Dent 153: Oral Surgery |1st Semester A.Y.

2018-2019

PRINCIPLES OF TOOTH EXTRACTION

Dr. Elmer Escoto, DDM |October 8, 2018

E. Malposed/Supra-erupted teeth
OUTLINE F. Fractured/Cracked teeth
G. Pre-prosthetic procedures
H. Impacted teeth
I. Introduction A. Uncontrolled
leukemia or I. Supernumerary teeth
II. Indications
A. Severe Caries lymphoma J. Teeth with associated pathologies
B. Severe B. Uncontrolled K. Pre-radiation treatment
Periodontal CVS disease L. Teeth involved in jaw fractures
Disease C. Pregnancy: M. Esthetics
C. Pupal Necrosis/ 1st trimester
Periapical D. Severe blood N. Economics
Pathologies dyscrasia or A. SEVERE CARIES
D. Pre- disorder  Non-restorable: remaining tooth structure is not enough to
orthodontic E. Steroids,
support fillings, onlays, or even crowns
Procedures F. immunosuppressiv
E. Malposed/ es and cancer  May or may not have pathologies (pulpal or periodontal),
Supra- erupted medications as long as it is unrestorable
teeth V. Essentials In Oral
F. Fractured/ Surgery
Cracked Teeth - Raffles B. PULPAL NECROSIS/PERIAPICAL PAT HOLOGY
G. Pre- VI. Clinical Evaluation  Includes
prosthetic VII. Radiographic  Periapical abscess – usually described as a diffused
Procedures Examination area of radiolucency in the radiograph
H. Impacted Teeth VIII. Principles of
I. Supernumerary Tooth  Gutta percha tracing may be done if several teeth are
Teeth Extraction involved.
J. Teeth Associated A. Guidelines in  Pulpal Necrosis: dead pulp
with Pathologies Using Forceps  If amenable to RCT, we may do this first
K. Pre-radiation B. Guidelines in
 Periapical Pathologies including cysts, granuloma, and
Therapy Using Elevators
L. Teeth Involved in IX. Mechanical Principles abscesses
Jaw Fractures A. Class I
M. Esthetics Lever C. SEVERE PERIODONT AL DISEASE
N. Economics Principle
B. Wedge Principle
 When teeth are no longer amenable to periodontal
III. Local Contraindications
A. Acute infections of C. Wheel and treatment (scaling, polishing, surgical/non-surgical root
the tooth or Axle planing)
surrounding tissues Principle  If there is no or insufficient bone support (mobile teeth)
B. Ongoing X. Chair Positioning
radiation A. Maxillary Teeth
therapy B. Mandibular Teeth D. PRE-ORT HODONTIC PROCEDURES
C. Teeth within XI. Role Of The Other Hand  Done to provide space prior to placement of orthodontic
malignant XII. Dentist’s Position
appliances
IV. Systemic XIII. Method Of Extraction
Contraindications XIV. Complications  For gaining space to allow movement of teeth and to
A. Severe/uncontroll prevent relapse

ed metabolic rd
Generally, 1st premolars and 3 molars (unless otherwise
diseases specified) are removed to facilitate the orthodontic
treatment
REFERENCES
 One of the 2 cases (along with pre-prosthetic procedure)
1. Lecture recording dated October 8, 2018 where you extract sound teeth
2. Batch 2018 and 2019 trans
E. MALPOSED/SUPRAERUPT ED TEET H
I. INTRODUCTION  Extracted depending on the situation [2018]
 Supraerupted - extracted if it causes soft tissue injury
 Tooth extraction is also known as EXODONTICS
other teeth
 It is the most basic form of oral surgery
 Tooth becomes so extruded like when it does not have
an antagonist anymore which may injure the mucosa. So
II. INDICATIONS
literally nakakagat ng patient yung sarili niya.
A. Severe Caries  Malposed tooth- extracted if it is difficult to clean
B. Pulpal necrosis/Periapical pathologies  E.g: 3rd molars that are mesially angulated may serve as
C. Severe Periodontal disease food traps, thus need to be extracted
D. Pre-orthodontic procedures

DDM 2020: Brillante, E., Figueroa, J., Martin, R., Rayos, M. Page 1 of 9
 F. FRACT URED/ CRACKED TEET H
 Case-to-case basis: extracted if not amenable to RCT
(kasi walang seal) or placement of restoration
 Usually caused by trauma between teeth
 E.g: Vertically-fractured teeth (fractured along the long
axis of the tooth) – usually non-restorable; you cannot
perform RCT anymore even if there is pulp exposure
 Horizontally-fractured teeth and incomplete fractures or
grazing, depending on the extent and location, are
sometimes still treatable [2018]
 Example by Sir, yung may post and core na picture pero
maikli yung post. How long should your post be? At least
the same length of your crown or just slightly shorter than
that. Kapag sobrang ikli, magpa-fracture yan.
G. PRE-PROST HETIC PROCEDURES
 Is the tooth still strategic as far as the denture is
concerned? Is it sound? Will it help stabilize the denture?
 Extracted if deemed not strategic for fabrication of
prosthesis
 If teeth are beneficial or strategic for prosthesis placement,
don’t extract
 E.g.: sound and stable cuspids/canines - strategic; good
abutments, more so if 1st molars = don’t extract),
 E.g.: 41 is the only tooth left – extract since non-strategic
 Consider retention of prosthesis
H. IMPACT ED TEETH
 Surgically removed
 Impacted, by definition means, tooth’s eruption path is
impeded by fibrous tissue or another tooth
 Indicated for removal because it can cause pericoronitis or
carious destruction of adjacent teeth if impacted tooth
renders the area uncleanseable (e.g: 3rd molars)
 Pero in OS, cases may look the same pero the treatment
may be sometimes different. Things vary in OS so need
ng good decision making if routine extraction or surgical
na ba
I. SUPERNUMERARY T EETH
 May also be impacted or cause diastema, so extract
 Example by Sir: Twinning. Orthodontic treatment usually
requires extraction.
 Pano kung pumunta sayo pero di naman magpapa-
orthodontic treatment? Also extracted if they cause
trauma to the soft tissues, or if it causes uncleansable
area that will make other teeth prone to
caries/periodontal problems
 Kapag ganitong cases, you need to warn the patient not to
bite on the area na binunutan for several weeks kasi
pwede maging mobile yung katabing tooth because when
you extract the tooth, mawawala rin yung bone – Patient’s
Problem.
 You can’t adapt the forceps properly so luxator-elevator
lang gagamitin mo – Dentist’s Problem
 If supernumerary tooth does not bother you and does not
cause any problems to other teeth, you may leave it alone,
but you may have some form of malocclusion
DDM 2020: Brillante, E., Figueroa, J., Martin, R., Rayos, M.
J. TEET H WIT H ASSOCIAT ED WIT H PAT HOLOGIES
 Includes:
 Periapical abscess - Makikita mo may large filling. So
yung filling ba yung cause of pulpal death? No. It’s the
caries extent
 Periodontal abscess – infection within the periodontium
caused either by loss of attachment or MOs entering into
a pocket
o to know by just looking at the picture if it’s periodontal
in origin is to examine if the tooth has caries. If wala,
the most likely periodontal in origin.
o Probably lang pero you need to do diagnostic tests to
confirm
 Periapical granulomas – may come from a root
fragment
 Periapical cysts
 Odontogenic tumors
 Ameloblastoma
 Teeth involved may be extracted for access purposes
 Infections due to pericoronitis (in partially erupted
rd
teeth) which developed an operculum – usually in 3
molars.
K. PRE-RADIAT ION T REAT MENT
 Complication of radiation: osteoradionerosis (ORN)
 If patient is about to undergo head and neck radiation
therapy, get medical clearance prior to radiation treatment
and the teeth should also be extracted before the treatment
 The blood supply is affected due to the radiation when
you do radiation therapy
 Radiation therapy can be done preferably TWO WEEKS
AFTER the last extraction
o Two weeks after so that you have some form of
healing already
 Boils down to the dentist’s judgment whether it is beneficial
to save the tooth or if it is better to start the radiation earlier
[2018]
L. TEETH INVOLVED IN JAW FRACT URES
 Case-to-case basis
 Extracted if teeth involved are fractured along with the
jaw
 Not extracted if teeth involved around the area of the jaw
fracture are stable and sound and can help stabilize the
jaw fracture
 If the tooth involved is vertically fractured or mobile and
will not help stabilize the fracture, then you extract it
M. ESTET HICS
 Shouldn’t actually be an indication—least acceptable
indication
 Extracting teeth due to esthetic reasons may not always be
of priority (i.e. problems in shape, color, malocclusion, etc.)
 Remember that there are other treatment options available.
You can put crowns or laminates, orthodontic treatment,
bleaching, FPD, etc.
N. ECONOMICS
 Plays a factor in treatment planning
Page 2 of 9
 Unfortunately, in the Philippines, this is probably the first
and foremost reason for extraction (no time or money for
RCT, can’t afford orthodontic treatment, crowns, etc.)
 There may also be problems with length of procedure
(because RCT is time consuming; may require more than 1
sitting) and skill of the clinician
III. LOCAL CONTRAINDICATIONS
 Local = in the area of the affected tooth
 All are relative (not absolute) contraindications only. They
can still be treated in other ways.
A. ACUT E INFECT IONS OF T HE TOOT H OR
SURROUNDING T ISSUES
 E.g. Acute Pericoronitis (case-to-case)
 Pero as we have learned from now, hindi porket acute
hindi na pwede bunutin. Merong case nga na after 2 days
of antibiotic treatment (IV or oral), pwede nang bunutin
yung ngipin.
B. ONGOING RADIAT ION THERAPY
 As much as possible contraindicated because of risk for
possible ORN
 What happens in ORN? The radiation affects the
vascularity of bone. Poor wound healing.
 Extractions (with primary closure) should be done prior to
radiation therapy
 In case of dental emergencies during the radiation therapy,
(example nabasag yung ngipin ng patient habang
kumakain):
1. You may coordinate with the patient’s oncologist
2. You may perform the extraction in between the
radiation treatment
3. You may do a surgical procedure then primary
closure (close the socket and suture the mucosa
together). You may need to remove a little amount
of bone.
4. Adjunct may be antibiotic therapy done orally or
IV, or hyperbaric oxygen chamber. Patient may
need to be confined [2019]
C. TEETH WIT HIN MALIGNANT T UMORS
 Will you extract the tooth if it is embedded in a malignant
tumor (e.g.: carcinoma)?
 Preferably no. Because malignant tumors are very
vascular. The vascularity of these tumors are friable
(madali masira yung blood vessels). Uncontrolled
bleeding can happen if you extract these teeth due to the
vast blood supply of tumors (neogenesis)
 If you can control the bleeding, then that’s not a problem;
otherwise, leave it alone.
IV. SYSTEMIC CONTRAINDICATIONS
A. Severe/Uncontrolled Metabolic Disease
 Diabetes, hyperthyroidism, etc.
o Uncontrolled diabetes  decrease in phagocytic
activity  poor healing  increased risk for infection
o Hyperthyroid  consequence: thyroid storm, esp.
when using vasoconstrictors
DDM 2020: Brillante, E., Figueroa, J., Martin, R., Rayos, M.
 There are times that you have to do extraction because it
will manage the metabolic disease
 In cases of hyperthyroid patients, you cannot give
anesthesia with epinephrine (vasoconstrictor). In case
of emergency procedures, it should be done in a
hospital setting together with the patient’s endocrinologist
 Uncontrolled diabetes is of lesser concern because there
would only be problems in healing and infection which can
be managed; still done with the endocrinologist
B. Uncontrolled Leukemia of Lymphoma
 There is the possibility of bleeding due to low platelet count
 May also be prone to infection
C. Uncontrolled CVS Disease
 Might aggravate the cardiovascular status
 Uncontrolled hypertension, unstable angina, recent
myocardial infarction, uncontrolled ischemic heart disease,
etc.
 Dental procedure may cause CVA (stroke)
st
D. Pregnancy: 1 Trimester
 If case is in need of extraction, procedure is to be done in a
hospital-based dental practice in cooperation with the
patient’s obstetrician. Procedure must be conservative.
[From 2018 Trans]
 Managed carefully because the fetus will be vulnerable to
any external stimuli (especially radiation – make sure lead
apron is intact, and medications – probably limited to
amoxicillin and paracetamol)
E. Severe Blood Dyscrasia or Disorders
 Uncontrolled bleeding
 Bleeding disorders:
 Idiopathic thrombocytopenic purpura (ITP)
 Disseminated Idiopathic Coagulopathy (DIC)
F. Steroids, Immunosuppressives, and Cancer
Medications
 Prone to infections due to poor/suppressed immune
system
 Steroids – suppresses inflammation; used for stress
management
 Immunosuppressives – prevents rejection of organ
(patients who have undergone transplant); prone to
infection
 Cancer medications – affects rapidly growing cells (tumor
cells, inflammatory cells); e.g. bisphophonates [From 2018
Trans]
NOTE:
If your patient has these, then you need to get a clearance
before treaingt the patient.
V. ESSENTIALS IN ORAL SURGERY
RAFFLES – these are what you have to do for an efficient
surgery; basic armamentaria
 Radiograph
 Anesthesia
 Forceps and Elevators
 Flap Tray
Page 3 of 9
 Lighting
 Efficient Assistant
 Suction
[From 2018 Trans]:
A. Radiograph
 Must be of diagnostic value – not foreshortened,
elongated, underfixed, or overdeveloped
 Digital radiography – madaling ulitin, less radiation
B. Anesthesia
 Use suitable agents and make sure that the area becomes
profound prior to surgical procedure (correct area of
injection)
C. Forceps and Elevators
 2 most basic instruments for extraction of teeth
 Specific for each tooth
REVIEW
 Maxillary Forceps:
 150 - anteriors to premolars, any root fragment
rd
 69 - small root fragments (middle to apical 3 nalang
natitira)
 65 - root fragments at posterior area
 240 - molars with fused trunked roots
 18L and 18R – molars; roots aren’t fused
 88L and 88R - molars with furcation involvement
 Mandibular Forceps:
 151 - anteriors to premolars, any root fragment
 215 and 17 - molars
 16 - "Cow Horn"; molars with furcation involvement
D. Flap Trays
 Instruments needed for flap
 You use this when you encounter problems during your
extraction. You create an opening via a flap to make the
extraction easier.
 Scalpels, Elevator, Retractors, Tissue forceps, Surgical
handpiece and burs, Suture set
E. Lighting
 Visibility is compromised due to bleeding or if extracted
tooth is embedded too deep
 For adequate visibility of the surgical site; you need to have
a good surgical light in order to illuminate the site
F. Efficient Assistant
 Efficient surgery especially for complicated procedures;
reduces your strain, your stress
 The role of the assistant is that they should more or less
know what you are going to do  to be able to give you
what you need, when you need it
 The assistant should not cause a hindrance on the
procedure at hand
In the clinics, get an assistant that is also a clinician. If not a
clinician, there is no efficiency in assisting.
G. Suction
 For visibility of the surgical site
 Saliva ejector is insufficient, use HVE instead
DDM 2020: Brillante, E., Figueroa, J., Martin, R., Rayos, M.
 High volume evacuator – because we have a lot of fluid to
remove e.g. blood, saliva, and excess water/irrigant
VI. CLINICAL EVALUATION
A. Access to the T ooth
 Determine [access] by simply referring to the long axis of
the tooth – relate the long axis to the path of removal of the
tooth
 Fully exposed – line of withdrawal/long axis (usually along
the long axis of the tooth) is unimpeded – most likely can
be removed in the routine manner (e.g. extracting 11)
 Impacted – line of withdrawal/long axis is
hindered/impeded by another tooth, bone, or soft tissue –
most likely to be removed through a surgical procedure
(e.g. third molar na horizontal, because of the second
molar, you cannot remove an impacted tooth through the
routine extraction procedure)
 Consider path of removal: obstructed or free?
 Do you need to section the teeth? Create a flap? Or simple
extraction?
B. Mobility of the T ooth

st rd
1 to 3 degree of mobility, or no mobility
 Meron bang “no mobility”? Applies to ankylosed teeth.
More often than not, it’s not ankylosed pero bakit
mahirap bunutin? It’s [because of] bone density – the
denser the bone, the harder it is to extract the tooth.
Moving the tooth bucco-lingually, expanding the bone
slowly, to luxate/loosen it  dense bone, bone not
expanding, becomes difficult exo
 It can tell the difficulty or complexity of extraction
 The more mobile, the easier it is to extract
 No need to use an elevator if the tooth has a 3 degree
rd
mobility due to lack of periodontal support
C. Conditions of the Crown
 In order to put in a large filling, you need to remove all
parts that are carious, and reach a stable tooth structure.
Problem with large fillings/carious extractions is that the
area that your forceps can grip onto becomes very small 
mas mataas yung chances na mapuputol yung ngipin.
 Does the tooth have a large filling or large carious
destructions? Because these teeth have a tendency to
fracture, and root surface usually is weak/soft already due
to possible periodontal involvement
VII. RADIOGRAPHIC EVALUATION
 SOP: periapical x-ray prior to exo because we need to
know the proximity of structures, root anatomy, and
number of roots, before we extract the tooth
 Radiographs are essential for surgery because you need to
see the condition of the bone, the anatomy of the tooth,
and relationship with other vital structures.
 Relationship with other vital structures
 Mental foramen – concerned with premolars
 Inferior Alveolar Nerve – close proximity of the third
molars
 Proximity to the Maxillary Sinus – maxillary posterior
teeth
Page 4 of 9
 o Sometimes, roots extending inside the sinus, when
you extract, there would be an oro-antral opening
o Infections (periapical) from maxillary posterior teeth
could travel upwards and perforate into the sinus
Figure 1. Mental Foramen
Figure 2. Mandibular Canal/Inferior Alveolar Nerve (broken lines).
Radiographically, your mandibular canal is two parallel radiopaque lines
which represent the superior and inferior border of the canal. If a third
molar (with roots extending to the mandibular canal) is about to be
extracted, inform the patient prior to surgery that he/she might
experience paresthesia (prickling feeling) after the procedure.
Figure 3. Maxillary Sinus Perforation. Take into consideration, because
sometimes the roots are inside the sinus. Exposure of the sinus after
exo, walang magagawa doon dahil it’s the normal anatomy of the px.
Manage after it has been detected.
NOTE: [From 2018 Trans]
Oro-antral Opening
- It’s not a complication because it is part of the anatomy of the
patient
- Not an error in extraction
 Root Configuration
 Number of root, size, shape, curvature, resorption, and
position  these information help determine difficulty of
extraction
 Does caries extend up to the root portion?
 If you have multi-rooted tooth, you have to consider
multi-path removal
o Extracting lower molars: expected root shape is
ovoid, pero kapag in-extract, may isang ovoid, isa
bilog, ibig sabihin may isa pang naiwan, and most
likely it’s the distal root (the distal root is the one that
is commonly split into a DL/B root). Take note of what
should be the normal anatomy, if it’s not normal, then
you might have an accessory root somewhere.
 Long and slender roots
o If it’s long, [there are] more PDL fibers holding it back;
slender, increases the chances of fracture.
DDM 2020: Brillante, E., Figueroa, J., Martin, R., Rayos, M.
o Cut/Section the root at the center and individually
remove components  distributing the force of
extraction per root rather than as a whole
 Dilacerations
o Higher chance of fracturing the apical third of the root;
use a root tip pick or surgically remove it
o Can you leave the root fragment behind?
 Case-to-case. If it’s going to harm the patient more
by retrieving it, then you decide to leave it. But
when it’s going to be detrimental to the patient, then
you have to take it – when the tooth is infected,
leaving a fragment will not resolve the infection. But
when it’s a chronic infection, patient is healthy, or
odontectomy on a sound tooth, but it’s near the IAN,
probably best to leave it alone.
EXAMPLE:
Root Configuration
- 36 with mesial and distal roots pointing at opposite directions,
away from each other
- If you try to extract this as a whole, it may or may not come
out. The easiest way to do it is to section the tooth at its center
and extract them individually. [From 2018 Trans]
TIP (from Dr. Escoto):
After 5 mins, you cannot extract using the routine manner, next
option: section the tooth down the center and remove them
independently. After 5 minutes, hindi pa rin magawa, open a
flap. Do not dwell on one procedure for a long time.
 Conditions of surrounding bone
 Densities – the denser the bone, the more difficult it is to
extract; How do you know if it’s very dense or not? It
depends on the opacity of your x-ray – the whiter the
bone, the denser
 Pathologies – it can help remove the tooth easier
because of bone resorption; or it can make debridement
harder because you now have to remove whatever
pathology is seen in the periapical area
o Assuming you have two maxillary first molars: 16 with
irreversible pulpitis vs another 16 with chronic
periapical abscess. Which one’s easier to extract? 
16 with CAP because of the partially resorbed bone
[From 2018 Trans]
VIII. PRINCIPLES OF TOOTH EXTRACTION
A. Guidelines in using Forceps
1. Forceps beaks should be parallel to the long axis
 It puts the force of extraction along the long axis
 Minimizes chance of fracture (it does not prevent)
2. Grip the root surfaces firmly as low as possible
 Remember: forceps are designed to adapt to the root
surface
 You want to go as low down the root as possible so that
you minimize the chances of fracturing
 You want to grab as much root surface as possible since
the beaks of the forceps are designed to adapt to the root
not the crown. [From 2018 Trans]
3. Grip the handles as far from the beak as possible
 For leverage; the farther you hold it down the handle, the
better your grip would be on the tooth.
4. Apical pressure is applied
 By putting apical pressure first:
Page 5 of 9
 1) Puts the forceps as low as possible down the root
surface
2) Helps reduce fracturing by lowering the centroid/center
of rotation
 The center of rotation/centroid is normally at the center of
the tooth  Coronally to #2  By doing this, the center
of rotation lowers which minimizes chances of fracturing
5. Slowly move the forceps bucco-lingually/palatally to
slowly expand the alveolar bone
 Use a slow, concentrated motion
 By slowly moving the forceps buccally and
lingually/palatally, you are also slowly expanding the
alveolar bone surrounding the tooth
 Technically, we don’t pull the teeth, we expand the bone
1) If you pull, the tooth might fracture or the tooth might
pop out
2) If it pops out, you might hit the antagonist, causing
trauma.
 You need to have a good grip.
 Handle as far from the beak as possible
 One hand holds the forceps; the other supports the
alveolar bone.
 You put gauze when doing lingual/palatal guard; put
finger on the gauze para may padding
 Reciprocation – by using your other hand to
counteract the force when the patient’s head is
pushed  stabilizes the head
IX. MECHANICAL PRINCIPLES
A. CLASS I LEVER PRINCIPLE
 Straight elevators employ this
 Used to pry out
 Resistance arm- tooth; Effort arm- handle and the arm;
Fulcrum- bone
 In physics, if you have a long effort arm and small
resistance arm, you multiply the amount of force on the
resistance by simply applying a small amount of force.
 Resistance arm is shorter than your fulcrum
LONG EA
SHORT RA

FULCRUM

Figure 4. Forceps is parallel to the long axis of the tooth. Correct way
of holding the forceps Figure 4. Class I Lever Principle- (EA- effort arm; RA-
[From 2018 Trans]
resistance arm)
B. Guidelines in using Elevators B. WEDGE PRINCIPLE
1. Hold the elevator in a firm palm grasp  Luxators employ
2. Engage the blade tip into the purchase area (the PDL this principle
space) between the tooth and the bone  Wedged in
 Wedge the elevator inside the PDL space to luxate the between in order to loosen
roots of the tooth the tooth
3. Make sure the elevator fulcrums on bone and not just
the adjacent tooth
 Straight elevators can be used in 2 ways: 1.) If you’re Figure 5. Wedge Principle
going to pry it out using a first class lever, or 2.) As a using a Cow Horn Forceps
wedge, if you’re going to force it inside the PDL space – which acts as a double
either way you need to put the elevator on bone to act as wedge
fulcrum
 If you intend to extract the adjacent tooth, you can put
the elevator in between them  Cowhorn acts on the furcation. As you now grip/ squeeze
4. Have a lingual or palatal guard when using the the handle, the cowhorns bury itself into the furcation and
elevators at the same time pushes against the alveolar bone to lift
 Elevators are always placed at the buccal/labial side. the tooth up.
Why? C. WHEEL AND AXLE PRINCIPLE
 Mandible - Lingual alveolar bone (the lingual cortical  Crier/ crossbar elevators employ this
plate) is thin; can easily fracture  Blade is at 90 degrees from the axis
 Danger of slipping (both mx and md) if placed in the  Used in a rotating manner
lingual. Can cause cheek perforation  The idea here is, if you have a fragment that’s embedded,
 Lingual/ Palatal Guard – if your right hand is holding the insert the crier and by turning the handle, the fragment
elevator, use the fingers (index and middle) of your left would be lifted up.
hand to oppose the forces and protect the soft tissues of
the patient at the lingual side.

DDM 2020: Brillante, E., Figueroa, J., Martin, R., Rayos, M. Page 6 of 9
 st
 If it’s difficult to extract, let’s say you’re extracting the 1
molar, four finger are outside supporting the jaw and
nd
thumb is on the 2 molar (literally holding the mandible).

XII. DENTIST’S POSITION

Table 1. Dentist's position relative to the patient (assuming that

you're right handed).

TOOTH TO ORIENTATION DENTIST’S

Figure 6. Wheel and Axle Principle EXTRACT OF PATIENT’S POSITION
HEAD
X. CHAIR POSITIONING Maxillary
8 o’ clock
Anteriors
 In OS, we usually position ourselves in 7, 8, or 9 o’ clock Looks forward
Maxillary Right
for extractions (most common positions); 12 o’ clock 7 or 8 o’ clock
Quadrant
position usually for lower anteriors (for right- handed) Maxillary Left Slightly turned
A. MAX ILLARY TEET H Quadrant towards the dentist
 Occlusal plane: about 45- 60 degrees from the vertical (tilt (“turn niyo po yung 7 or 8 o’ clock
of the backrest) ulo niyo towards
 Level of maxilla: should be about the level of operator’s me”)
elbow (most ergonomic position to prevent strain) Mandibular
12 o’ clock
 Multiple extractions Anteriors
Looks forward
 Start from the most posterior going anteriorly (back to Mandibular Right
7 or 8 o’ clock
front) Quadrant
 For visibility and generally, it is easier to extract anterior Mandibular Left Slightly turned
7 or 8 o’ clock
teeth Quadrant towards dentist
 If you start form the front going backwards there wil be  If you’re left handed, you may have your dental chair
difficulty in visibility because of bleeding customized and just revert the positions to its counterpart.
 After multiple extractions, alveoloplasty is usually done.
 After extraction, there could be presence of sharp XIII. METHOD OF EXTRACTION
interseptal or inter- radicular bone; therefore,
alveoloplasty is done wherein sharp edges of bone are  First and foremost, apply anesthesia.
rounded off with the use of a bone file. And most For maxillary teeth, usually infiltration.
probably, you would do suturing afterwards. For mandibular molars, IAN block. For mandibular
B. MANDIBULAR T EET H anteriors, most of the time, infiltration is done, but there
are cases (usually cuspid) that you would need to do IAN
 Occlusal plane: parallel to the floor
block.
 Level of mandibular occlusal plane: at or slightly below the
 STEP 1: Loosening tissue attachment from around the
dentist’s elbow
tooth using either MPE or gum separator
XI. ROLE OF THE OTHER HAND  Insert the MPE inside the crevice then you swing it
around the tooth. Insert it on one side, swing it to the
 Reflecting the cheeks, lips and tongue other side (buccal and lingual/palatal sides). Purpose is
 Hold the alveolar bone over the tooth being extracted to to cut out gingival fibers.
support bone and feel for movement  Do not do it in a walking probe/ segmental motion
 As one hand holds the forceps, the other hand retracts the because there might still be fibers left attached to the
cheeks and lips and also holds the alveolar bone tooth.
 One finger is on the buccal side, and one finger is on the  . Test profoundness of anesthesia:
palatal side. If you’re working on the right quadrant, given  Subjective sign: When you ask the patient about what
that you’re right handed, your index finger is on the they feel
palatal side and the thumb is on the buccal side. On the  Objective sign: By manipulating or move the tissues
other hand, if you’re working on the left quadrant, given around and the patient does not feel anything
that you’re right handed, your index finger is on the  The basic reason is to move the tissues away so that you
buccal side and the thumb is on the palatal side. WHY? don’t damage the tissues when you apply the forceps. In
 Because as you move the forceps bucco-lingually, it case you damage, post- operative discomfort may delay
makes you feel if the bone is expanding/moving. healing.
 And it also stabilizes the head of the patient.  STEP 2: Luxation of teeth using an elevator
 Protects the teeth to serve as guard.  Loosens the tooth from the socket by tearing the
 Stabilizes the lower jaw periodontal ligament
 Thumb retracts the teeth.  Insert the elevator, wedge it in or lever, but commonly it
 Other fingers, extraorally, supports the jaw. is wedged in to help luxate or loosen the tooth. In case of

DDM 2020: Brillante, E., Figueroa, J., Martin, R., Rayos, M. Page 7 of 9
 periodontally-involved tooth, with grade III (severe)  STEP 7: Debridement of the socket
mobility, elevation may not be necessary.  Curettage of the socket to remove granulation tissue,
calcular deposits, tooth fragments, and other foreign
 STEP 3: Adaptation of the appropriate forceps to the material from the socket to prevent any post-op infection
tooth  Be sure to not go beyond the apical areas
 Forceps are designed to adapt to the specific root  STEP 8: Irrigation of socket
configuration to a particular tooth  Using copious amount of NSS to flush out any debris
 NSS: Normal Saline Solution (0.9% NaCl solution)
Table 2. Review of Types of Forceps and their respective  Why 0.9%? Because it’s isotonic.
indications  STEP 9: Compression of socket
 Using a gauze, hold the buccal and lingual/palatal
MAXILLARY FORCEPS MANDIBULAR FORCEPS
alveolar plates and gently squeeze the socket to return
NO. INDICATION NO. INDICATION
the expanded bone back to its original shape
150  Anterior- 151  Anterior-  Minimizes post-op pain (because squeezing causes the
premolars premolars bone to become rounded) and facilitates faster healing
 Any root  Any root  STEP 10: Pressure pack
fragment fragment  Done before dismissing the patient
69 Small root  Fold a piece of gauze small enough to fit into the
fragments extraction site but big enough to cover the opening
(when only  2x2 gauze then fold it in such a way that you have
middle to apical pressure over the socket
rd
3 remains)  Have the patient bite on the gauze with firm pressure for 30
65 Root fragments 215 & 17 Molars minutes
at posterior  You want firm pressure on the extraction site as a form
area of tamponade (external pressure is higher than the
240 Molars with arterial pressure to stop the bleeding)
fused roots  Coagulation time is 10-15 mins = initiation of clot and
18L/ 18R Molars 16 Molars with it’s just starting to form; you just want to double the time
88L/ 88 R Molars with “cow horn” furcation so by the time you take out the gauze, the clot is
furcation involvement already relatively stable
involvement  STEP 11: Post-op instructions
 emphasize post-op instructions to the patient because
 STEP 4: Movement of the forceps not following post-op instructions may lead to post-op

Done to expand the alveolar bone complications

Adapt the forceps with apical pressure and move the  Diet
forceps bucco-palatally or bucco-lingually (posterior  Soft and cold food for the 1st 24 hours (e.g ice cream and
teeth)/ labio- palatally or labio- lingulaly (anterior teeth) to yogurt)
expand the alveolar bone. o Cold – vasoconstriction; minimize bleeding
 Larger force is applied bucally, slower force is applied o Soft – to minimize trauma; so it will be easy to chew
palatally or lingually. because patient may be experiencing trismus
 Do the bucca- palatal or bucco- lingual motion until the  After 24 hours (DAT – diet as tolerated)
tooth is extracted, usually on a buccal direction. An o Take in food hours later that are tolerable but are not
exception to the buccal direction extraction is the loss of too hot; patient must not open mouth too wide
lingual wall.  Chew on the opposite side – so as not to cause trauma
 And the only teeth that you can rotate are the upper on the site where you operated
st
central and lower 1 premolars because the root  Straws (or anything that would create negative
anatomy of these teeth are straight and conical. Rotating, pressure) should be avoided
not like what you do with screw, rather small rocking  Oral hygiene
back and forth motion of at least 1- 2 mm rocking motion.  Avoid brushing near the surgical site to prevent
 STEP 5: Removal from the socket bleeding
 The tooth is gently picked up from the socket  Mouthwash can be used but avoid those with alcohol
 Never pull the tooth out from the socket because you content
may fracture the tooth or if it suddenly comes out, you  Post-op pain and discomfort
may hit the antagonist  Determine the amount of post-op pain expected and the
 STEP 6: Palpation of the socket analgesic to be prescribed for that pain
 Check for sharp edges  if there are sharp edges, bone  Give analgesic before the anesthetic wears out.
file  rounded off  minimizes post- operative pain  (anesthesia wears out after 1-2 hrs.)
 How to use bone file?  By the time that the anesthetic wears out, the analgesic
 Single, horizontal serrations- adapt, pull, adapt, pull should already be working
 Criss- cross serrations- push and pull motion

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  Pre-emptive analgesia may be given, but some journals
say that there is no difference in the effect between pre-
emptive and post-op analgesia
 Post-op bleeding
 Place gauze over the socket and bite for 30 minutes
under firm pressure
 Apply a new gauze if it continues to ooze
 Keep talking to a minimum of 3-4 hours
 No smoking for at least 12 hours because components
of cigarette are irritants
 No drinking through a straw
 Avoid spitting
o Sucking in during smoking, drinking through a straw,
and spitting create negative pressure, dislodging the
clot
 No strenuous activities for 24 hours
 Edema/swelling
 Maximum swelling expected within 48-72 hours post-
op then it tapers off.
 For most patients, it takes about a week for the swelling
be completely disappears
 Edema/swelling is something you expect because it’s a
physiologic response but if it increases or if pain
persists, it may be pathologic.
 Amount of swelling varies depending on the following
factors:
o Extent of surgical procedure - more extensive=
more swelling
o Physiologic response - each person has different
response from another person
 Cold compress – ice wrapped in cloth placed
intermittently every 15-20 minutes for the first 24 hours
o For vasoconstriction → lessen swelling, bleeding,
pain and inflammation
o Limit swelling, limit discomfort (limit, not prevent)
o Cyclic to prevent ischemia
 Warm compress on 3rd post-op day (but sir Escoto said
that he usually does not say this to his patients
because it might cause bleeding)
 Trismus
 May occur in some cases more so in the mandibular
surgery (e.g., odontectomy of 48)
 Amount of trismus is relative to the amount of trauma
o The more traumatic the procedure, the more that
trismus is expected
 Ecchymosis
 Seen in traumatic cases or extensive surgery (e.g.
odontectomy when blood seeps in between the flap;
may be seen intraorally or extraorally)
 May be seen more in the elderly due to decrease in
tissue tone and decreased intercellular attachment
 Can be seen extraorally from the
cheek, submandibular area up to the clavicle
 In the maxilla, it is usually limited to the zygomatic area
 Can be minimized by using ice packs
IX. COMPLICATIONS
 Soft tissue injuries:
 Lacerations – from scalpel, surgical burs, unstable
elevator
DDM 2020: Brillante, E., Figueroa, J., Martin, R., Rayos, M.
 Abrasions – from surgical burs and retractors -> may be
countered by minimizing the movement of the retractor
 Punctures – from unstable elevators or burs
 Burns – from improper use of cautery, burs, and endo
procdures (heating of gutta percha)
 Adjacent tooth
 Hitting with forceps – when forceps are pulled
 Errors in elevation – can damage adjacent tooth
 Pulling forceps and hitting the adjacent/antagonist may
loosen or even fracture the adjacent/antagonist
 Extracting the wrong tooth
 Root fracture – a problem that can be easily dealt with
 Displaced tooth
 May end up in the pharyngeal area, sinus,
submandibular, or sublingual space
 May be swallowed or aspirated
 Air Emphysema
 Sudden facial swelling
 Post-op swelling
 Alveolar fractures
 Causes post-op pain
 Happens during traumatic surgeries
 Tuberosity fractures
 May cause exposure of sinus
 Happens during extraction of third molars
 Mandibular fractures
 Commonly occurs when removing a third molar using
crossbar with too much force
 Usually at the angle of the mandible
 Can be due to incorrect use of Crossbar or Cryer
 Can be due to incorrect elevator use
 Nerve injury – IAN, mental nerve, nasopalatine nerve
 Hematoma – May be unavoidable secondary to traumatic
procedures
 Ecchymosis – May be unavoidable secondary to
traumatic procedures
 Edema – Determine if edema is physiologic or from a
cellulitis (pathologic)
 Pain- common result of post-op infections
 Post-op infections
 Dry socket/ Alveolalgia/ Localized
alveolitis/osteomyelitis
o no pus, socket is open, and there might be necrotic
tissue inside; usually seen 2-3 days post- op. Patient
complains of intense pain and sometimes foul odor
o Most common reason: patient failed to follow post op
instructions.
o Fibrinolysis = no blood clot
 Anesthetize, debride, irrigate, and cover with dressing
(pack with iodophor gauze and cover with ZOE). Change
dressing every 2-3 days
 Post-op bleeding
 Usually due to not following post-op instructions
 Know the coagulation cascade
 Broken needle
 Syncope – usually happens during IAN block in patients
 Aggravation of systemic disease
“The d iff erence betw een st up idit y a nd ge ni us is that geni us
ha s it s l im its” -N ej i H yuga
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