
method and that the surgeon view the field with a more 
upside-down perspective. The left hand of the surgeon 
goes around the patient's head and supports the jaw. 



The usual behind-the-patient approach is seen in Fig- 
ures 7-29 and 7-30. 

If the surgeon chooses to sit while performing extrac- 
tions, several modifications must be made. For maxillary 
extractions, the patient is positioned in a reclining position 
similar to that used when the surgeon is standing. However, 
the patient is not reclined quite as much; therefore the max- 



Principles of Uncomplicated Exodontia 



CHAPTER 7 



129 





FIG. 7-28 For extraction of mandibular posterior teeth, 
patient turns slightly toward surgeon. 



FIG. 7-30 Behind-the-patient approach for extraction of posterior 
left mandibular teeth. Hand is positioned under forceps. 




FIG. 7-29 Behind-the-patient approach for extraction of posterior 
right mandibular teeth. This allows surgeon to be in comfortable, 
stable position. 

illary occlusal plane is not perpendicular to the floor as it is 
when the surgeon is standing. The patient should be low- 
ered as far as possible so that the level of the patient's mouth 
is as near as possible to the surgeon's elbow (Fig. 7-31). The 
arm and hand position for extraction of the maxillary ante- 
rior and posterior teeth is similar to the position used for the 
same extractions performed while standing (Fig. 7-32). 




FIG. 7-31 In seated position, patient is positioned as low as possi- 
ble so that mouth is level with surgeon's elbow. 



As when the surgeon is standing, for extraction of teeth 
in the lower arch, the patient is a bit more upright than for 
extraction of maxillary teeth. The surgeon can work from 
the front of the patient (Figs. 7-33 and 7-34) or from behind 
the patient (Figs. 7-35 and 7-36). When the English style of 
forceps is used, the surgeon's position is usually behind the 
patient (Fig. 7-37). It should be noted that the surgeon and 
the assistant have hand and arm positions similar to those 
used when the surgeon is in the standing position. 



PART 11 ■ Principles of "Exodontia 





FIG. 7-32 For extraction of maxillary teeth, patient is reclined back 
approximately 60 degrees. Hand and forceps positions are same as 
for standing position. 



FIG. 7-34 For removal of mandibular posterior teeth, patient's 
head is turned toward surgeon. 





PNfci 







1* 



FIG. 7-33 For extraction of mandibular teeth, operator's hand and 
arm position is similar to that used for standing position. Patient is 
placed more upright so that mandibular occlusal plane of open 
mouth is nearly parallel to floor. Surgeon's opposite hand helps sup- 
port mandible. 



'is 


■f v**^^Pt[ 





FIG. 7-35 For removal of anterior teeth, surgeon moves to position 
behind patient so that mandible and alveolar process can be sup- 
ported by surgeon's opposite hand. 



MECHANICAL PRINCIPLES INVOLVED IN 
TOOTH EXTRACTION 

The removal of teeth from the alveolar process employs 
the use of the following mechanical principles and sim- 
ple machines: the lever, wedge, and wheel and axle. 

Elevators are used primarily as levers. A lever is a 
mechanism for transmitting a modest force — with the 
mechanical advantages of a long lever arm and a short 
effector arm — into a small movement against great resist- 
ance (Fig. 7-38). When an elevator is used for tooth 
extraction, a purchase point can be made and a crane 



Pick can be used to elevate the tooth or a tooth root from 
the socket (Fig. 7-39). The small, straight elevator is fre- 
quently used to help mobilize teeth in a similar fashion, 
without the preparation of a purchase point. 

The second machine that is useful is the wedge (Fig. 7- 
40). It is useful in several different ways for the extraction of 
teeth. First the beaks of the extraction forceps are usually 
narrow at their tips; they broaden as they go superiorly. 
When the forceps is used, there should be a conscious effort 
made to force the tips of the forceps into the periodontal 
ligament space to expand the bone and force the tooth out 



Principles of Uncomplicated Exodontia ■ CHAPTER 7 



131 




FIG. 7-36 The behind-the-patient position can be used for 
removal of mandibular posterior teeth. Hand is positioned under for- 
ceps for maximum control. 



■ "i- :i:.iX v v ^ : J- ^ 




FIG. 7-37 When English style of forceps is used, a behind-the- 
patient position is preferred. 



of the socket (Fig. 7-41). The wedge principle is also useful 
when a straight elevator is used to luxate a tooth from its 
socket. A small elevator is forced into the periodontal liga- 
ment space, which displaces the root toward the occlusion 
and therefore out of the socket (Fig. 7-42). 

The third machine used in tooth extraction is the 
wheel and axle, which is most closely identified with 
the triangular, or pennant-shaped, elevator. When one 
root of a multiple-rooted tooth is left in the alveolar 
process, the pennant-shaped elevator is positioned into 
the socket and turned. The handle then serves as the 
axle, and the tip of the triangular elevator acts as a 
wheel and engages and elevates the tooth root from the 
socket (Fig. 7-43). 




FIG. 7-38 First-class lever transforms small force and large move- 
ment to small movement and large force. 



PRINCIPLES OF FORCEPS USE 

The primary instrument used to remove a tooth from the 
alveolar process is the extraction forceps. Although eleva- 
tors may help in the luxation of a tooth, the instrument 
that does most of the work is the forceps. The goal of for- 
ceps use is twofold: (1) expansion of the bony socket by 
use of the wedge-shaped beaks of the forceps and the 
movements of the tooth itself with the forceps, and (2) 
removal of the tooth from the socket. 

The forceps can apply five major motions to luxate the 
teeth and expand the bony socket: The first is apical pres- 
sure, which accomplishes two goals. Although the tooth 
moves in an apical direction minimally, the tooth socket 
is expanded by the insertion of the beaks down into the 
periodontal ligament space (Fig. 7-44). Thus apical pres- 
sure of the forceps on the tooth causes bony expansion. A 
second accomplishment of apical pressure is that the cen- 
ter of the tooth's rotation is displaced apically. Because the 
tooth is moving in response to the force placed on it by 
the forceps, the forceps becomes the instrument of expan- 
sion. If the fulcrum is high (Fig. 7-45), a larger amount of 
force is placed on the apical region of the tooth, which 
increases the chance of fracturing the root end. If the 
beaks of the forceps are forced into the periodontal liga- 
ment space, the center of rotation is moved apically, 
which results in greater movement of the expansion 
forces at the crest of the ridge and less force moving the 
apex of the tooth lingually (Fig. 7-46). This process 
decreases the chance for apical root fracture. 

The second major pressure or movement applied by 
forceps is the buccal force. Buccal pressures result in 
expansion of the buccal plate, particularly at the crest of 
the ridge (Fig. 7-47). Although buccal pressure causes 
expansion forces at the crest of the ridge, it is important 
to remember that it also causes lingual apical pressure. 

Third, lingual pressure is similar to the concept of buc- 
cal pressure but is aimed at expanding the linguocrestal 
bone and, at the same time, avoiding excessive pressures 
on the buccal apical bone (Fig. 7-48). 

Fourth, rotational pressure, as the name implies, ro- 
tates the tooth, which causes some internal expansion of 
the tooth socket. Teeth with single, conic roots, such as 
the maxillary incisors, and mandibular premolars, with 



132 PART II ■ Principles ofExodontia 




FIG. 7-39 In removal of this mandibular premolar tooth, purchase point has been placed in tooth, which 
creates first-class lever situation. When Crane pick is inserted into purchase point and handle forces api- 
caliy (A), tooth is elevated occlusally out of socket with buccoalveolar bone used as fulcrum (B). 




FIG. 7-40 Wedge can be used to expand, split, and displace por- 
tions of substance that receives it. 




FIG. 7-41 Beaks of forceps act as wedge to expand alveolar bone 
and displace tooth in occlusal direction. 



roots that are not curved, are most amenable to luxation 
by this technique (Fig. 7-49). Teeth that have other than 
conic roots or that have multiple roots — especially if 
those roots are curved — are more likely to fracture under 
this type of pressure. 

Finally, fractional forces are useful for delivering the 
tooth from the socket once adequate bony expansion is 
achieved. Tractional forces should be limited to the final 
portion of the extraction process and should be gentle 
(Fig. 7-50). 

In summary, a variety of forces can be used to remove 
teeth. A strong apical force is always useful and should be 
applied whenever forceps is adapted to the tooth. Most 



teeth are removed by a combination of buccal and lingual 
forces. Because maxillary buccal bone is usually thinner 
and the palatal bone is a thicker cortical bone, maxillary 
teeth are usually removed by strong buccal forces and less 
vigorous palatal forces. In the mandible the buccal bone 
is thinner from the midline posteriorly to the area of the 
molars. Therefore the incisors, canines, and premolars are 
removed primarily as a result of strong buccal force and 
less vigorous lingual pressures. The mandibular molar 
teeth have stronger buccal bone and usually require a 
stronger lingual pressure than the other teeth in the 
mouth. As mentioned earlier, rotational forces are useful 
for single-rooted teeth that have conic roots and no 



Principles of Uncomplicated Exodontia ■ CHAPTER 7 133 




FIG. 7-42 Small, straight elevator, used as wedge to displace tooth 
root from its socket. Its use in this fashion gives this elevator the nick- 
name "shoehorn." 



severe curvatures at the root end. The maxillary incisors, 
particularly the central incisor and mandibular premolars 
(especially the second premolar), are most amenable to 
rotational forces. 



PROCEDURE FOR CLOSED EXTRACTION 

An erupted root can be extracted using one of two major 
techniques: (1) closed or (2) open. The closed technique 
is also known as the simple, or forceps technique. The 
open technique is also known as the surgical, or flap, 
technique. This section discusses the closed, or forceps, 
extraction technique; the open technique is discussed in 
Chapter 8. 

The closed technique is the most frequently used tech- 
nique and is given primary consideration for almost every 
extraction. The open technique is used when the clinician 
believes that excessive force is necessary to remove the 
tooth or when a substantial amount of the crown is miss- 
ing and access to the root of the tooth is difficult. 

The correct technique for any situation should lead to 
an atraumatic extraction; the wrong technique may 
result in an excessively traumatic extraction. 

Whatever technique is chosen, the three fundamental 
requirements for a good extraction remain the same: (1) 
adequate access and visualization of the field of surgery, 
(2) an unimpeded pathway for the removal of the tooth, 
and (3) the use of controlled force to luxate and remove 
the tooth. 




FIG. 7-43 Triangular elevator in role of wheel-and-axle machine, 
used to retrieve root from socket. 




FIG. 7-44 Extraction forceps should be seated with strong apical 
pressure to expand crestal bone and to displace center of rotation 
(*) as far apically as possible. 



For the tooth to be removed from the bony socket, it 
is necessary to expand the alveolar bony walls to allow 
the tooth root an unimpeded pathway, and it is necessary 
to tear the periodontal ligament fibers that hold the 
tooth in the bony socket. The use of elevators and forceps 
as levers and wedges with steadily increasing force can 
accomplish these two objectives. 

Five general steps make up the closed-extraction 
procedure: 

Step 1: Loosening of soft tissue attachment from the 
tooth. The first step in removing a tooth by the closed 



134 I'AKT 11 



Principles of Exodontia 




FIG. 7-45 If center of rotation (*) is not far enough apicaliy, it is too far occlusally, 
which results in excess movement of tooth apex (A). B, Excess motion of root apex 
caused by high center of rotation results in fracture of root apex. 




FIG. 7-46 If forceps is apicaliy seated, center of rotation (*) is displaced apicaliy and 
less apical pressures are generated (A). This results in greater expansion of buccal cor- 
tex, less movement of apex of tooth, and therefore less chance of fracture of root (B). 



Principles of Uncomplicated Exodontia ■ CHAPTER 7 135 




FIG. 7-47 Buccal pressure applied to tooth will expand buccocor- 
tical plate toward crestal bone, with some lingual expansion at api- 
cal end of root. * Center of rotation. 




FIG. 7-48 Lingual pressure will expand linguocortical plate at cre- 
stal area and slightly expand buccal bone at apical area. * Center of 
rotation. 





FIG. 7-49 Rotational forces, useful for teeth with conic roots, such 
as maxillary incisors and mandibular premolars. 



FIG. 7-50 Tractional forces are useful for final removal of tooth 
from socket. They should always be small forces, because teeth are 
not "pulled." 



136 PART II 



Prin cipks of Exodontia 



extraction technique is to loosen the soft tissue from 
around the tooth with a sharp instrument, such as the 
Woodson elevator or the sharp end of the no. 9 periosteal 
elevator (Fig. 7-51). The purpose of loosening the soft tis- 
sue from the tooth is twofold. First, it allows the surgeon 
to ensure that profound anesthesia has been achieved. 
When this step has been performed, the dentist informs 
the patient that the surgery is about to begin and that the 
first step will be to push the soft tissue away from the 
tooth. A small amount of pressure is felt at this step, but 
no sensation of sharpness or discomfort. The surgeon 
then begins the soft tissue-loosening procedure, gently at 
first and then with increasing force. 

The second reason that the soft tissue is loosened is to 
allow the tooth-extraction forceps to be positioned more 
apically, without interference from or impingement on the 
soft tissue of the gingiva. As the soft tissue is loosened away 
from the tooth, it is slightly reflected, which thereby 
increases the width of the gingival sulcus and allows easy 
entrance of the beveled wedge tip of the forceps beaks. 




FIG. 7-51 Woodson elevator, used to loosen gingival 
attachment 



If a straight elevator is to be used to luxate the tooth, 
the Woodson elevator is also used to reflect the tooth's 
adjacent gingival papilla where the straight elevator will 
be inserted (Fig. 7-52). This allows the elevator to be 
placed directly onto alveolar bone, without crushing or 
injuring the gingival papilla. 

Step 2: Luxation of the tooth with a dental elevator. The 
next step is to begin the luxation of the tooth with a den- 
tal elevator, usually the straight elevator. Expansion and 
dilation of the alveolar bone and tearing of the periodon- 
tal ligament require that the tooth be luxated in several 
ways. The straight elevator is inserted perpendicular to the 
tooth into the interdental space, after reflection of the 
interdental papilla (Fig. 7-53). The elevator is then turned 
in such a way that the inferior portion of the blade rests 
on the alveolar bone and the superior, or occlusal, portion 
of the blade is turned toward the tooth being extracted 
(Fig. 7-54). Strong, slow, forceful turning of the handle 
moves the tooth in a posterior direction, which results in 
some expansion of the alveolar bone and tearing of the 
periodontal ligament. If the tooth is intact and in contact 
with stable teeth anterior and posterior to it, the amount 
of movement achieved with the straight elevator will be 
minimal. The usefulness of this step is greater if the 
patient does not have a tooth posterior to the tooth being 
extracted, or if it is broken down to an extent that the 
crowns do not inhibit movement of the tooth. 

In certain situations the elevator can be turned in the 
opposite direction and more vertical displacement of the 
tooth will be achieved, which can possibly result in com- 
plete removal of the tooth (Fig. 7-55). 

Luxation of teeth with a straight elevator should be 
performed with caution. Excessive forces can damage and 
even displace the teeth adjacent to those being extracted. 
This is especially true if the adjacent tooth has a large 
restoration or carious lesion. It must be kept in mind that 
this is only the initial step in the extraction process, and 
that the forceps is the major instrument for tooth luxa- 
tion and removal in most situations. 

Step 3: Adaptation of the forceps to the tooth. The proper 
forceps is then chosen for the tooth to be extracted. The 





FIG. 7-52 Reflection of gingival papilla to allow straight elevator to 
be used to luxate tooth without injury to papilla. 



FIG. 7-53 Small, straight elevator, inserted perpendicular to tooth 
after papilla has been reflected. 



Principles of Uncomplicated Exodontki ■ CHAPTER 7 13 



beaks of the forceps should be shaped to adapt anatomi- 
cally to the tooth, apical to the cervical line, that is, to the 
root surface. The forceps is then seated onto the tooth so 
that the tips of the forceps beaks grasp the root under- 
neath the loosened soft tissue (Fig. 7-56). The lingual 
beak is usually seated first and then the buccal beak. Care 
must be taken to confirm that the tips of the forceps 
beaks are beneath the soft tissue and not engaging an 
adjacent tooth. Once the forceps has been positioned on 
the tooth, the surgeon grasps the handles of the forceps 
at the very ends to maximize mechanical advantage and 
control (Fig. 7-57). 

If the tooth is malopposed in such a fashion that the 
usual forceps cannot grasp the tooth without injury to 
adjacent teeth, another forceps should be employed. The 
maxillary root forceps can often be useful for crowded 
lower anterior teeth (Fig. 7-58). 

The beaks of the forceps must be held parallel to the 
long axis of the tooth so that the forces generated by the 
application of pressure to the forceps handle can be 
delivered along the long axis of the tooth for maximal 
effectiveness in dilating and expanding the alveolar 
bone. If the beaks are not parallel to the long axis of the 
tooth, it is increasingly likely that the tooth root will 
fracture. 

The forceps is then forced apically as far as possible to 
grasp the root of the tooth as apically as possible. This 
accomplishes two things: First, the beaks of the forceps 
act as wedges to dilate the crestal bone on the buccal and 
lingual aspects. Second, by forcing the beaks apically, the 
center of rotation (or fulcrum) of the forces applied to the 
tooth is displaced toward the apex of the tooth, which 
results in greater effectiveness of bone expansion and less 
likelihood of fracturing the apical end of the tooth. 

At this point the surgeon's hand should be grasping 
the forceps firmly, with the wrist locked and the arm held 
against the body; the surgeon should be prepared to 
apply force with the shoulder and upper arm without any 
wrist pressure. The surgeon should be standing straight, 
with the feet comfortably apart. 

Step 4: Luxation of the tooth with the forceps. The sur- 
geon begins to luxate the tooth by using the motions 
discussed earlier. The major portion of the force is direct- 
ed toward the thinnest and therefore weakest bone. Thus 
in the maxilla and all but the molar teeth in the 
mandible, the major movement is labial and buccal (i.e., 
toward the thinner layer of bone). The surgeon uses 
slow, steady force to displace the tooth buccally. The 
motion is deliberate and slow, and it gradually increases 
in force. The tooth is then moved again toward the 
opposite direction with slow, deliberate, strong pressure. 
As the alveolar bone begins to expand, the forceps is api- 
cally reseated with a strong, deliberate motion, which 
causes additional expansion of the alveolar bone and 
further displaces the center of the rotation apically. Buc- 
cal and lingual pressures continue to expand the alveo- 
lar socket. For some teeth, rotational motions are then 
used to help expand the tooth socket and tear the peri- 
odontal ligament attachment. 

Beginning surgeons have a tendency to apply inade- 
quate pressure for insufficient amounts of time. The fol- 
lowing three factors must be reemphasized: (1) The for- 



/ 1 \ t 


^~T^K 


bm'm 

ML 


w 





FIG. 7-54 Handle of small straight elevator, turned so that occlusal 
side of elevator blade is turned toward tooth. 




FIG. 7-55 Handle of elevator, which may be turned in opposite 
direction to displace tooth further from socket. This can be accom- 
plished only if no tooth is adjacent posteriorly. 




7-56 Tips of forceps beak, forced apically under soft tissue. 



138 PART II 



Priiwiptes of Exodontia 




FIG. 7-57 Forceps handles, held at very ends to maximize mechanical advantage and control. A, 
Maxillary universal forceps. B, Mandibular universal forceps. 



ceps must be apically seated as far as possible and 
reseated periodically during the extraction; (2) the 
forces applied in the buccal and lingual directions 
should be slow, deliberate pressures and not jerky wig- 
gles; and (3) the force should be held for several seconds 
to allow the bone time to expand. It must be remem- 
bered that teeth are not pulled; rather, they are gently 
lifted from the socket once the alveolar process has been 
sufficiently expanded. 

Step 5: Removal of the tooth from the socket. Once the 
alveolar bone has expanded sufficiently and the tooth 
has been luxated, a slight tractional force, usually direct- 
ed buccally, can be used. Tractional forces should be min- 
imized, because this is the last motion that is used once 
the alveolar process is sufficiently expanded and the peri- 
odontal ligament completely severed. 



It is useful to remember that luxation of the toot 
with the forceps and removal of the tooth from the bone 
are separate steps in the extraction. Luxation is directed 
toward expansion of the bone and disruption of the 
peri-odontal ligament. The tooth is not removed 
from bone until these two goals are accomplished. The 
novice surgeon should realize that the major role of the 
forceps is not to remove the tooth but rather to expand 
the bone so that the tooth can be removed. 

For teeth that are malopposed or have unusual positic 
in the alveolar process, the luxation with the forceps and 
removal from the alveolar process will be in unusual dire 
tions. The surgeon must develop a sense for the direction 
the tooth wants to move and then be able to move it in 
that direction. Careful preoperative assessment and 
planning help to make this determination during the 
extraction 



Principles of 'Uncomplicated Exodonthi ■ CHAFIER 7 139 




FIG. 7-58 A, No. 151 forceps, too wide to grasp premolar to be extracted without luxating adjacent 
teeth. B, Maxillary root forceps, which can be adapted easily to tooth for extraction. 



Role of Opposite Hand 

When using the forceps and elevators to luxate and 
remove teeth, it is important that the surgeon's opposite 
hand play an active role in the procedure. For the right- 
handed operator, the left hand has a variety of functions. 
It is responsible for reflecting the soft tissues of the 
cheeks, lips, and tongue to provide adequate visualiza- 
tion of the area of surgery. It helps to protect other teeth 
from the forceps, should it release suddenly from the 
tooth socket. It helps to stabilize the patient's head dur- 
ing the extraction process. In some situations, large 
amounts of force are required to expand heavy alveolar 
bone; therefore the patient's head requires active assis- 
tance to be held steady. The opposite hand plays an 
important role in supporting and stabilizing the lower 
jaw when mandibular teeth are being extracted. It is 
often necessary to apply considerable pressure to expand 
heavy mandibular bone, and such forces can cause dis- 
comfort and even injury to the TMJ unless a steady hand 
counteracts them. A bite block placed on the contralater- 
al side is also used to help support the jaw in this situa- 
tion. Finally, the opposite hand supports the alveolar 
process and provides tactile information to the operator 
concerning the expansion of the alveolar process during 
the luxation period. In some situations it is impossible for 
the opposite hand to perform all of these functions at the 
same time, so the surgeon requires an assistant to help 
with some of them. 



Role of Assistant during Extraction 

For a successful outcome in any surgical procedure, it is 
essential to have a competent assistant. During the 
extraction the assistant plays a variety of important roles 
that contribute to making the surgical experience atrau- 
matic. The assistant helps the surgeon visualize and gain 
access to the operative area by reflecting the soft tissue of 



the cheeks and tongue so that the surgeon can have an 
unobstructed view of the surgical field. Even during a 
closed extraction, the assistant can reflect the soft tissue 
so that the surgeon can apply the instruments to loosen 
the soft tissue attachment and adapt the forceps to the 
tooth and tooth root in the most effective manner. 

Another major activity of the assistant is to suction 
away blood, saliva, and the irrigating solutions used dur- 
ing the surgical procedure. This prevents fluids from 
accumulating and makes proper visualization of the sur- 
gical field possible. Suctioning is also important for 
patient comfort, because most patients are unable to tol- 
erate an accumulation of blood or other fluids in their 
mouths. During a surgical procedure it is almost impossi- 
ble for the assistant to suction too much. 

During the extraction the assistant should also help to 
protect the teeth of the opposite arch, which is especially 
important when removing lower posterior teeth. If trac- 
tion forces are necessary to remove a lower tooth, occa- 
sionally the tooth releases suddenly and the forceps strike 
the maxillary teeth and sometimes fracture a tooth cusp. 
The assistant should hold either a suction tip or a finger 
against the maxillary teeth to protect them from an unex- 
pected blow. 

During the extraction of mandibular teeth, the assis- 
tant may play an important role by supporting the 
mandible during the application of the extraction forces. 
A surgeon who uses the hand to reflect the soft tissue may 
not be able to support the mandible. If this is the case, 
the assistant plays an important role in stabilizing the 
mandible to prevent TMJ discomfort. Most often the sur- 
geon stabilizes the mandible, which makes this role less 
important for the assistant. 

The assistant also provides psychologic and emotional 
support for the patient by helping alleviate patient anxi- 
ety during the surgery. The assistant is important in gain- 



part n 



I'rin cip tel ofExvdou tia 



ing the patient's confidence and cooperation by using 
positive language and physical contact with the patient 
during the preparation and performance of the surgery. 
The assistant should avoid making casual, offhand com- 
ments that may increase the patients' anxiety and lessen 
their cooperation. 

SPECIFIC TECHNIQUES FOR REMOVAL 
OF EACH TOOTH 

This section describes specific techniques for the removal 
of each tooth in the mouth. In some situations several 
teeth are grouped together (e.g., the maxillary anterior 
teeth), because the technique for their removal is essen- 
tially the same. 

Maxillary Teeth 

In the correct position for extraction of maxillary left or 
anterior teeth, the left index finger of the surgeon should 
reflect the lip and cheek tissue; the thumb should rest on 
the palatal alveolar process (Fig. 7-59). In this way the left 
hand is able to reflect the soft tissue of the cheek, stabi- 
lize the patient's head, support the alveolar process, and 
provide tactile information to the surgeon regarding the 
progress of the extraction. When such a position is used 
during the extraction of a maxillary molar, the surgeon 
can frequently feel with the left hand the palatal root of 
the molar becoming free in the alveolar process before 
realizing it with the forceps or extracting hand. For the 
right side, the index finger is positioned on the palate 
and the thumb on the buccal aspect. 

Maxillary incisor teeth. The maxillary incisor teeth 
are extracted with the upper universal forceps (no. 150), 
although other forceps can be used. The maxillary inci- 



sors generally have conic roots, with the lateral ones 
being slightly longer and more slender. The lateral incisor 
is more likely also to have a distal curvature on the apical 
one third of the root, so this must be checked radio- 
graphically before the tooth is extracted. The alveolar 
bone is thin on the labial side and heavier on the palatal 
side, which indicates that the major expansion of the 
alveolar process will be in the buccal direction. The initial 
movement is slow, steady, and firm in the labial direc- 
tion, which expands the crestal buccal bone. A less vigor- 
ous palatal force is then used, followed by a slow, firm, 
rotational force. Rotational movement should be mini- 
mized for the lateral incisor, especially if a curvature 
exists on the tooth. The tooth is delivered in the labial- 
incisal direction with a small amount of tractional force 
(Fig. 7-60). 

Maxillary canine. The maxillary canine is usually 
the longest tooth in the mouth. The root is oblong in 
cross section and usually produces a bulge called the 
canine eminence on the anterior surface of the maxilla, 
The result is that the bone over the labial aspect of the 
maxillary canine is usually quite thin. In spite of the 
thin labial bone, this tooth can be difficult to extract 
simply because of its long root. Additionally, it is not 
uncommon for a segment of labial alveolar bone to frac- 
ture from the labial plate and be removed with the 
tooth. 

The upper universal (no. 150) forceps is the preferred 
instrument for removing the maxillary canine. As with all 
extractions, the initial placement of the beaks of the for- 
ceps on the canine tooth should be as far apically as 
pos-sible. The initial movement is to the buccal aspect, 
with return pressure to the palatal. As the bone is 
expanded and the tooth mobilized, the forceps should be 
reposi-tioned apically. A small amount of rotational 
force may 




FIG. 7-59 Extraction of maxillary left posterior teeth. Left index finger reflects lip and cheek 
and supports alveolar process on buccal aspect. Thumb is positioned on palatal aspect of alve- 
olar process and supports alveolar process. Head is steadied by this grip, and tactile information 
is gained regarding tooth and bone movement. 



Principles of Uncomplicated Exodontia ■ CHAFTiiR 7 



141 



be useful in expanding the tooth socket, especially if the 
adjacent teeth are missing or have just been extracted. 
After the tooth has been well luxated, it is delivered from 
the socket in a labial-incisal direction with labial frac- 
tional forces (Fig. 7-61). 

If, during the luxation process with the forceps, the 
surgeon feels a portion of the labial bone fracture, a deci- 



sion must be made concerning the next step. If the pal- 
pating finger indicates that a relatively small amount of 
bone has fractured free and is attached to the canine 
tooth, the extraction should continue in the usual man- 
ner, with caution taken not to tear the soft tissue. Howev- 
er, if the palpating finger indicates that a relatively large 
portion of labial alveolar plate has fractured, the surgeon 



The forceps is seated 
as far apically as possible. 




Luxation is begun with 
labial force. 



Slight lingual force is 
used, 



The tooth is 
removed to the 
labial incisal. 



FIG. 7-60 A, Maxillary incisors are extracted with no. 150 forceps. Left hand grasps alveolar process. 
Assistant helps reflect and protect soft tissue. B, Forceps is seated as far apically as possible. C, Luxation 
is begun with labial force. D, Slight lingual force is used. E, Tooth is delivered to labial incisor with rota- 
tional, fractional movement. 



142 PART II ■ Principles of Exodontia 




FIG. 7-61 A, Hand and forceps position for removal of maxillary canine is similar to that for 
incisors. Forceps is seated as far apically as possible. B, Initial movement is buccally. C, Small 
amounts of lingual force are applied. D, Tooth is delivered in labial-incisal direction with slight 
rotational force. 



Principles of Uncomplicated Exodonthi ■ CHAPTER 7 



should stop the surgical procedure. Usually the fractured 
portion of bone is attached to periosteum and therefore is 
viable. The surgeon should use a thin periosteal elevator 
to raise a small amount of mucosa from around the tooth, 
down to the level of the fractured bone. 

The canine tooth should then be stabilized with the 
extraction forceps, and the surgeon should attempt to 
free the fractured bone from the tooth, with the 
periosteal elevator as a lever to separate the bone from 
the tooth root. If this can be accomplished, the tooth can 
be removed and the bone left in place attached to the 
periosteum. Normal healing should occur. If the bone 
becomes detached from the periosteum during these 
attempts, it should be removed, because it is probably 
nonvital and may actually prolong wound healing. This 
procedure can be used whenever alveolar bone is frac- 
tured during extraction. 

Prevention of fractured labial plate is important. If 
during the luxation process with the forceps a normal 
amount of pressure has not resulted in any movement of 
the tooth, the surgeon should seriously consider doing an 
open extraction. By reflecting a soft tissue flap and 
removing a small amount of bone, the surgeon may be 
able to remove the stubborn canine tooth without frac- 
turing a larger amount of labial bone. By using the open 
technique, there will be an overall reduction in bone loss 
and in postoperative healing time. 

Maxillary first premolar. The maxillary first premo- 
lar is a single-rooted tooth in its first two thirds, with a 
bifurcation into a buccolingual root usually occurring in 
the apical one third to one half. These roots may be 
extremely thin and are subject to fracture, especially in 
older patients in whom bone density is great and bone 
elasticity is small (Fig. 7-62). Perhaps the most common 
root fracture when extracting teeth in adults occurs with 
this tooth. As with other maxillary teeth, the buccal bone 
is relatively thin compared with the palatal bone. 

The upper universal (no. 150) forceps is the instru- 
ment of choice. Alternatively, the no. 150A forceps can be 
used for removal of the maxillary first premolar. 

Because of the high likelihood of root fracture, the 
tooth should be luxated as much as possible with the 
straight elevator. If root fracture does occur, a mobile root 
tip can be removed more easily than one that has not 
been well luxated. 

Because of the bifurcation of the tooth into two rela- 
tively thin root tips, extraction forces should be carefully 
controlled during removal of the maxillary first premolar. 
Initial movements should be buccal. Palatal movements 
are made with relatively small amounts of force to pre- 
vent fracture of the palatal root tip, which is harder to 
retrieve. When the tooth is luxated buccally, the most 
likely tooth root to break is the labial. When the tooth is 
luxated in the palatal direction, the most likely root to 
break is the palatal root. Of the two root tips, the labial is 
easier to retrieve because of the thin, overlying bone. 
Therefore buccal pressures should be greater than palatal 
pressures. Any rotational force should be avoided. Final 
delivery of the tooth from the tooth socket is with frac- 
tional force in the occlusal direction and slightly buccal 
(see Fig. 7-62). 



Maxillary second premolar. The maxillary second 
premolar is a single-rooted tooth for the root's entire 
length. The root is thick and has a blunt end. Conse- 
quently, the root of the second premolar fractures only 
rarely. The overlying alveolar bone is similar to that of 
other maxillary teeth in that it is relatively thin toward 
the bucca, with a heavy palatal alveolar palate. 

The recommended forceps is the maxillary universal 
forceps, or no. 150; some surgeons prefer the no. 150A. 
The forceps is forced as far apically as possible so as to 
gain maximal mechanical advantage in removing this 
tooth. Because the tooth root is relatively strong and 
blunt, the extraction requires relatively strong move- 
ments to the bucca, back to the palate, and then in the 
buccoocclusal direction with a rotational, fractional force 
(Fig. 7-63). 

Maxillary molar. The maxillary first molar has three 
large and relatively strong roots. The buccal roots are usu- 
ally relatively close together, and the palatal root diverges 
widely toward the palate. If the two buccal roots are also 
widely divergent, it becomes difficult to remove this tooth 
by closed, or forceps, extraction. Once again the overlying 
alveolar bone is similar to that of other teeth in the max- 
illa; the buccal plate is thin and the palatal cortical plate 
is thick and heavy. When evaluating this tooth radio- 
graphically, the dentist should note the size, curvature, 
and apparent divergence of the three roots. Additionally 
the dentist should look carefully at the relationship of the 
tooth roots to the maxillary sinus. If the sinus is in close 
proximity to the roots and the roots are widely divergent, 
sinus perforation caused by removal of a portion of the 
sinus floor during tooth removal is increasingly likely. If 
this appears to be likely after preoperative evaluation, the 
surgeon should strongly consider a surgical extraction. 

The paired forceps no. 53R and no. 53L are usually 
used for extraction of the maxillary molars . These two 
forceps have tip projections on the buccal beaks to fit 
into the buccal bifurcation. Some surgeons prefer to use 
the no. 89 and no. 90 forceps, which are sometimes called 
the upper cowhorn forceps. These two forceps are especially 
useful if the crown of the molar tooth has large caries or 
large restorations. 

The upper molar forceps is adapted to the tooth and 
apically seated as far as possible in the usual fashion (Fig. 
7-64). The basic extraction movement is to use strong 
buccal and palatal pressures, with stronger forces toward 
the buccal than toward the palate. Rotational forces are 
not useful for extraction of this tooth because of its three 
roots. As mentioned in the discussion of the extraction of 
the maxillary first premolar, it is preferable to fracture a 
buccal root than a palatal root (because it is easier to 
retrieve the buccal roots). Therefore if the tooth has widely 
divergent roots and the dentist suspects that one root 
may be fractured, the tooth should be luxated in such a 
way as to prevent fracturing the palatal root. The dentist 
must minimize palatal force, because this is the force that 
fractures the palatal root. Strong, slow, steady, buccal 
pressure expands the buccocortical plate and tears the 
periodontal ligament fibers that hold the palatal root in 
its position. Palatal forces should be used but kept to a 
minimum. 



144 PART II 



Principles of 'Exodontia 




FIG. 7-62 A, Maxillary first premolar has two thin roots that are quite subject to fracture during extraction. B, Maxillary 
premolars are removed with no. 150 forceps. Hand position is similar to that used for anterior teeth. C, Firm apical pressure 
is applied first to lower center of rotation as far as possible and to expand crestal bone. D, Buccal pressure is applied initially 
to expand buccocortical plate. Apices of roots are pushed lingually and are therefore subject to fracture. E, Palatal pressure is 
applied but less vigorously than buccal pressure. F, Tooth is delivered in buccoocclusal direction with combination of buccal 
and fractional forces. 



Principles of Uncomplicated Exodontia m CHAPTER 7 145 




FIG. 7-63 A, When extracting maxillary second premolar, forceps is seated as far apically as 
possible. B, Luxation is begun with buccal pressure. C, Very slight lingual pressure is used. 
D, Tooth is delivered in buccoocclusal direction. 



146 PART II ■ Principles of Exodonthi 




FIG. 7-64 A, Extraction of maxillary molars. Soft tissue of lips and cheek is reflected, and alveolar process is grasped 
with opposite hand. B, Forceps beaks are seated apically as far as possible. C, Luxation is begun with strong buccal 
force. D, Lingual pressures are used only moderately. E, Tooth is delivered in buccoocclusal direction. 



Principles of Uncomplicated Exodontia 



CHAPTER 7 



147 



The maxillary second molar's anatomy is similar to 
that of the maxillary first molar except that the roots 
tend to be shorter and Jess divergent, with the buccal 
roots more commonly fused into a single root. This 
means that the tooth is more easily extracted by the same 
technique described for the first molar. 

The erupted maxillary third molar frequently has conic 
roots and is usually extracted with the no. 210S forceps, 
which is universal forceps used for both the left and right 
sides. The tooth is usually easily removed, because the buc- 
cal bone is thin and the roots are usually fused and conical. 
The erupted third molar is also frequently extracted by the 
use of elevators alone. It is important to clearly visualize the 
maxillary third molar on the preoperative radiograph, 
because the root anatomy of this tooth is quite variable and 
often small, dilacerated, hooked roots exist in this area. 
Retrieval of fractured roots in this area can be very difficult. 

Mandibular Teeth 

When removing lower molar teeth, the index finger of 
the left hand is in the buccal vestibule and the second 
finger is in the lingual vestibule, reflecting the lip, cheek, 
and tongue (Fig. 7-65). The thumb of the left hand is 
placed below the chin so that the jaw is held between the 
fingers and thumb, which support the mandible and 
minimize TMJ pressures. This technique provides less tac- 
tile information, but during extraction of mandibular 
teeth the need to support the mandible supersedes the 
need to support the alveolar process. A useful alternative 
is to place a bite block between the teeth on the con- 
tralateral side (Fig. 7-66). The bite block allows the 
patient to help provide stabilizing forces to limit the pres- 
sure on the TMJs. The surgeon's hand should continue to 
provide additional support to the jaw. 

Mandibular anterior teeth. The mandibular incisors 
and canines are similar in shape, with the incisors being 
shorter and slightly thinner and the canine roots being 
longer and somewhat heavier. The incisor roots are more 
likely to be fractured, because they are somewhat thin 
and therefore should be removed only after adequate pre- 
extraction luxation. The alveolar bone that overlies the 
incisors and canines is quite thin on the labial and lin- 
gual sides. The bone over the canine may be somewhat 
thicker, especially on the lingual side. 

The lower universal (no. 151) forceps are usually used 
to remove these teeth. Alternative choices include the no. 
151A or the English style of Ashe forceps. The forceps 
beaks are positioned on the teeth and seated apically with 
strong force. The extraction movements are generally in 
the labial and lingual directions, with equal pressures both 
ways. Once the tooth has become luxated and mobile, 
rotational movement may be used to expand the alveolar 
bone further. The tooth is removed from the socket with 
fractional forces in a labial-incisal direction (Fig. 7-67). 

Mandibular premolars. The mandibular premolars 
are among the easiest teeth to remove. The roots tend to 
be straight and conic, albeit sometimes slender. The over- 
lying alveolar bone is thin on the buccal aspect and 
somewhat heavier on the lingual side. 







'/■■' - . 




FIG. 7-65 Extraction of mandibular left posterior teeth. Surgeon's left 
index finger is positioned in buccal vestibule, reflecting cheek, and 
second finger is positioned in lingual vestibule, reflecting tongue. 
Thumb is positioned under chin. Jaw is grasped between fingers and 
thumb to provide support during extraction. 




FIG. 7-66 To provide support for the mandible to prevent excessive 
temporomandibufar joint (TMJ) pressures, a rubber bite block can be 
placed between the teeth on the contralateral side. 



The lower universal (no. 151) forceps is usually chosen 
for the extraction of the mandibular premolars. The no. 
151 A forceps and the English style of forceps are both 
popular alternatives for extraction of these teeth. 

The forceps is apically forced as far as possible, with 
the basic movements being toward the buccal aspect, 
returning to the lingual aspect, and, finally, rotating. 
Rotational movement is used more when extracting these 
teeth than any others, except perhaps the maxillary cen- 
tral incisor. The tooth is then delivered in the occluso- 
buccal direction (Fig. 7-68). Careful preoperative radio- 
graphic assessment must be performed to assure the 



148 PART II 



[Principles of Exodonlia 




FIG. 7-67 A, When extracting mandibular anterior teeth, no. 151 forceps is used. Assistant reflects lip, 
and surgeon stabilizes jaw with left hand. B, Forceps is seated apically as far as possible. C, Moderate 
labial pressure is used to initiate luxation process. D, Lingual force is used to continue expansion of 
bone. E, Tooth is delivered in labial-incisal direction. 



Principles of 'Uncomplicated Exodontia ■ CHAPTER 7 149 




FIG. 7-68 A, Extraction of mandibular premolar. Jaw is stabilized, soft tissue is reflect- 
ed, and no. 151 forceps is positioned. B, Hand position is modified slightly for behind- 
the-patient technique. C, English style of forceps can also be used. 

Continued 



m 



ISO PART II 



Principles of Exodontia 




FIG. 7-68 — cont'd D, Forceps is seated apically as far as possible to displace center of rotation and 
to begin expansion of crestal bone. E, Buccal forceps is applied to begin luxation process. F, Slight lin- 
gual pressure is used. C, Tooth is delivered with rotational, tractional force. 



operator that no root curvature exists in the apical third 
of the tooth. If such a curvature does exist, the rotation- 
al movements should be reduced or eliminated from the 
extraction procedure (Fig. 7-69). 

Mandibular molars. The mandibular molars are usu- 
ally two rooted, with roots of the first molar more widely 
divergent than those of the second molar. Additionally 
the roots may converge at the apical one third, which 
increases the difficulty of extraction. The roots are gener- 
ally heavy and strong. The overlying alveolar bone is 
heavier than the bone on any other teeth in the mouth. 
The combination of relatively long, strong, divergent 
roots with heavy overlying buccolingual bone makes the 
mandibular first molar the most difficult of all teeth to 
extract. 

The no. 17 forceps is usually used for extraction of the 
mandibular molars; it has small tip projections on both 
beaks to fit into the bifurcation of the tooth roots. The 
forceps is adapted to the root of the tooth in the usual 
fashion, and strong apical pressure is applied to set the 
beaks of the forceps apically as far as possible. Strong 
buccolingual motion is then used to expand the tooth 
socket and allow the tooth to be delivered in the bucco- 
occlusal direction. The linguoalveolar bone around the 
second molar is thinner than the buccal plate, so the sec- 



ond molar can be more easily removed with stronger lin- 
gual than buccal pressures (Fig. 7-70). 

If the tooth roots are clearly bifurcated, the no. 23, or 
cowhorn, forceps can be used. This instrument is; 
designed to be closed forcefully with the handles, thereby 
squeezing the beaks of the forceps into the bifurcation. 
This creates force against the crest of the alveolar ridge on 
the buccolingual aspects and literally forces the tooth 
superiorly directly out of the tooth socket {Fig. 7-71). If 
initially this is not successful, the forceps is given bucco- 
lingual movements to expand the alveolar bone, and 
more squeezing of the handles is performed. Care must 
be taken with these forceps to prevent damaging the 
maxillary teeth, because the lower molar may actually 
pop out of the socket and thus release the forceps to strike 
the upper teeth (see Fig. 7-71). 

Erupted mandibular third molars usually have fused 
conical roots. Because a bifurcation is not likely, the no. 
222 forceps — a short-beaked, right-angled forceps — is 
used to extract this tooth. The lingual plate of bone is def- 
initely thinner than the buccocortical plate, so most of 
the extraction forces should be delivered to the lingual 
aspect. The third molar is delivered in the linguloocclusal 
direction. The erupted mandibular third molar that is in 
function can be a deceptively difficult tooth to extract. 



Text continued on page 154 



Principles of Uncomplicated Exodontia ■ CHAPTER 7 151 




FIG. 7-69 If curvature of premolar root exists, rotational extraction forces will result in 
fracture of curved portion of root, and therefore such forces should be minimized. 




FIG. 7-70 A, Mandibular molars are extracted with no. 1 7 or no. 23 forceps. Hand positions of sur- 
geon and assistant are same for both forceps. 



Continued 



152 PART [I ■ Principles of Exodontin 




FIG. 7-70 — cont'd B, No. 1 7 forceps is seated as far apically as possible. C, Luxation of molar is begun with strong 
buccal movement. D, Strong lingual pressure is used to continue luxation. E, Tooth is delivered in buccoocclusal 
direction. 



Prktciples of Uncomplicated Excdontia 



CHAPTER 7 



153 




FIG. 7-71 A, No. 23 forceps is carefully positioned to engage bifurcation area of lower molar. 
B, Handles of forceps are squeezed forcibly together, which causes beaks of forceps to be forced into 
bifurcation and exerts fractional forces on tooth. C, Strong buccal forces are then used to expand sock- 
et. D, Strong lingual forces are used to luxate tooth further. E, Tooth is delivered in buccoocclusal 
direction with buccal and tractional forces. 



154 PARI' f] 



I'rin cipks of Exoclon tia 




FIG. 7-72 Amalgam fragment left in this tooth socket after extraction, because surgeon failed to 
inspect and debride surgical field. 



The dentist should give serious consideration to using the 
straight elevator to achieve a moderate degree of luxation 
before applying the forceps. Pressure should be gradually 
increased, and attempts to mobilize the tooth should be 
made before final strong pressures are delivered. 

Modifications for Extraction of Primary Teeth 

It is rarely necessary to remove primary teeth before sub- 
stantial root resorption has occurred. However, when 
removal is required, it must be done with a great deal of 
care, because the roots of the primary teeth are very long 
and delicate and subject to fracture. This is especially true 
because the succedaneous tooth causes resorption of coro- 
nal portions of the root structure and thereby weakens it. 
The forceps usually used is an adaptation of the upper and 
lower universal forceps, the no. 15 OS and the no. 15 IS. 
They are adapted and forced apically in the usual fashion, 
with slow, steady pressures toward the buccal aspect and 
return movements toward the lingual aspect. 

Rotational motions may be used but should be mini- 
mal and used judiciously with multirooted teeth. The 
dentist should pay careful attention to the direction of 
least resistance and deliver the tooth into that path. If the 
roots of the primary molar tooth embrace the crown of 
the permanent premolar, the surgeon should consider 
sectioning the tooth. Rarely the roots hold the crown of 
the permanent premolar firmly enough in their grasp to 
cause it to be extracted also. 

POSTEXTRACTION CARE OF TOOTH SOCKET 

Once the tooth has been removed from the socket, it is 
necessary to provide proper care. The socket should be 
debrided only if necessary. If a periapical lesion is visible 



on the preoperative radiograph and there was no granu 
loma attached to the tooth when it was removed, the 
periapical region should be carefully curetted to remove 
the granuloma or cyst. If any debris is obvious, such as 
calculus, amalgam, or tooth fragment remaining in 
the socket, it should be gently removed with a curette or 
suc-tion tip (Fig. 7-72). However, if neither periapical 
lesion nor debris is present, the socket should not be 
curetted. The remnants of the periodontal ligament and 
the bleed-ing bony walls are in the best condition to 
provide for rapid healing. Vigorous curettage of the 
socket wall mere-ly produces additional injury and may 
delay healing. 

The expanded buccolingual plates should be com- 
pressed back to their original configuration. Finger pres- 
sure should be applied to the buccolingual cortical plate 
to gently but firmly compress the plates to their original 
position or approximate them even more closely, if pos- 
sible. This helps prevent bony undercuts that may have 
been caused by excessive expansion of the buccocortical 
plate, especially after first molar extraction. 

If the teeth were removed because of periodontal dis- 
ease, there may be an accumulation of excess granulation 
tissue around the gingival cuff. If this is the case, special 
attention should be given to removing this granulation 
tissue with a curette or hemostat. The arterioles of granu- 
lation tissue have little or no capacity to retract and con- 
strict, which leads to bothersome bleeding if excessive 
granulation tissue is left. 

Finally, the bone should be palpated through the over- 
lying mucosa to check for any sharp, bony projections. If 
any exist, the mucosa should be reflected and the sharp 
edges smoothed judiciously with a bone file. 

To gain initial control of hemorrhage, a moistened 
2X2 inch gauze is placed over the extraction socket. 
The gauze should be positioned so that when 



Principles of Uncomplicated Exodoniut ■ CHAFfER 7 155 



" s * 6 ^ 





FIG. 7-73 A, After extraction of single tooth, small space exists 
where crown of tooth was located. B, Gauze pad (2X2 inch pad) 
is folded in half twice and placed into space. When patient bites 
on gauze, pressure is transmitted to gingiva and socket. C, If large 
gauze is used, pressure goes on teeth, not on gingiva or socket. 



The extraction of multiple teeth at one sitting is 
a more involved and complex procedure. It is 
discussed in Chapter 8. 



patient closes the teeth together, it fits into the space 
previously occupied by the crown of the tooth. The 
pressure of biting the teeth together is placed on the 
gauze and is transmitted to the socket. This pressure 
results in hemostasis. If the gauze is simply placed on 
the occlusal table, the pressure applied to the bleeding 
socket is insufficient to achieve adequate hemostasis 
(Fig. 7-73). A larger gauze sponge (4x4 inch) may be 
required if multiple teeth have been extracted or if the 
opposing arch is edentulous. 



BIBLIOGRAPHY 



Berman SA: Basic principles of dentoalveolar surgery. 
In Peterson LJ, editor: Principles of oral and maxillofacial 
surgery, Philadelphia, 1992, JB Lippincott. 

Byrd DL: Exodontia: modern concepts, Dent Clin North 
Am 15:273, 1971.