EXTRACTION OF

TEETH

Asoc. Prof. Georgiev PhD, DMD
Department of Oral and Maxillo-facial
Surgery
Medical University - Varna
Indications for extraction

 The common position of modern dentistry is that all
teeth should be treated and maintained in the oral
cavity as long as possible, provided they fulfil
functional and even esthetic criteria. However, it is
sometimes inevitable that teeth have to be removed
for various reasons. General indications for
extractions will be discussed below, but the reader
should be aware that the decision to extract has to be
made individually for each case, and that
recommendations are not absolute.
 Indications for extraction
 Caries

 Periodontal disease
 Pulp disease
 Pathologic lesions, surrounding teeth
 Before radiation therapy
 Crown and root fracture
 Teeth in bone fracture lines
 Malposition of teeth
 Impacted teeth
 Supernumerary teeth
 Orthodontic indications
 Before prosthetic extractions
 Before surgical extractions
 Other reasons for extractions
 Caries

 Severe caries and an extensive loss of tooth substance
that will not permit restorative procedures is perhaps
the most common reason why teeth are extracted.
The decision to extract a carious tooth instead of
trying restorative procedures is something to be
made by the surgeon and patient together.
 Periodontal disease

 Another common reason for tooth extraction is
periodontal disease. Severe bone loss and
irreversible tooth hypermobility is an indication for
extraction. However, bone regeneration techniques
exist today and the dentist should consider this
alternative before the decision to extract. The
severity of periodontal disease, long-term prognosis,
and even cost/benefit aspects should be considered
in the decision-making process.
 Pulp disease

 The presence of irreversible pulpitis, pulp necrosis or
internal resorption of the root canal where
endodontic procedures are not possible are other
indications for tooth extraction. This could be
because of obliterated root canals, canals that are not
accessible due to root anatomy, failure of endodontic
therapy or when patient chooses not to undergo such
treatment.
 Pathologic lesions
surrounding teeth

 The most common pathologic lesion associated with
teeth is apical or juxtaradicular periodontitis. If
endodontic procedures are not possible, then
extraction should be considered. Besides, if teeth
compromise the surgical treatment of other
pathologic lesions found in the tissues surrounding
them, then extraction should be considered, e.g. in
the treatment of osteomylelitis of the jaw.
Before radiation therapy

 Careful consideration should be given to patients
who are to undergo radiation therapy due to tumors.
in the head and neck region. Teeth associated with
pathologic conditions such as periapical
periodontitis should be considered either for swift
endodontic procedures or extraction. Extractions
should preferably be carried out before the start of
the radiation therapy. A radical approach before
radiation is recommended to avoid later
complications in the irradiated bone.
Crown and root fracture

 Crown, crown–root, and root fractures after trauma
can often be successfully treated and extraction
avoided. However, there are other situations where
fractures of the crown and root do not allow
successful restorative therapy. In these cases
extraction is the only alternative.
Teeth in bone fracture lines

 Sometimes teeth in the line of a jaw fracture should
be considered for extraction in order to prevent
infection. Tooth luxation can almost always be
treated by repositioning and fixation, but where
there is severe luxation of teeth associated with
complex jaw fractures, where teeth are in the line of
the fractures and interfering with the repositioning,
these teeth should be extracted.
 Malposition of teeth

 Malposition of teeth in itself is not an indication for
extraction. However, malposition associated with
other conditions such as trauma to soft tissue or
blockage of eruption of adjacent teeth is an
indication for extraction. Where there is elongation of
teeth due to the missing antagonist and where
prosthetic rehabilitation is considered in the
opposing jaw, the elongated tooth may be
considered for extraction.
 Impacted teeth

 Some impacted teeth do not reach functional occlusion,
often because of lack of space. These teeth should be
investigated and considered for extraction if they
interfere with adjacent teeth or present a potential for the
development of pathology in the future. These could
include the risk for root resorption of adjacent teeth, loss
of bone around adjacent roots or development of other
pathologic conditions such as cysts. Impacted third
molars are the most common teeth considered for
extraction. For more details regarding strategies for third
molar extraction.
 Supernumerary teeth

 Supernumerary teeth that are potential sources for
future pathology should be removed. The rules for
impacted teeth apply to supernumerary teeth, which
are often impacted. However, supernumerary teeth
without pathology do not have to be routinely
removed.
 Orthodontic indications

 Extraction of teeth is sometimes required to create
space in order to carry out planned orthodontic
treatment. The decision on which tooth/teeth are to
be extracted is made by the orthodontist.
Before prosthetic extractions

 Before prosthetic reconstructions it is sometimes
necessary to extract teeth. Teeth could interfere with
the proper placement of a fixed or removable
prosthetic appliance and should be extracted. In the
case of rehabilitation of a jaw with implants where
there are one or two incisors remaining that have a
dubious prognosis, it may sometimes be better to
extract the remaining teeth and perform a full arch
implantsupported reconstruction.
Before surgical extractions

 Sometimes teeth have to be removed prior to other
surgical procedures. The most common indication in
this regard is the removal of impacted molars prior
to LeFort-I or sagittal split osteotomies. This is done
if the teeth lie in the line of the planned osteotomies
or increase the risk for other complications such as
undesired fractures.
Other reasons for extraction

 Economic reasons
 Due to esthetic reasons
 Malformed or severe discolored teeth
 Due to difficulty in maintaining adequate oral
hygiene
Contraindications for extraction

 The decision to extract a tooth cannot be made entirely
based on the status of the tooth and immediate surrounding
tissue. The dentist should also consider the
contraindications to extracting the tooth, for example with
consideration of the patient’s general health, which might
overwhelm the indications for extraction.
 Systemic contraindications

 These constitute all general health factors and mental factors which have
influence on the patient’s ability to withstand the surgical procedure. Severe
dental anxiety is a relative contraindication to extraction unless the procedure is
planned under general anesthesia.
 Patients with hemophilia or other coagulopathies should first have their
disorders controlled before extraction. In general, most uncontrolled metabolic
diseases such as diabetes constitute a contraindication until they are brought
under control. Similarly, patients with severe uncontrolled hypertension and
cardiac diseases should be treated for these conditions first before extractions
are carried out. Ongoing radio- and/or chemotherapy is also a relative
contraindication. In all cases, one should be aware of the medications patients
are on or have had, especially those drugs that affect the immune system, delay
or impair the healing process, or could interact with medication administered to
manage an extraction. One should pay extra attention to patients on
anticoagulant drugs, cancer medication, glucocorticoids and
immunosuppressants.
 Local contraindications

 The most common local contraindication is an ongoing acute
inflammatory or infectious process. The acute infection/inflammation
should first be treated before proceeding with the extraction, depending
on the location of the acute process. Extraction of a third lower molar
during an ongoing acute pericoronitis could lead to a life-threatening
postoperative infection. However, there are also situations where an acute
abscess is best drained by extraction of the tooth even in an acute phase.
An acute infectious process caused by pulpal disease is resolved most
quickly by extraction of the tooth. Therefore an acute infectious and
inflammatory process should not be considered as an absolute
contraindication for extraction. The dentist should, however, bear in mind
that there could be other problems, such as severe pain, swelling, reduced
mouth opening, and anxiety, which could make extractions associated
with other acute conditions suboptimal. In such cases extractions should
be deferred until the acute symptoms have subsided.
 Local contraindications

 One of the most important contraindications to
extraction is radiation therapy, past and present,
involving the jaws. Delayed healing, dehiscence, and
necrosis of the bone are often complications due to
extractions performed in irradiated bone. Some
cancer medications can also cause necrosis of the
jaws after extractions. Finally, teeth within the area
of a tumor, especially if it is malignant, should not be
removed.
 Clinical evaluation of
teeth before
 extraction
 The condition of the crown is assessed in order to evaluate if there
is a high risk for fracture of the crown during extraction, which
would thereby complicate the procedure. Surgical extraction of
teeth with missing crowns or severe caries may be considered.
Other factors to consider are tooth/root mobility and access to
perform the extraction. Again, pathology of the pulp and
surrounding soft tissues should be assessed so that the extraction
can be carried out with a minimum of discomfort to the patient.
Severe gingivitis or pulpitis, for example, could result in excessive
bleeding or inadequate effect of local anaesthesia respectively,
which could add to patient discomfort. The clinical evaluation of
the tooth to be removed is done in conjunction with a radiographic
assessment.
 Preoperative
radiographic assessment

 It is imperative that a thorough radiographic examination be done prior to
extraction of teeth. This helps the dentist to evaluate the degree of difficulty
of extraction by assessing root anatomy, presence of pathology in the root or
surrounding bone, vital structures and relation to other roots, and other
factors such as ankylosis or hypercementosis of the root . The most common
and adequate radiograph is a good quality intraoral periapical radiograph.
Other techniques such as panoramic radiographs, scanograms, and cone-
beam radiological techniques are more valuable in the mapping of impacted
teeth.
 In the maxilla, the proximity of the roots of the molars to the sinus should be
assessed. In some cases the sinus membrane can rupture during extraction of
maxillary molars causing an oroantral communication. In the mandible, the
position of the mandibular canal should be noted, especially in relation to
third molars. The position of the mental foramen should be noted in cases
where a flap has to be raised in order to remove the premolars .
 Preparation for extraction

 The concept of cross-infection control must be adopted during
extraction. Patients must be regarded as possible carriers of blood-
borne diseases that can be transmitted to the surgical team and the
surgeon should practice the universal precautions to prevent injury
or transmission of disease to their patients or themselves. Therefore,
surgical gloves, surgical masks, and glasses or eyescreens with side
shields should be worn by the surgeon even for simple extractions.
The surgical team should wear long-sleeved gowns. For the patient,
a minimal draping is necessary for performing simple extractions,
with a sterile drape placed across the patient’s chest. Hair should be
ideally be covered both on surgeon and patient. Preoperative
mouthrinse with antiseptic, such as chlorhexidine, is recommended
to reduce the number of microorganisms at the surgical site.
 Patient position

 To ensure adequate visualization and comfort during the various manipulations
required for the tooth extraction, the dental chair must always be positioned
correctly. For the extraction of a maxillary tooth, the patient’s mouth must be at
the same height as the dentist’s shoulder and the angle between the dental chair
and the horizontal (floor) must be approximately 120°. Also, the occlusal surface
of the maxillary teeth must be at a 45° angle compared to horizontal when the
mouth is open. During mandibular extractions, the chair is positioned lower, so
that the angle between the chair and the horizontal is about 110o. Furthermore,
the occlusal surface of the mandibular teeth must be parallel to the horizontal
when the patient’s mouth is open. The position of right-handed dentists during
extraction using forceps is in front of and to the right of the patient; left-handed
dentists should be in front of and to the left of the patient.
 For the extraction of anterior mandibular teeth right-handed dentists should be
positioned in front of the patient, or behind them and to their right; lefthanded
dentists should be in front of them or behind them and to their left.
 Surgeon’s position for
extraction with forceps

 The positions of the patient and surgeon are important for
successfully performing extraction. The optimal position is when both
patient and surgeon are comfortable. Dental extraction can be
performed with the surgeon sitting or standing. Most surgeons prefer
the standing position. Regardless of whether the surgeon is sitting or
standing, the correct positioning of the surgeon should allow him/her
to deliver a controlled force to the patient’s tooth through the forceps.
The correct position allows the surgeon to provide stability and
support and to enable the wrist to be straight with controlled force
delivered from the arm and shoulder. The importance of this
controlled force during extraction is to prevent any injury following
sudden loss of resistance from the fracture of a root. The patient’s
chair should be tilted backwards. The height of the chair should be
such that the patient’s mouth is at the surgeon’s elbow.
 Surgeon’s position for
extraction 
with forceps
 When extracting teeth in the maxilla, the surgeon should
stand in front or by the side of the patient. For extraction
of the mandibular teeth, the surgeon should approach
the patient from behind during extraction of right
posterior and anterior teeth. When extracting left
posterior mandibular teeth, the surgeon should approach
the patient from the front. The mandible can be
supported by the surgeon’s nonextraction hand. The
approach from behind gives the surgeon great visibility
of the extraction site and it allows the surgeon to be in a
comfortable and stable position.
 Extraction

 The extraction itself is accomplished in two stages.
During the first stage, the tooth is separated from the
soft tissues surrounding it using a desmotome or
elevator; during the second stage, the tooth is
elevated from the socket using forceps or an elevator.
 Separation of tooth from
soft 
tissue
 Severing soft tissue attachment
 The desmotome is held in the dominant hand, with a pen grip and, after
being positioned at the bottom of the gingival sulcus, it is used to sever the
periodontal ligament. This is accomplished in one continuous motion,
beginning at the distal surface of the tooth and moving toward the mesial
surface, first buccally and then lingually or palatally.
 While severing the soft tissue attachment, the index finger and thumb of the
nondominant hand are positioned buccally and palatally or the index finger
and middle finger are placed buccally and lingually, to protect the soft
tissues from injury (tongue, cheeks and palate).
 Reflecting soft tissue
 An elevator is used to push or slightly reflect the gingiva around an intact
tooth, to allow the extraction forceps to grasp the tooth beneath the cervical
line of the tooth as apically as possible.
 Extraction technique
using tooth
 forceps
 After reflecting of the gingiva, the beaks of the forceps are
positioned at the cervical line of the tooth, parallel to its long axis,
without grasping bone or gingivae at the same time. The initial
extraction movements applied are very gentle. More specifically, the
dentist applies slow steady pressure to move the tooth buccally at
first, and then palatally or lingually. Movements must become
greater gradually and the buccal pressure is greater than the
corresponding palatal or lingual pressure, because the labial or
buccal bone is thinner and more elastic compared to that of the
palate. If anatomy of the root permits (single, conical roots),
rotational force may be applied in addition to buccopalatal or
buccolingual pressure. These movements expand the alveolar bone
and also sever all the periodontal fibers. Slight traction is also
employed at the same time, facilitating the tooth extraction.
 Extraction technique
using tooth
 forceps
 During the final extraction phase, traction is not
permitted, because there is risk of damage due to
sudden removal of the tooth and the risk of the
forceps knocking the teeth of the opposite arch. To
avoid such a possibility, the final extraction
movement must be labial or buccal, and in a curved
direction that is outwards and upwards for the
maxilla, and outwards and downwards for the
mandible.
 Extraction of maxillary
central incisor

 The initial extraction movements are gentle, first in a
labial direction, and then palatal. After the initial force is
applied to the tooth, motions gradually become greater
and the final extraction force is applied labially. Because
the root of the central incisor is conical in shape, its
removal may also be achieved using rotational forces.
More specifically, the tooth is rotated first in one
direction and immediately afterwards in the other
direction, until the periodontal fibers are completely
severed. The tooth is then delivered from the socket
using slight traction.
 Extraction of maxillary
lateralincisor
 The extraction movements for removal of the lateral
incisor are labial and palatal. Because the lateral
incisor has a thin root and there is usually curvature
of the root tip distally, rotational force is not allowed.
Slight rotational motions may be employed only in
the final stage, with simultaneous traction of the
tooth from the socket.
 Extraction of maxillary
canines

 The extraction movements are labial and palatal,
with gradually increasing intensity. Because the
canine has a flattened root and the root tip is usually
curved distally, rotational motions are not permitted,
or if they are used, they must be done so very gently
and with alternating buccopalatal pressure. The final
extraction movement is labial.
 Extraction of maxillary
premolars

 As for the first premolar, because it usually has two roots,
buccal and palatal pressure should be gentle and slight. If
movements are vigorous and abrupt, there is a risk of
fracturing the root tips. If one of the root tips does break, it
may be removed easily, since they are not very curved and
the tooth has already been mobilized during the extraction
attempt. Rotational motions are not allowed due to the
tooth’s anatomy.
 Extraction of the second premolar is easier, because the
tooth has one root. Movements are the same as those for the
first premolar. The final movement for both teeth is buccal.
 Extraction of maxillary
molars

 The maxillary molar has three diverging roots: the palatal, which is
the largest and most widely divergent toward the palate, and the two
buccal roots, which are often curved distally. The tooth is firmly
anchored in the alveolar bone and its buccal surface is reinforced by
the extension of the zygomatic process. This tooth therefore requires
the application of strong force during its extraction, which may cause
fracture of the crown or root tips. To avoid this from happening,
initial movements must be gentle, with buccopalatal pressure and an
increasing range of motion, especially buccally, where resistance is
less. The final extraction movement is a buccal upwards curved
motion, following the direction of the palatal root. Because the root
tips are close to the maxillary sinus, their removal requires careful
consideration, due to the risk of oroantral communication.
 Extraction of maxillary
thirdmolar
 If the third molar has erupted completely and its roots are fused
(conical shape), its extraction does not usually present any difficulty
and it may be removed with only buccal pressure. The risk of
fracturing the palatal alveolar process is avoided this way, which
would otherwise occur if force were applied palatally (the palatal
bone is thinner and lower than the buccal bone). When the tooth has
three or more roots, though, its extraction is accomplished by
applying buccal pressure and very gentle palatal pressure.
 The final extraction movementmust always be buccal. Root anatomy
of the third molar permitting, extraction is easily accomplished
using the straight elevator. The elevator is positioned between the
second and third molars and the tooth is luxated according to the
direction of its roots.
 Extraction of mandibular
anterior teeth

 Mandibular incisors have narrow flattened roots, which are not very firmly
anchored in the alveolar bone. These teeth have one root and are curved at the
root tip, especially the lateral incisor. Their extraction is easy, due to their
morphology and the thin labial alveolar bone surrounding the root. Extraction
pressure is applied labially and lingually, gradually increasing in intensity.
Due to the flattened roots of the teeth, only slight rotational force is permitted.
 Mandibular canines usually have only one root. Seventy per cent of these teeth
have a straight root, while 20%present distal curvature. Compared to incisors,
canines are more difficult to extract, due to the long root and frequent
curvature of the root tip. Extraction movements are the same as those
employed for central and lateral incisors.
 The final extractionmovement for all anterior teeth is labial, curved outwards
and downwards. Damage of maxillary teeth by the forceps is thus avoided.
 Extraction of
mandibular
 premolars
 The extraction of is mandibular premolars is
considered quite easy because their roots are straight
and conical, although sometimes they may be thin or
the root tip may be large. Buccolingual force is
applied for extraction of these teeth. Gentle
rotational force may also be applied when extracting
the second premolar. The final extraction movement
is outwards and downwards.
 Extraction of
mandibular
 molars
 The mandibular first molar usually has two roots, a mesial and a distal
one. The mesial root is larger, more flattened than the distal root and
usually is curved distally. The distal root is straighter and narrower than
the mesial root, and more rounded. The mandibular second molar has a
morphology similar to that of the first molar. Even though this tooth is
surrounded by dense bone, it is removed more easily than the first molar,
because its roots are smaller and less divergent, and they are often fused
together. The extraction technique is the same for both molars.
 More specifically, the forceps are adapted to the tooth as apically as
possible, beneath the cervical line of the tooth, with the beaks parallel to
the long axis of the tooth. Initially the movements are gentle with buccal
and lingual pressure. After the tooth is slightly mobilized, force is
gradually increased and the final extraction movement is buccal, taking
care not to damage the maxillary teeth with the forceps.
 Extraction of
mandibularthird molar
 The mandibular third molar usually has two roots, whose morphology
is similar to that of the other molars. They are smaller, though, and
usually are fused in a conical shape, widely diverging distally.
Buccolingual pressure is applied and the range of motion depends on
the morphology of the buccal and lingual alveolar bone. The lingual
alveolar bone is very thin compared to the buccal alveolar bone, which
is unyielding in the third molar area; therefore, the force that mobilizes
the tooth must be applied in the lingual direction. Afterwards, pressure
must be applied very carefully, so as to avoid fracture of both the tooth,
due to excessive buccal force, and the lingual plate of bone.
 If the third molar has one root or if the roots converge and are curved
in the same direction, the extraction may be accomplished using the
straight elevator alone. In this case the elevator is positioned at the
mesial surface of the tooth, which is delivered according to the
direction of curvature of the roots.
 Extraction of deciduous
teeth

 The extraction technique for deciduous teeth is similar to
that used for permanent teeth. The dentist must pay
particular attention when extracting deciduous molars
because of the risk of simultaneously extracting the bud of
the subjacent permanent tooth . More specifically, because
the crown of the deciduous molar is short, the beaks of the
forceps may accidentally grasp the crown of the bud of the
underlying permanent tooth as well and remove both. This
is why the beaks of the forceps must be positioned on the
mesial or the distal area of the tooth and not the center (root
bifurcation), underneath which is the permanent tooth.
 Extraction technique
using 
elevator
 A variety of elevators may be used to extract roots and root tips. The most commonly used elevator is the
straight elevator. This elevator, besides root extractions, may also be used to remove intact teeth – especially
the maxillary and mandibular third molars, root anatomy permitting. There is no doubt that the straight
elevator is the ideal instrument in everyday dentistry, as long as it is used correctly. Otherwise, it may cause a
number of undesirable complications. In order to avoid such situations, certain basic rules must be followed:
 􀁏 The straight elevator must be held in the dominant hand and the index finger placed along the blade,
leaving its anterior end exposed, which is used to luxate the tooth or root.
 􀁏 This instrument must always be used buccally, and never on the lingual or palatal side.
 􀁏 The concave surface of the blade must be in contact with the mesial or distal surface of the tooth to be
extracted, and be seated between the tooth and alveolar bone.
 􀁏 When the instrument is placed between the maxillary posterior teeth, it must be perpendicular to their long
axis. As for the rest of the teeth of both the maxilla and mandible, it may be perpendicular, parallel, or at an
angle.
 􀁏 During luxation, a cotton roll or gauze should be placed between the finger and palatal or lingual side, to
avoid injury of the finger or tongue in case the elevator slips during luxation, the adjacent tooth should not be
used as a fulcrum, but only the alveolar bone. Otherwise, there is a risk of damaging the periodontal ligament
fibers.
 􀁏 The straight elevator should not be used to extract multi-rooted teeth, because there is a risk of fracturing
their roots if they have not been sectioned previously. During the luxation attempt using the straight elevator,
the fingers of the nondominant hand must be in a certain position.
 Postextraction care of
toothsocket
 After extraction of the tooth, the bottom of the socket is curetted (as long as the
tooth is nonvital) with a periapical curette, to remove any periapical lesion
from the area. Curetting must be done carefully, because if any remnants of
granulation tissue remain in the socket, there is a chance they will develop into
a cyst, because a large percentage contain epithelial cells. Sometimes the lesion
is firmly attached to the root tip of the tooth and is extracted together with the
tooth. Even in this case, the socket must be inspected, but only in the apical
region. When the lesion is large and the entire lesion cannot be removed
through the socket alone, then surgery is required.
 Afterwards, and only if considered necessary (e.g., there are sharp bone
edges), the alveolar margin is smoothed using rongeur forceps or a bone file,
and then the lingual and buccal plates are compressed using finger pressure.
This is done to restore the expansion of the socket caused by the extraction,
and also for initial control of hemorrhage. Hemostasis is also aided by the
patient applying pressure on gauze placed over the socket for 30–45 min.
 Postoperative instructions

 After finishing the surgical procedure, oral and written instructions are given to the patient, concerning
exactly what to do in the next few days. These instructions normally include the following:
 Rest: After surgery, the patient should stay at home and not go to work for 1 or 2 days, depending on the
extent of the surgical wound and the patient’s physical condition.
 Analgesia: Take a painkiller (but not salicylates, aspirin), every 4 h, for as long as the pain persists.
 Edema: After the surgical procedure, the extraoral placement of cold compresses (ice pack wrapped in a
towel) over the surgical area is recommended. This should last for 10–15 min at a time, and be repeated
every half hour, for at least 4–6 h.
 Bleeding: The patient must bite firmly on gauze placed over the wound for 30–45 min. In case bleeding
continues, another gauze is placed over the wound for a further hour.
 Antibiotics: These are prescribed only if the patient has certain medical conditions or inflammation.
 Diet: The patient’s diet on the day of the surgical procedure must consist of cold, liquid foods (pudding,
yogurt,milk, cold soup, orange juice, etc.).
 Oral hygiene: Rinsing the mouth is not allowed for the first 24 h. After this, the mouth may be rinsed with
warm chamomile or salt water, three times a day for 3–4 days. The teeth should be brushed with a
toothbrush and flossed, but the patient should avoid the area of surgery.
 Removal of sutures: If sutures were placed on the wound, the patient must have them removed a week
later.
 
Thank you for your
attention!