Dental Extraction

Dental extraction is one of the most frequently performed procedures in general dental practice and oral surgery. Despite its routine nature, tooth extraction should never be considered trivial. It is, by definition, a minor surgical procedure that involves deliberate trauma to hard and soft tissues, with the potential for local and systemic complications. A sound understanding of anatomy, pathology, patient factors, and surgical principles is therefore essential to ensure safe, predictable outcomes.

Pre-Extraction Considerations

Medical History and Risk Assessment

Before performing any extraction, a thorough medical history is mandatory. Particular attention must be paid to:

  • Bleeding disorders (e.g. haemophilia, von Willebrand disease)
  • Anticoagulant or antiplatelet therapy
  • Immunosuppression
  • Previous radiotherapy to the jaws
  • Systemic diseases such as diabetes or cardiovascular disease
  • Medication-related osteonecrosis of the jaw (MRONJ) risk

 

Although extraction is a minor surgical procedure, the consequences of ignoring systemic factors can be significant. Current NICE guidelines state that routine antibiotic prophylaxis is not required for patients at risk of infective endocarditis, a change from older practice that emphasizes evidence-based decision-making.

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Patient Factors Influencing Extraction Difficulty

Several patient-related variables influence the complexity of an extraction:

  • Age: Younger patients often have more elastic bone, whereas older patients may have dense, sclerotic bone.
  • Sex and build: Heavily built patients may require greater force; smaller patients may present access difficulties.
  • Behaviour and cooperation: Children may be technically easy but behaviourally challenging, while elderly patients may tolerate procedures well despite difficult extractions.

 

A commonly cited clinical aphorism describes elderly teeth as “glass set in concrete”—brittle crowns embedded in dense alveolar bone—highlighting the need for caution.

Dental Factors

Tooth-related factors also play a crucial role:

  • Malpositioned teeth may limit access
  • Isolated teeth, especially maxillary second molars, are often ankylosed
  • Heavily restored or root-filled teeth are more brittle
  • Root morphology (length, curvature, divergence) directly affects technique

 

For these reasons, pre-extraction radiography is essential in most cases. An X-ray allows assessment of root anatomy, proximity to anatomical structures, bone density, and pathological changes.

 

Patient Positioning and Operator Ergonomics

Correct positioning is fundamental to successful extraction and operator safety.

Patient Positioning

  • For maxillary extractions, the patient is positioned supine, with the maxillary occlusal plane approximately at the level of the operator’s elbow.
  • For mandibular extractions: Right-handed operators usually stand behind the patient for right-sided lower teeth. Stand in front of the patient for left-sided lower teeth

 

Left-handed practitioners reverse these positions, although many dental chair designs remain biased toward right-handed use, which can compromise ergonomics.

Operator Ergonomics

Good posture reduces fatigue, improves control, and minimizes risk of musculoskeletal injury. Excessive force is often a sign of poor technique or inadequate planning rather than insufficient strength.

 

Principles of Tooth Extraction

Biomechanical Principles

Tooth extraction relies on controlled application of force to:

  1. Expand the alveolar socket
  2. Disrupt the periodontal ligament
  3. Disengage the tooth from bone

Bone is viscoelastic and responds to sustained pressure by expanding slightly. Sudden jerking movements increase the risk of root fracture or bone damage.

Socket Dilation

Socket dilation can be achieved by:

  • Using an elevator between tooth and bone
  • Seating forceps blades apically along the root surface
  • Engaging molar bifurcations when appropriate (permanent teeth only)

 

The key principle is apical pressure before movement, ensuring controlled expansion rather than levering against the crown.

 

Common Extraction Techniques by Tooth Type

Incisors and Canines (Teeth 1, 2, 3)

  • Typically have single conical roots
  • Best managed with rotation followed by traction
  • Excessive buccal force risks labial plate fracture

 

Premolars (Teeth 4 and 5)

  • Often have two fine roots or flattened roots
  • Best removed using bucco-palatal movement
  • Movement continues until a characteristic “give” is felt
  • Tooth is then delivered downward and buccally

 

Rotation should be used cautiously, especially in maxillary first premolars, due to frequent root bifurcation.

Molars (Teeth 6 and 7)

  • Maxillary molars usually have three divergent roots
  • Mandibular molars often have two roots

 

These teeth are removed using:

  • Controlled buccal movement
  • Sustained apical pressure
  • Gentle rocking motions

 

Molar extractions frequently require patience; excessive force risks tuberosity fracture or root separation.

Supporting the Mandible

During mandibular extractions, the operator must support the patient’s jaw to prevent:

 

Extraction of Deciduous Teeth

The principles of extraction are similar, but important differences exist:

  • Roots are often resorbing
  • Crowns are more fragile
  • Forceps engaging bifurcations must not be used, as this risks damage to developing permanent teeth

 

Gentle luxation and minimal force are essential.

 

Third Molars

Third molar extraction often falls under dento-alveolar surgery rather than simple extraction. Techniques may include:

  • Surgical flap elevation
  • Bone removal
  • Tooth sectioning
  • Coronectomy in selected cases

 

Because of proximity to vital structures such as the inferior alveolar nerve and maxillary sinus, careful case selection and planning are critical.

 

Difficulties Encountered During Extraction

Access Problems

Limited access may arise from:

  • Small mouth opening
  • Crowding
  • Malpositioned teeth
  • Trismus

 

In cases of infective trismus (e.g. submasseteric abscess), extraction should be deferred and managed in hospital where airway protection and drainage facilities are available.

Pain During Extraction

If a patient experiences pain:

  1. Confirm whether it is pain or pressure
  2. If pain persists: Administer additional local anaesthetic. Consider alternative techniques (block, infiltration, intraligamentary)
  3. Persistent pain despite adequate anaesthesia often indicates acute infection

In many cases, extraction should be delayed in favour of drainage and infection control. Very few adult extractions truly require general anaesthesia.

Inability to Move the Tooth

When a tooth does not luxate:

  • Stop and reassess

  • Obtain or review radiographs

  • Look for:

    • Ankylosis

    • Divergent roots

    • Long roots

    • Sclerotic bone

Persisting with force risks patient harm and operator frustration. A trans-alveolar approach is often quicker, safer, and more predictable.

 

Complications of Tooth Extraction

Tooth Fracture

Crown fracture with retained roots is common. Management depends on root size and position:

  • Small (<3 mm), deeply buried apices may be left in situ
  • Patient must be informed
  • Antibiotics prescribed if indicated
  • Close follow-up arranged

 

Larger retained roots should be removed due to higher infection risk.

Alveolar and Basal Bone Fracture

  • Alveolar fractures involving the extracted tooth socket are relatively common
  • Loose bone fragments without periosteal attachment should be removed
  • If adjacent teeth are involved, splinting may be required

 

Basal bone fractures are rare but serious and require referral for reduction and fixation.

Loss of the Tooth

A lost tooth fragment may be:

  • Under the mucoperiosteum
  • In a tissue space
  • In the suction system
  • In the maxillary sinus
  • Through the lingual cortex
  • Swallowed or inhaled

 

If not located, a chest X-ray is mandatory to exclude aspiration.

Oro-Antral Communication

This occurs when a communication forms between the oral cavity and maxillary sinus, most commonly during maxillary molar extraction.

Management includes:

  • Immediate closure with a mucoperiosteal flap if possible
  • Referral if beyond operator competence
  • Advice to avoid nose blowing
  • Nasal decongestants (e.g. ephedrine drops for 5 days)

 

Damage to Adjacent Teeth or Wrong Tooth Extraction

Preventive strategies include:

  • Careful confirmation with the patient
  • Accurate record keeping
  • Clear surgical planning

 

If the wrong tooth is extracted:

  • Replant immediately if feasible
  • Inform the patient honestly
  • Document fully

 

Dislocation of the Jaw

TMJ dislocation may occur, particularly during mandibular extractions. Management includes prompt reduction, followed by reassurance and aftercare.

 

Medication-Related Osteonecrosis of the Jaw (MRONJ)

MRONJ is associated with:

 

The key principle is avoidance of procedures requiring bone healing where possible. If extraction is unavoidable:

  • Perform a risk assessment
  • Obtain informed consent
  • Use atraumatic technique
  • Follow established preventive protocols

 

Conclusion

Dental extraction is a foundational skill in dentistry, but one that demands respect, planning, and clinical judgement. Successful outcomes depend on:

  • Thorough assessment
  • Sound anatomical knowledge
  • Appropriate technique selection
  • Recognition and management of complications

 

By approaching extraction as a controlled surgical procedure rather than a routine task, clinicians can minimize risk, improve patient experience, and maintain professional confidence.

 

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