Simple extractions are the most common surgical procedures performed in oral surgery for the removal of dentition which is no longer salvageable due to severe caries and related periodontal pathology. The procedure is most often performed under local anesthetic. However, in some instances patients may elect to have sedation due to anxiety. There are also scenarios in which removal of a tooth may be contraindicated and these must be determined by the clinician prior to the planned procedure. The procedure involves proper patient assessment, clinical and radiographic evaluation of the tooth/teeth to be removed, patient and surgeon preparation, and appropriate mechanical principles, in order to avoid iatrogenic injury.
The extraction of a tooth is a procedure that combines the principles of surgery and principles from physics and mechanics.1 The removal of a tooth using these principles minimizes the need for physical strength, and, rather, it relies on the surgical skill of the clinician. As a result, the tooth is not pulled from the alveolar bone socket, which may cause fracture and soft tissue trauma. Instead, the tooth is gently lifted from the alveolar process.1 In order to properly plan for such a procedure, the clinician must first thoroughly assess the patient, both clinically and radiographically, in order to determine the relative difficulty of the extraction procedure. The anticipation of potential difficulty will allow the clinician to be prepared pre-operatively for any untoward outcomes.
Prior to performing any surgical procedure, the clinician should be fully aware of the patients’ medical status. This involves a thorough review of their medical and dental history, including previous surgeries, medications, allergies and any social behaviors such as smoking, alcohol or illicit drug use. Next, the clinician must properly evaluate the tooth/teeth indicated for extraction. This involves both clinical and radiographic assessment to determine caries, pulpal necrosis, periodontal disease, mobility, fractures, anatomical anomalies and periradicular pathology.
In some instances, the patient may require sedation such as oral, nitrous oxide or intravenous anesthesia. The administration of sedation by a surgeon is based on appropriate clinical training. However, in the majority of cases, the use of local anesthetic is sufficient to perform a simple extraction procedure.
As is the case with most simple oral surgery procedures, there is a basic set up of instrumentation which is required. In the case of simple extraction procedures, in addition to these basic instruments (i.e. Minnesota retractor, periosteal elevator, ronguers, curette etc), the selection of proper elevators and extraction forceps must be made relative to the tooth/teeth to be extracted.
The overall procedure can be summarized in the following order:
- Preparation of the patient and clinician – proper sterile technique
Seat the patient comfortably in the dental chair in a comfortable, upright position.
Ask the patient to either pin back long hair or wear a surgical bonnet/cap to keep hair out of the surgical field.
Drape the patient with a fluid-proof surgical bib or drape to prevent contamination of his/her clothing.
Surgeon should wear a surgical gown, bonnet/cap, surgical mask and gloves during the procedure.
- Administration of local anesthetic – local infiltration and/or regional blocks
Select anesthetic relative to the length of the procedure, although additional administration of local anesthetic can be performed during the procedure.
Be aware of any allergies to anesthetics prior to administration.
Be cautious of the volume and concentration of local anesthetic and vasoconstrictor administered to the patient, based on the patient’s weight and medical status.
Always aspirate prior to injection of a local anesthetic when performing regional blockanesthesia.
- Proper chair positioning for the proposed extraction
When extracting mandibular dentition, the patient chair position should be such that the
patient’s mandibular occlusal plane is approximately parallel to the floor.
When extracting maxillary dentition, the patient chair position should be such that the patient’s maxillary occlusal plane is approximately 60° to the floor.
- Release of soft tissue attachment from the root and crown surface of the tooth to be removed
Using a # 15 surgical blade or the pointed end of the # 9 periosteal elevator, gently release the fibrous attachments of the gingival crestal fibers from the tooth surface.
In the case of grossly decayed dentition or retained tooth roots with soft tissue overgrowth, excision of the soft tissue pedicle may be necessary for improved visualization.
It is not necessary to release dental papilla attachment in simple extraction cases. However, it may be necessary to do so if access to the alveolar bone is required and a surgical extraction is planned.
- Elevation and luxation of the tooth/teeth
Elevator selection is based on the anatomical space present between the tooth to be extracted and the adjacent dentition.
Sequential increase in elevator blade size may be necessary to obtain sufficient luxation of the tooth prior to extraction.
As a general rule, elevation should not be performed using the adjacent tooth as a lever.
Elevator position should be between the tooth to be extracted and the adjacent alveolar bone,
within the periodontal ligament space.
Elevation from the mesial aspect of the tooth to be removed is recommended.
- Manual support of alveolar bone during forcep removal of the tooth/teeth (based on right-handed clinicians)
Always use a mouth prop or bite block if inserting fingers into the patient’s mouth between the occlusal surfaces of the maxillary and mandibular teeth to avoid unintentional trauma from biting.
When extracting maxillary anterior teeth or teeth from the right posterior maxillary arch, the thumb of the left hand should support the buccal bone, while the index finger supports the
When extracting teeth from the left maxillary arch, the index finger of the left hand supports the buccal bone, while the thumb supports the palatal bone.
When extracting mandibular anterior teeth or teeth from the right posterior mandibular arch the thumb of the left hand should support the buccal bone, while the index finger supports the lingual bone.
When extracting teeth from the left mandibular arch, the index finger of the left hand supports the buccal bone, while the thumb supports the lingual bone.
- Curettage of the extraction socket (using a curette, tissue scissors and hemostats) to remove granulation tissue
Once the tooth is removed from the socket, all periapical granulation tissues should be gently curetted using a double ended curette.
Tissue scissors may be used to remove granulation tissue tags from the healthy gingival tissues.
Hemostats or ronguers may also be employed to remove granulation tissue from the socket.
- Irrigation of the extraction socket with sterile saline solution
Whenever possible, sterile saline solution at room temperature should be used in place of sterile water when irrigating an extraction socket, to minimize cellular injury.
- Gauze pressure to the extraction socket to achieve hemostasis
Sterile 2 x 2 cm or 3 x 3 cm gauze should be placed directly onto the extraction site, while having the patient apply gentle yet firm pressure with the opposing arch.
The patient should be provided with a packet of sterile gauze to take home and advised to Change the gauze until the clot has stabilized in the socket.
One of the most common areas of contention associated with this procedure is improper pre-operative assessment and planning of the surgery by the clinician. Consequently, this may result in a clinical scenario which may be out of the realm of the clinician’s surgical capabilities. Another common area of contention involves the excessive use of force during the elevation and luxation of the tooth to be removed, leading to both hard tissue and soft tissue injury. Ultimately, this will lead to increased surgical time and cause the patient to have increased post-operative pain and morbidity.
The use of antibiotics post operatively is controversial. Most clinicians believe that simple extraction procedures leading to the removal of the source of potential infection (i.e., tooth/teeth) are sufficient to allow the patient to heal without the risk of infection. In some medically compromised patients (e.g., poorly controlled diabetics, immunocompromised patients) the need for post-operative antibiotics may be necessary.
Hupp JR, Elllis E III, Tucker MR. Contemporary Oral and Maxillofacial Surgery. 5th ed. St. Louis: Mosby, 2008.