The removal of teeth—whether by simple or complex techniques—is one of the most common surgical procedures performed in dentistry. Dental practitioners are uniquely trained and qualified to examine a patient, obtain radiographs, read and interpret the imaging to formulate a diagnosis, then administer local anesthesia (the safety record of which, for similar surgical procedures, is extraordinary), and then perform the necessary dentoalveolar surgery in the office, which saves the patient time and money. The purpose of the first half of this chapter is to provide the novice dental practitioner a step-by-step approach to perform the simple and surgical removal of teeth efficiently and proficiently, as well as to describe techniques for suturing the surgical extraction site. This very thorough chapter demonstrates the proper surgical armamentarium required to complete the surgical tasks, as well as describes the indications and contraindications for the removal of teeth. There is also detailed discussion of the normal healing process, as well as possible postoperative surgical complications of dentoalveolar surgery and their management. The second half of the chapter provides the reader a very focused, but comprehensive, review of the indications for management of third molars.
Extraction Procedure—Nonsurgical Extraction
Preparation—Preoperative Considerations
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Patient’s health/medical history:
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Potential complications and how to best treat those conditions.
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Initial blood pressure reading should be less than 160/100 for elective dental treatment (see Chapter 12, Hypertension Guidelines).
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Your approach to the treatment:
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Aseptic technique (in chronologic order): wear mask and protective eyewear and surgical gown, wash hands, don gloves and avoid contact with nonsurgical surfaces.
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Postop prescription options (see Chapter 15, Prescription Writing).
Presentation
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Depending on the setting (e.g., dental school clinic), the provider may be expected to give a brief verbal presentation to a supervising faculty on the proposed extraction.
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Typically, this presentation includes the following components:
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Perform time out procedure (see Chapter 3, Time Out Policy: Correct Patient, Correct Procedure, Correct Site).
Clinical Attire
Surgical Armamentarium
Proper surgical instrumentation is required to successfully complete simple or surgical extraction procedure. The practitioner must develop familiarity with the armamentarium to understand which instruments he/she prefers for each procedure, and then develop a standard tray with all of the desired instruments.
Each instrument, even those similar in appearance to others, serves a unique function; therefore, a well-developed, consistently arranged surgical tray provides a familiar workspace for greater ease with each planned procedure. This also helps prevent the practitioner from using an inappropriate instrument for something other than its planned purpose.
▶ Fig. 8.1 demonstrates a typical oral surgery tray set-up for either a simple or surgical extraction procedure. Items shown are named and described (left to right, starting from the top row left):
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Shaded lightweight protective glasses for the patient to wear.
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Tongue blade with petroleum jelly and a cotton tip applicator to apply the jelly to the patient’s lips.
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Needle holder (Mayo Hegar 6″): a holder used to grasp the suture needle while suturing.
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Scissors (Kelly Straight 6¼″): surgical scissors used to cut the suture knot.
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Adson-Brown tissue forceps: used for holding and manipulating delicate tissues.
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Adson tissue forceps: used to stabilize soft tissue for suturing, manipulation, or dissection.
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Child-sized bite block: firm block used to help assist patient in mouth opening.
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Adult-sized bite block: firm block used to help assist patient in mouth opening.
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Periotome (bayonet tip): gentle tapping facilitates atraumatic controlled extractions, especially of maxillary teeth.
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Mallet: used to gently tap periotome, facilitating atraumatic controlled extractions, especially of maxillary teeth.
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Minnesota retractor: an offset retractor used for the retraction of cheeks and soft-tissue flaps.
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Topical anesthetic (shown is 20% benzocaine gel in a single-use package): used on oral mucosa prior to local anesthesia injections.
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Dental injection syringe: a standard syringe used to administer local anesthetic.
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A #3 scalpel handle with a #15 blade attached: standard surgical blades dull quickly when they contact bone, teeth, or even with repeated use through soft tissue.
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Hirschfeld #20 periosteal elevator: a rounded elevator used primarily to reflect soft tissue once an incision has been made.
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Bayonet elevator: a specialized “lever” used to loosen teeth by stretching then severing the periodontal ligament attachments.
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#77 R elevator: a specialized “lever” used to loosen teeth by stretching then severing the periodontal ligament attachments.
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Double-ended bone file: used for smoothing small, sharp edges of bone.
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#9 periosteal elevator: a double-sided elevator that may be used to reflect soft tissue once an incision has been made. This can be accomplished through three methods:
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Twisting or prying motion: the pointed end is used to reflect soft tissue, most commonly when elevating a dental papilla from between teeth or the attached gingiva around a tooth to be extracted.
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Push stroke: the pointed or the broad end of the instrument is pushed underneath the periosteum, separating it from the underlying bone to produce a clean reflection.
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Pull stroke: a withdrawing motion that tends to shred or tear the periosteum unless made carefully.
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Molt #2 angled double-ended (spoon) curette: used to remove granulation tissue from the extraction socket.
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Rongeur forceps: a grasping and cutting instrument used for removing bone.
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#150 Universal maxillary forceps: used to luxate and deliver maxillary teeth.
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#151 Universal mandibular forceps: used to luxate and deliver mandibular teeth.
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Hemostat (Kelly 5½″): a holder used to remove granulation tissue from the extraction socket and/or to pick up small debris (such as root tips, amalgam, or bone fragments).
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#190/191 elevators: a pair of specialized “levers” used to loosen teeth by stretching then severing the periodontal ligament attachments.
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12 mL curved-tipped plastic syringe(s): used for procedural irrigation with normal saline.
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Weider tongue retractor (sweetheart retractor): a broad, heart-shaped retractor that is serrated on one side to firmly engage the tongue and retract it anteromedially.
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4″ × 4″ gauze: soft, absorbent material often used as a throat pack/guard while performing the oral surgical procedure.
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(Not shown, but recommended for use in surgery) 3.0 mm modified Frazier stainless steel aspirator/suction (tip): an aspirator used for surgical suction.
Preparing the Patient—Patient Positioning
Postural comfort of both the patient and the provider is an important consideration when performing surgery. Most patients can tolerate lying relatively flat for the short duration of time it will take to perform the procedure. However, a small number of patients may require other considerations before being placed in a supine position, such as those with cardiopulmonary issues who experience a drowning sensation when reclined (e.g., congestive heart failure patients), patients with claustrophobia, or those with neck or back issues who experience pain.
For a typical oral surgery procedure, the patient should be placed horizontally on his/her back with the head elevated about 20 to 30 degrees—reminiscent of a “beach chair” position. A level, even surgical field allows for the greatest ease of movement for a focused practitioner. It is worth noting that with the patient in this position and with the mouth opened, the maxillary teeth are essentially perpendicular to the floor, and the mandibular teeth are parallel to the floor. This permits use of the surgical instrumentation to maximum advantage.
Another very important consideration is the height of the chair once the patient is reclined. To assert a relaxed and comfortable posture, the surgeon’s elbows should remain comfortably at his/her sides at approximately 90 degrees (▶ Fig. 8.2).
A chair positioned too low may lead to lumbar or leg pain from strain, while a high chair could force a “shrugged” position and sore shoulders. Determining one’s proper chair height is a trial-and-error process that is worthwhile before entering practice. Most dental chairs feature preset capabilities that allow them to “remember” a preferred height.
Patient Protection and Comfort Devices
The safety of the patient is the utmost priority, followed closely by patient comfort. To accomplish these goals, a hair net or surgical hair cover is recommended to keep the patient’s own hair out of the surgical site. Shaded, protective eyewear can also keep the eyes protected from any instruments or irritants while preventing ocular irritation from the bright surgical lights overhead. A bite block should be placed to alleviate tension in the muscles and to allow the temporomandibular joints (TMJs) to relax while the procedure is being performed (▶ Fig. 8.3).
Lubricating or moisturizing products such as petroleum jelly should be applied to the patient’s lips to coat all the skin surfaces, including the commissures, to prevent and protect against dryness and damage from desiccation (▶ Fig. 8.4). If the lips are not particularly dry, then delaying this until the procedure is complete may be preferable to avoid the inevitable transfer of lubricant from the patient to the practitioner, with the potential for loss of instrument control.
Obtain Profound Local Anesthesia—Topical Anesthesia
A Minnesota retractor is used to gently retract the patient’s lip to place the topical local anesthetic gel (▶ Fig. 8.5).
The gel should be left in place for 60 seconds to exert an appropriate anesthetic response. Care should be taken to avoid retracting the lip so much as to cause (nasal) airway obstruction or to cause damage to the underlying vestibular mucosa, as the metal edge of the Minnesota retractor may cause abrasion or ulceration if placed too firmly against the epithelium.
Local Anesthetic Administration—Maxillary Infiltration
In the case shown in these photos, the maxillary right lateral incisor is to be extracted. The maxillary buccal infiltration, palatal infiltration, and periodontal ligament (PDL) or intragingival infiltration injections are recommended to achieve profound local anesthesia and chemical hemostasis that will allow for the most comfortable, painless, and bloodless procedure. Maxillary buccal infiltration (▶ Fig. 8.6) alone may provide profound pulpal and buccal soft-tissue anesthesia to most upper dentition, but will likely fall short of achieving complete, profound anesthesia for an extraction procedure.
Palatal Infiltration
Palatal infiltration (▶ Fig. 8.7) is necessary to anesthetize the palatal soft tissues and, in some cases, to achieve accessory pulpal anesthesia in 2-rooted maxillary premolars and 3-rooted maxillary molars. It is prudent to deliver this injection very slowly to avoid severe pain.
Periodontal Ligament or Intragingival Infiltration
PDL or intragingival infiltration (▶ Fig. 8.8) provides additional assurances for profound pulpal anesthesia while displacing capillary blood cells from the area—evidenced by blanching of the soft tissues—that can help reduce bleeding during extraction.
Protecting the Airway—Placing the Throat Pack/Guard
A single 4″ × 4″ gauze (do not use 2″ × 2″ or 3″ × 3″ as they are too small) is unfolded and gently placed as a throat pack/guard to protect the patient’s airway from extraction debris. This will prevent unnecessary aspiration or swallowing hazards. The throat pack/guard should be comfortably tucked and secured posterior to the surgical site to eliminate spaces for the extraction debris to fall into (▶ Fig. 8.9).
Confirming Profound Local Anesthesia
The surgeon may test for adequate local anesthesia by placing a surgical instrument in the sulcus of the tooth to be removed. The instrument should be used to gently elevate the soft tissues—as well as the tooth—as the surgeon inquires, “Do you feel any pain when I do this?” instead of asking, “Do you feel anything when I do this?” The inquiry must be specific about pain because the sensation of pressure is normally present even under proper anesthesia. If the patient affirms that they do not feel pain, but only feel pressure, remind them that pressure is normal. Should the patient feel pain, more anesthetic may be administered. Instruments such as the double-ended Molt #2 spoon-shaped curette (▶ Fig. 8.10), a #9 periosteal elevator, or the Hirschfeld periosteal elevator are appropriate for this confirmation test.
Each of these instruments can also be used to gently and circumferentially sever the crestal/sulcular dentogingival fibers.
Periotomes
For every erupted maxillary tooth requiring removal, the use of the periotome may be helpful. The dental assistant should facilitate the procedure by gently retracting the patient’s cheek with a Minnesota retractor to allow good visibility and light. With his/her other hand, the dental assistant should keep the suction tip around the sulcus of the tooth to be extracted to allow for a bloodless view of the operative site.
The surgeon should then place the tip of the periotome in the sulcus ensuring it is placed between the tooth (to be removed) and surrounding alveolar bone following the long axis of the tooth. Using a mallet with the other hand, the surgeon then gently taps the opposite end of the periotome, slowly advancing the working end of the periotome toward the tooth’s apex (▶ Fig. 8.11). Care must be taken to ensure the tapping is gently performed, as patients can experience dizziness or headache if the tapping is too intense.
Gentle, circumferential tapping around the entire tooth slowly maneuvers the periotome apically so that the horizontal and oblique fibers of the periodontal ligament are severed, loosening the tooth in a rapid and atraumatic fashion. The patient may be told, “You will feel some tapping in the area—like a little woodpecker tapping on the tooth.” This paints somewhat of a less threatening mental imagery for the patient who is often anxious and apprehensive at the sight and sounds of a mallet. Alternatively, the periotome can be “rocked” back and forth to gently advance it into the socket. A twisting motion can be used once engaged into the PDL space to disrupt the PDL fibers and luxate the tooth.
Elevators
Using a bayonet elevator (or a #301 small, straight elevator), the tooth to be extracted should carefully, slowly, and gently be elevated/luxated to further loosen it prior to placement of the forceps. The tooth should always be approached from the facial surface. It is never recommended to elevate a tooth from the lingual/palatal. The elevator may slip to cause significant and unnecessary soft-tissue damage, puncture wounds, or bleeding.
Insert the elevator into the mesial or distal periodontal ligament space with firm and controlled apical pressure. The elevator should follow the long axis of the tooth. The concave surface of the blade of the elevator should face the tooth that is to be extracted. The elevator is then slowly rotated in such a manner as to move the tooth toward the facial aspect. This is called luxation of the tooth. Care must be taken to avoid luxating adjacent teeth. Care must also be taken to avoid the use of elevators if they pose potential harm to adjacent teeth with large restorations or crowns.
Forceps Delivery
Following the circumferential use of the periotome around the tooth to its apex as well as luxation with the elevator, the #150 forceps (universal maxillary forceps) should be applied gently and carefully to the tooth to prevent pinching or tearing of the marginal gingiva (▶ Fig. 8.12).
A constant and firm apical pressure should be applied to the tooth using the forceps. This converts the center of rotation of the tooth from the apical third to the apex and helps to prevent root tip fractures. Take time to firmly establish the forceps position on the tooth as apically as possible. Using a combination of small circular movements, figure-8 movements, and a slight twisting motion (for teeth with a singular, conical root), the tooth may be delivered gently out of the socket. Take time while using the forceps to luxate and loosen the tooth. Allow the bone of the socket to expand rather than risk fracture from quick, uncontrolled movements. Once the tooth has been removed, place it onto the surgical tray table.
Care should also be taken to ensure that the gauze throat pack/guard remains in its proper place prior to tooth delivery in case any portion of the tooth cracks and fragments dislodge posteriorly. It is also critical for the dental assistant to use surgical suction/aspirators to provide a clear and bloodless view of the surgical site, helping ensure against notable tissue damage.
While individual preferences differ, an underhand grasp of the forceps (▶ Fig. 8.13) may be helpful in maintaining proper posture when extracting maxillary teeth.
This grasp encourages an ergonomic placement of the hands and wrists that keeps the elbows in a comfortable 90-degree angle and the spine in a straight posture. A natural vertebral positioning is also conducive to a relaxed stance of the shoulders. Note that the Minnesota retractor in the figure is gently reflecting the upper lip just enough to visualize the surgical site without obstructing the patient’s nostrils and interfering with their ability to breathe comfortably.
