Intra-Alveolar Extraction of Teeth - General Consideration

Definition Of Extraction

It is the painless removal of tooth or root from its alveolar socket with least trauma to the surrounding hard and soft tissues and with no complication.

Indications And Contraindications For Removal Of Teeth

Teeth are extracted for different causes. It is true that the aim of modern dentistry is to take every possible measure to preserve and maintain teeth in the oral cavity, however, occasionally it is necessary to remove some teeth. General indications for teeth removal are shown in table 9-1.

On the other hand, occasionally a tooth that is indicated for removal is not to be removed. This is because of the presence of some other factors which contraindicate its extraction. However, these factors are relative and vary in their strength. In some cases extraction is possible when some additional pre and/or postoperative measures has been taken. Generally contraindications are divided into systemic and local contraindications.

Systemic contraindications prevent teeth extraction because the patients general systemic health is compromised. The ability of the patient to withstand the surgical insult is affected by his systemic conditions. This group of contraindications had been discussed in volume I. Local contraindications, on the other hand, are shown in table 9-2.

Preoperative Assessment

Successful extraction procedure depends mainly on good preoperative assessment of difficulties that may be encountered during extraction and complication that may occur. Through good history taking and clinical examination valuable information can be revealed, for example:

  • Access to the tooth: The position of the tooth to be extracted in the alveolus and the extent to which the patient can open his mouth should be noticed. If the patient can not open his mouth normally surgical extraction should be considered instead of forceps extraction. Additionally the cause of this limitation of mouth opening should be considered. The most likely cause is trismus associated with infection.
  • Tooth mobility: The degree of mobility of the tooth to be extracted should be assessed. When the tooth is excessively mobile, as the case with sever periodontal diseases, an uncomplicated extraction is to be expected.
  • Condition of the crown: The amount of the remaining sound teeth structure should be assessed. When the crown is excessively destroyed by caries or has a large restoration a complicated extraction is to be expected.
  • Condition of adjacent teeth: When the adjacent teeth has large restoration or crowns, the elevators, when used, should be used with extreme caution as there is always the risk for these restorations to be damaged.

Preoperative Radiograph

Ideally any tooth to be extracted should be radiographed preoperatively (Fig. 9-1). However, practically this is not always possible. In practice the following conditions necessitate preoperative radiograph of the tooth to be extracted:

  • If the patient gave history of previous difficulties during extraction.
  • Badly destroyed teeth and heavily restored teeth.
  • Endodontically treated teeth.
  • Non-vital teeth.
  • Malposed teeth.
  • All lower and upper third molars as their roots are subjected to great variation in size, shape and number.

Position Of The Patient

The patient is seated comfortably in the dental chair and the back of the chair adjusted so that the head, neck and trunk of the patient are at straight line making 45 degree angle with the floor. Accordingly, when the patient open his mouth the lower occlusal plane will be parallel to the floor and the upper occlusal plane will make 45 degree angle with the floor. (Fig. 9-2)

Position Of The Operator

During extraction of lower right posterior teeth, molars and premolars, the operator stands behind the patient and to the right side (Fig. 9-3). For extraction of all other teeth the operator stand infront of the patient and to the right side (Fig. 9-4).

The height of the dental chair is an important factor for successful extraction. If the operative site is too high or too low the operator will work in mechanically disadvantages and uncomfortable position.

  • For maxillary extraction: The upper occlusal plane should be about two inches below the shoulder level when the operator is working from the standing position.
  • For mandibular extraction: The lower occlusal plane should be about two inches above the elbow joint when the operator is working from the standing position.
  • For extraction of mandibular right posterior teeth: The chair is lowered enough to enable the operator to have a clear view to the field from behind.

The Extraction Forceps

The forceps are the most widely instrument used for teeth extraction. The simplest forceps is the upper straight forceps (Fig. 9-5, B) which is used for extraction of upper anterior teeth. All forceps consists of three parts which are two handles, two blades, connecting together with one joint (Fig 9-5).

As teeth varies greatly in number, size and location of their roots, it is unlogic to extract all teeth with the same forceps. The blade which fit one tooth or group of teeth definitely will not fit all other teeth.

The Extraction Set Of Forceps

The extraction set of forceps consists of six forceps in addition to the bayonet forceps. The forceps differ from each other in the shape of their blades (in order to fit the different shapes of the roots of the teeth) and in the angle between the handles and the blades (to give maximum accessibility to the tooth to be extracted). In figure 9-6 (A) it is very difficult to extract an upper premolar tooth using upper anterior forceps. However, when using upper premolar forceps, which has an angle between the handles and the blades, proper tooth gripping is possible. (Fig. 9-6B)

1. Upper Anterior Forceps: Upper anterior forceps has straight handle with the blades at the same level, i.e. there is no angle between the handles and the blades. The blades are mirror image, exactly the same size and shape, and are fine and sharp as they are gripping a single rooted teeth (Fig. 9-7, A). It is used for extraction of upper anterior teeth.

2. Upper Premolar Forceps: The upper premolar forceps has mirror image blades that are sharp and smooth. There is an angle between the handles and the blades for accessibility (Fig.9-7 B). The handles are concave from one side and convex from the other side. It is used for extraction of maxillary premolars

3. Upper Molars Forceps: The upper molars have three roots, one palatal and two buccal. Therefore, the blades of the forceps which extract them should be different from each other as one blade will grip only one root while the other will grip two roots. Accordingly, the palatal blade is smooth while the buccal blade has a peak to be engaged in the bifurcation on the buccal aspect. The handles of this forceps are curved and make an angle with the blades for better accessibility and proper tooth gripping. Accordingly, there are two upper molar forceps, one for extraction of the right molars and the other for extraction left molars. (Fig. 9-7 C and D)

To differentiate between the right and left upper molar forceps, the forceps is held in the hand, with the blades facing you, if the peaked blade is to your right side, it is a left forceps and if it is to your left side it is a right molar forceps used for extraction of the upper right molars.

4. The Lower Forceps: Blades of the lower forceps are at right angle to the handles for better accessibility. Blades of the lower anteriors and premolars forceps are fine, sharp, smooth and mirror image. The lower anterior forceps (Fig. 9-8, left) may be used for extraction of roots. The premolar forceps (Fig. 9-8, middle) has a slightly wider space between the blades when the forceps is closed. This is to accommodate the bulge of the crown of the premolars.

The blades of the lower molar forceps (Fig. 9-8, right) are mirror image and with peaks to be engaged in the bifurcation both buccally and lingually. This is because the lower molars has two roots, one mesial and one distal.

5. Bayonet Forceps: This forceps is especially designed to reach inaccessible areas in the oral cavity as when extracting an upper third molar. This is achieved by a double angle in the blades (Fig. 9-9) The blades of this forceps are relatively long, smooth, mirror image and fine.

Mechanical Principles of Extraction

A. Expansion: Expansion of the bony socket is the most important factor in forceps extraction. This is achieved by using the tooth as a dilating instrument. Therefore sufficient tooth mass must be firmly grasped by the forceps. Also the nature of the surrounding bone is important, the bone must be elastic enough to allow the expansion to occur. The elasticity of bone is maximum in young individuals and decrease with age. (Fig. 9-10)

B. Lever and Fulcrum: The use of this principle to force the tooth or root out of its socket is the basic principle which govern the use of elevators. (Fig 9-11)

C. Wedging: The insertion of a wedge or wedges between the tooth root and the socket wall will cause the tooth to raise in its socket. This factor is not given a great consideration because it is counteracted by the elasticity of the bone. However, this principle explain why, sometimes, conically rooted teeth as lower premolars and incisors jump out of their socket when the forceps blades are applied with apical pressure. (Fig. 9-12)

Forceps Extraction Procedure

The basic steps for forceps extraction procedures are incision of the gingiva around the tooth to be extracted, gripping the forceps, the use of left hand, tooth gripping and extraction movements required to deliver the tooth out of its alveolus. These are followed by the post-extraction procedures.

Incision: Many dentists depends on the blades of the forceps to strip the gingival attachment from the tooth neck. However, to avoid the possible stripping and laceration of the gingiva during extraction an incision should be made using number 11 Bard Parker blade inserted in the gingival crevice and carries all around the tooth.

Gripping the forceps: The forceps is held in the palm of the hand with the thumb supporting it at the joint (Fig.9-13 and 9-14). On gripping upper premolars and molars forceps as well as the bayonet forceps the concave side of the handles should rest on the palm of the hand. The little finger is placed inside the handles and is used to open the forceps during its application to the tooth. When the tooth is properly gripped the little finger is placed outside the handles.

Common errors in gripping the forceps:

  • Placing the index finger inside the handle just below the joint (Fig. 9-15) is a common error that should be avoided.
  • Gripping the upper premolars and molars forceps or bayonet forceps with the convex side of the handles resting on the palm of the hand is another common error with beginners. This will make the proper application of the forceps to the tooth not possible.
  • Gripping the forceps too near to the joint (Fig.9-15). This will decrease the amount of force that can be applied to the tooth.
  • Gripping the forceps too far from the joint (Fig.9-15). This will decrease the control of the operator over the forceps.

The Use Of Left Hand: The correct use of the left hand greatly facilitate the extraction procedure (Fig 9-16). The role of the left hand is as follows:

  • Displace the tongue cheeks and lips from the side of operation to improve the visual and mechanical access and push the soft tissues out of the harm way, i.e. retraction of the soft tissues.
  • Supports and fixing the mandible during the extraction of mandibular teeth to prevent dislocation of the temporomandibular join.
  • Supports the alveolar bone around the tooth to be extracted. This transmits very useful information to the operator during extraction.
  • Compression of the dilated socket after extraction is completed to decrease the size of the blood clot and thus favour rapid uncomplicated healing.

Griping The Tooth

A. Root Gripping: The dental forceps is an instrument designed to grip the root and never the crown of the tooth. The tooth should be gripped at or just below the cemento-enamel junction. Accordingly, the blades of the forceps should be sharp enough to be easily forced in the periodontal ligament space to grip the root. Gripping the crown usually result in tooth fracture. (Fig. 9-17)

It is a good practice to apply the forceps blades to the less accessible side of the tooth first under direct vision and then apply the other blade. For example if one side of the tooth is destroyed by caries the blade is applied to that side first and the initial extraction movement is toward that side as well.

B. Role of parallelism: The forceps blades should be applied to the tooth in a line with or parallel to the long axis of the tooth (Fig. 9-18 A and C). Figure 9-18 (B) shows wrong application of the blades as they are not parallel to the long axis of the tooth.

C. Role of two point contact: Ideally the inner surface of the forceps blade should snugly fit the root surface (Fig.9-19 left). However, this is practically not possible due to the great variation in the root size, shape and location.

In practice the right way to grip the root is by the two edges of the blades, i.e. two points contact between the blades and the root surface (Fig.9-19 middle). If there is only a linear contact between blades and the root, as with using forceps with large blades (Fig.9-19 right), the tooth most probably will be crushed due to concentration of the force. For this reason it is always better to use narrow fine blades rather than broad heavy ones.

The Extraction Movements

After correct gripping of the tooth it is delivered out of its socket by applying the extraction movements. The extraction movements are essentially three movements which are outward, inward and rotatory movements. The movement should be steady and with a reasonable force. Jerky movement affects fracture of the tooth instead of its delivery. The extraction movements differ from tooth to tooth and even in the same tooth according to the presence of any abnormalities. The extraction movements serves for:

  • Cutting the periodontal ligament attachment
  • Dilating the bony socket around the tooth.

A. Outward (Buccal or Labial) Movement: It is the initial movement in the extraction of all teeth except the lower second and third molars where the buccal plate of bone is reinforced by the external oblique ridge (Fig 9-20A).

B. Inward (Lingual of Palatal) Movement: It is the initial movement during the extraction of the second and third molars as the lingual cortical plate of the alveolar bone at this region is much thinner than the buccal cortical plate. The buccal cortical plate at this region is reinforced by the external oblique ridge of the mandible. (Fig. 9-20B)

As a role the initial movements should be toward the side of less resistance and this is not essentially toward the buccal side. An extensive carious lesion may be present on the lingual side. In such cases although the buccal plate is thinner than the lingual yet the first movement is toward the lingual side due to the expected alveolar resorption at this side. Also the extraction movements in general should be stressed toward the side of less resistance.

C. Rotatory Movement: This movement may be the initial movement in cases of lower premolars and upper centrals, as these teeth have conical roots. Secondary rotatory movement, on the other hand, is used to complete the removal of any tooth previously loosened by outward and inward movements. (Fig. 9-20C)

D. Final Movement: It is the movement by which the tooth is removed from its bony socket outside the oral cavity. This movement should always be directed outward and occlusally to avoid traumatizing the opposing teeth (Fig 9-20D). 

Extraction of Individual Teeth

Maxillary Central And Lateral Incisors

Root: The root of the central incisor is conical, straight and rarely deformed. Labial surface forms larger arch than the palatal. The root of the lateral incisor is flattened mesio-distally and taper to a fine point apically, mesial and distal surfaces may be grooved. In most cases there is an apical distal curvature. The root is more palatally placed than that of the central. (Fig. 9-21)

Alveolar Process: The labial alveolar plate is very thin but it is slightly thicker at the lateral incisor region. Palatally there is a wedge of spongy bone between the lamina propria and the palatal plate of bone, this is called "Retroalveolar Spongiosa".

Extraction: Upper straight forceps is used for extraction of these teeth. Rotatory movement with labiopalatal movement are enough to deliver the central incisor. Primary rotation movement can be done safely as the root is conical. For the lateral incisors primary rotatory movement is contraindicated due to the presence of apical distal curvature.

Maxillary Canine

Root: This tooth has the longest and the strongest root of all the human dentation. The root is triangular in cross section and commonly has an apical distal curvature. The mesial and distal surfaces of the root are broad, flat and commonly grooved.

Alveolar Process: It has the general features of the alveolar process at the region of the central and lateral incisor but the labial plate is much more thinner.

Extraction: Broad bladed upper straight forceps is used for extraction of upper canine. Labial and palatal movement are enough to deliver this tooth. (Fig 9-22)

Maxillary First And Second Premolar

Roots: In 50% of cases the first premolar is birooted and the roots are tapered and curved toward each other. When there is only one root it is usually flattened bucco-lingually and grooved (Fig 9-23). The second premolar, on the other hand, is single rooted in 80% of cases. The roots of second premolar are flattened bucco-palatally and deeply grooved mesially and distally. The root is more closely related to the floor of the maxillary sinus than the roots of the first premolar. (Fig. 9-24)

  • Alveolar bone: The buccal plate of bone is very thin and composed almost entirely from compact bone. The palatal plate is thicker and contain a retroalveolar spongiosa.
  • Extraction: Upper premolar forceps is used For extraction of these teeth. Primary buccal movement followed by palatal movement are enough to extract this teeth. The second premolar is much more easier to extract than the first premolar as it is mostly unirooted.

Maxillary First And Second Molars

Roots: These two teeth has three roots which are straight and widely divergent. Roots of the second molar are generally shorter and less divergent. The strongest and the longest of the three roots is the palatal one. In case of the second molar the mesiobuccal root is commonly fused with the palatal.

Alveolar Process: The alveolar process at the region of the first molar is reinforced buccally by the malar bone of the zygomatic process of the maxilla. Retroalveolar spongiosa is very little. (Figs 9-25 and 9-26)

Extraction: Upper molar forceps is used for extraction of these teeth. Bucco-palatal movements are enough to deliver these teeth but generally the second molar is more easily extracted as the roots are shorter and less divergent than those of the first molar.

Maxillary Third Molar

Roots: There is a wide variation in the number and shape of the roots of this tooth. Roots are generally less divergent than the roots of the first and second molars and very commonly the three roots are fused to form one cone shaped root. (Fig 9-27)

Alveolar Process: Generally the alveolar process is similar to that in the region of the second molar. Distal to the tooth there is the maxillary tuberosity. Excessive distal force may result in tuberosity fracture.

Extraction: Upper molar forceps is used for extraction of this tooth. Bayonet forceps may be used to aid in the accessibility. Bucco-palatal movement are enough to deliver this tooth.

Mandibular Incisors And Canine

Roots: The root of the central and lateral mandibular incisors is straight, taper apically, flattened bucco-lingually and grooved on both the mesial and distal surfaces. The root of the central incisor is shorter than that of the lateral. The root of the canine is longer than that of the incisors, flattened bucco-lingually and occasionally shows apical bifurcation.

Alveolar Process: Both buccal and lingual plates are very thin and devoid of spongy bone which is only found in the interdental bone. (Fig. 9-28)

Extraction: Lower incisor forceps is used for extraction of these teeth. Buccal and lingual movements are enough to deliver these teeth. Primary rotatory movement should be avoided as the roots are flattened labio-lingually. Greater force is needed to extract the canine.

Mandibular Premolars

Roots: The root of the first premolar is oval in cross section and slightly flattened bucco-lingually, while that of the second premolar is longer, more straight and more clyndrical. (Fig 9-29)

Alveolar Process: Crowns of the premolars inclined lingually and the sockets are more buccally placed. The outer cortical plate is thinner than the lingual cortical plate. The mental foramen lies near there apices. (Fig 9-29)

Extraction: As the crowns of the premolars are bulky, the lower premolar forceps have curved blades to accommodate the crown. Buccolingual movement with secondary rotation is used to extract these teeth. Primary rotation can be used with the second premolar as it has a conical straight clyndrical root.

Mandibular First And Second Molar

• Roots: Each of these two teeth has two roots one mesial and one distal. Roots are broad, flattened bucco-lingually and often curved distally. Those of the second molar are somewhat smaller and more straight. (Figs 9-30 and 9-31)

• Alveolar Process: At the first molar region the alveolar process has the same general features as at the premolar region. At the second molar region the buccal plate of bone is reinforced by the external oblique ridge and is thicker than the lingual plate. (Fig. 9-31)

• Extraction: Bucco- lingual movement using lower molar forceps is enough to deliver these teeth. In case of second molar the initial movement is lingually as the lingual cortical plate is thinner than the buccal.

Mandibular Third Molar

• Roots: This tooth shows a wide variation in size, shape, number and location of its roots.

Alveolar Process: Similar to that at the second molar region but the buccal plate is much thicker than the lingual.

• Extraction: Normal lower third molars are usually easily extracted with a lingo-buccal movement using lower molar forceps. The initial movement is toward the lingual side as the buccal plate of bone, being reinforced by the external oblique ridge, is much thicker than the lingual plate. (Fig. 9-32) 

Extraction of Deciduous Teeth

Radiograph showing the relationship of the deciduous molar roots to the underlying forming premolar. (Left)
Correct application of the forceps blades to a deciduous lower molar. (Right

Usually extraction of anterior deciduous teeth is very easy. However, extraction of the deciduous molars may sometimes show some difficulty. This is because of the following factors:

  • The child mouth is small and provides limited access.
  • The developing premolars are enclosed within the roots of the deciduous molars, thus they are liable to damage during extraction (Fig. 9-33)
  • The deciduous teeth has no root mass and caries usually invade the roots, making it difficult to grip the root during extraction.
  • Resorption of the root of the deciduous teeth do not occur uniformly from the apex , usually the side of the root may be resorbed, thus the root is more liable for fracture.

Technique Of Extraction

The technique for extraction of deciduous teeth is essentially the same as that used for the permanent teeth. However, the following should be considered:

  • Use a fine blade forceps to be apple to grip the root and be sure not to endanger the permanent successor (Fig. 9-34)
  • It is better to leave a small root fragment of a deciduous tooth to undergo resorption or exfoliation rather than damaging the permanent successor during its removal.
  • After extraction the roots of the deciduous tooth is examined to be sure that they are complete. You should be able to differentiate between resorbed root and fractured root. Fractured root surface are flat and shiny with sharp edges, resorbed roots, on the other hand, are ragged, matt and has irregular margins. 

Post-Extraction Care

Immediate Post-Operative Procedures

Once the tooth is removed from the socket the bony walls of the socket, which has been dilated by the extraction movements, are compressed between the thumb and the index finger. This is done to decrease the size of the socket and promote rapid healing. The following should be performed:

  • The socket is inspected for any tooth fragment or filling fragments which should be removed if present.
  • Any sharp bony edge is smoothened using bone file.
  • Inspect the interradicular bone, if it projects trim it using bone rongeur.
  • Inspect the soft tissue around the extraction socket for any laceration.

Post-Operative Instruction

  •  Bite on the gauze pack for one hour, if after one hour still there is blood oozing bite on another pack for one more hour.
  • Do not disturb the site of extraction or surgery by foreign objects, your finger or tongue.
  • Avoid vigorous rinsing of the mouth or excessive spitting for the next 24 hours after surgery so as not to disturb the newly formed blood clot..
  • Avoid hot food and drinks for the first 24 hours after surgery.
  • Soft and cold food are allowed on the other side of surgery.
  • In case of surgical removal, ice pack should be applied to the site of surgery. Apply the ice pack 20 minutes/hour for the first postoperative day.
  • Take your medications as prescribed.
  • Pain, swelling and mild ooze of blood is normal in the immediate postoperative period, however, if these symptoms are sever contact your dentist.
  • Sutures, if present, will be removed in the 5th to 7th postoperative day.
  • Smoking is not allowed in the day of surgery or extraction as it may lead to bleeding.
  • Avoid hard work in the first 24 hours after surgery or extraction.
  • Use warm saline mouth wash the second day of surgery 3 times/day for 5-7 days.