COMPREHENSIVE NOTES ON

TOOTH EXTRACTION
Types · Techniques · Instruments · Forceps · Complications
Dental Sciences — Examination Reference
Prepared for: Health Professions Students (Uganda / East Africa)
 1. TOOTH EXTRACTION — DEFINITION & OVERVIEW

Tooth extraction (exodontia) is the surgical removal of a tooth from its socket in the alveolar bone. It is
one of the most commonly performed procedures in dentistry and requires a thorough understanding of
anatomy, instrumentation, and surgical principles.

1.1 Indications for Tooth Extraction

• Extensive caries: Tooth irreversibly destroyed and beyond restoration.
• Advanced periodontal disease: Severe bone loss with mobile teeth that cannot be treated.
• Periapical pathology: Chronic periapical abscess unresponsive to root canal treatment.
• Impacted teeth: Wisdom teeth causing infection, cysts, or crowding.
• Orthodontic reasons: Extraction to create space for alignment.
• Fractured teeth: Unrestorable crown or root fractures.
• Supernumerary teeth: Extra teeth causing eruption problems.
• Before radiotherapy: Extraction of compromised teeth in the radiation field.
• Prosthetic purposes: Extraction to facilitate denture construction.

1.2 Contraindications
Absolute Contraindications
• Recent myocardial infarction: Within the last 3–6 months.
• Uncontrolled haemorrhagic disorders: Severe haemophilia, thrombocytopenia.
• Active malignancy in the extraction site (bisphosphonate necrosis risk).
• Uncontrolled diabetes (HbA1c > 10%).

Relative Contraindications
• Blood dyscrasias (leukaemia, lymphoma)
• Anticoagulant therapy — liaise with physician
• Liver disease (impaired clotting factors)
• Acute local infection — treat with antibiotics first, then extract
• Pregnancy (first and third trimesters — elective extractions avoided)

★ EXAM TIP: EXAM FAVOURITE: 'Acute infection is NOT an absolute

contraindication — it is a relative one. Antibiotics are prescribed first, then extraction
is performed when acute inflammation subsides.'
 2. TYPES OF TOOTH EXTRACTION

2.1 Simple (Closed / Non-Surgical) Extraction

A simple extraction is performed on a tooth that is visible in the oral cavity, using only forceps and
elevators without raising a mucoperiosteal flap.

Characteristics:
• Tooth is erupted and accessible
• Performed under local anaesthesia
• Uses dental forceps and straight/curved elevators
• Socket is managed with pressure and haemostatic measures

Steps:
1. Administer local anaesthesia (infiltration or block)
2. Confirm adequate anaesthesia (analgesia test)
3. Loosen the gingival attachment with a periosteal elevator or luxator
4. Apply elevator to widen the periodontal ligament space
5. Apply forceps — beaks placed apically, below the gingival margin
6. Apply controlled luxation movements (buccal-lingual/palatal)
7. Deliver the tooth
8. Inspect the socket, curette if needed, irrigate
9. Achieve haemostasis with gauze pack
10. Give post-extraction instructions

2.2 Surgical (Open / Transalveolar) Extraction

Surgical extraction is performed when a tooth cannot be removed by simple means. It involves raising a
mucoperiosteal flap, removal of bone, and sometimes sectioning of the tooth.

Indications:
• Impacted teeth (especially mandibular third molars)
• Buried roots or root fragments
• Hypercementosed roots
• Dilacerated or curved roots
• Ankylosis (fused tooth-bone)
• Fractured teeth with subgingival fractures
• Long, divergent, or multiple roots

Steps:
11. Administer appropriate local anaesthesia
12. Design and incise a mucoperiosteal flap (envelope, triangular, or rectangular)
13. Elevate the flap with a periosteal elevator
 14. Remove bone with a surgical bur (high-speed handpiece with irrigation)
15. Section tooth if needed (mesiodistal or buccolingual)
16. Elevate and remove tooth/roots with elevators and forceps
17. Debride and irrigate the socket
18. Replace and suture the flap (3-0 or 4-0 vicryl/silk)
19. Apply bite pack for haemostasis

2.3 Extraction Under General Anaesthesia

Performed in theatre for anxious patients (children and adults), multiple extractions, medically
compromised patients, or patients in whom LA is inadequate.

KEY COMPARISON TABLE

Simple Extraction: Erupted tooth, no flap, faster, done in clinic under LA.
Surgical Extraction: Impacted/buried tooth, requires flap + bone removal ± tooth sectioning.
GA Extraction: Multiple/difficult teeth, special patients, done in theatre.

🧠 MNEMONIC: Types of Extraction — 'SSG'

S — Simple (straightforward, erupted teeth)
S — Surgical (sectioning, bone removal, suturing)
G — General anaesthesia (group/children/complex cases)
 3. INSTRUMENTS USED IN TOOTH EXTRACTION

Each instrument serves a specific function and is used at a specific stage of the procedure.
Understanding the function of every instrument is essential for both examinations and clinical practice.

3.1 Syringes and Needles (Local Anaesthesia Delivery)

Dental Aspirating Syringe
• Function: Delivers local anaesthetic solution into tissue.
• The aspirating syringe has a harpoon mechanism that allows negative pressure to check if a
blood vessel has been entered before injection.
• Types: Breech-loading, cartridge-type (thumb-ring design for aspiration).

★ EXAM TIP: Always aspirate before injecting to avoid intravascular injection.

Positive aspiration (blood in cartridge) means reposition the needle before injecting.

3.2 Periosteal Elevator (Mitchell Trimmer / Molt Elevator)

• Function: Detaches the gingival fibres and mucoperiosteum from the tooth and alveolar bone
before extraction.
• Used to reflect a mucoperiosteal flap in surgical extractions.
• Also protects soft tissues from the bur and elevator during surgery.
• Blade is flat on one side and curved on the other; used with a push-and-peel motion.
• The Molt No. 9 is the most commonly used periosteal elevator.

3.3 Luxators
• Function: Cut the periodontal ligament (PDL) fibres and widen the PDL space to loosen the tooth
before elevator or forceps application.
• Thinner, sharper blade than an elevator — designed to sever PDL fibres, not lever.
• Available in straight, curved, and angled forms.
• Reduces force needed and decreases risk of root fracture.

3.4 Dental Elevators

Elevators are levers. They work by one of three principles: lever, wedge, or wheel and axle.

3.4.1 Straight Elevator (Warwick-James Straight / Coupland's No. 1, 2, 3)

• Function: Used to loosen teeth by displacing them from the socket. Applied mesially or distally to
widen the socket and expand the bony walls.
• Mechanism: Acts as a lever using the alveolar crest as the fulcrum.
• Common use: Loosening single-rooted upper anterior teeth, elevating root fragments.
3.4.2 Curved Elevator (Warwick-James Curved — Left and Right)
• Function: Used for lower posterior teeth — applied to the distal of a lower tooth to push it
mesially into the extraction socket.
• Curved blade adapts to the mesial/distal root surface of lower molars.

3.4.3 Cryer Elevators (East-West Elevators — Left and Right pair)

• Function: Triangular blade used after sectioning a multi-rooted tooth. One root is removed; the
elevator is placed in the empty socket and rotated to elevate the remaining root.
• Works on: Lower molar roots; paired — use left for left roots, right for right roots.

3.4.4 Winter's Cross-Bar (Transalveolar) Elevator

• Function: T-shaped handle providing extra mechanical advantage for removing lower wisdom
teeth.
• Applied in the bifurcation of a sectioned lower molar to elevate individual roots.

3.4.5 Apical (Root Tip) Elevator — Potts Elevator

• Function: Very fine-tipped elevator specifically designed to retrieve small root fragments or root
tips from the apical end of the socket.

Elevator Primary Function

Coupland's 1, 2, 3 Loosen single-rooted teeth; graduated sizes for increasing

access

Warwick-James Straight General tooth loosening in anterior region

Warwick-James Curved (L/R) Lower posterior teeth, distal application

Cryer (L/R) Elevate individual roots after sectioning lower molars

Winter's Crossbar Surgical removal of lower wisdom teeth

Apical/Root Tip Retrieve root fragments from the socket base

3.5 Dental Forceps

Forceps are designed to grip the tooth firmly at its cervical margin and deliver it from the socket through
controlled luxation movements.

Parts of Forceps:
• Handle: Allows the operator to grip and apply controlled force.
• Hinge (joint): Connects handle to beaks; allows the two halves to open and close.
• Beaks (blades): The working end — placed below the gingival margin to grip the tooth at the
cemento-enamel junction (CEJ).

General Principles of Forceps Technique:

20. Beaks must be placed as far apically as possible, below the gingiva.
21. Force is applied parallel to the long axis of the tooth first (apical pressure).
22. Luxation: controlled slow rocking movements buccally and lingually/palatally.
23. Rotation is used only for single-conical roots (upper central incisors, upper canines).
24. Delivery: tooth delivered in the direction of least resistance.

3.6 Curettes (Bone Curette)

• Function: Remove pathological granulation tissue, cyst remnants, infected granuloma, or foreign
material from the extraction socket after tooth removal.
• Also smooth sharp bone edges within the socket.
• Cup-shaped or spoon-shaped working ends.

3.7 Surgical Bur (Fissure Bur / Round Bur)

• Function: Removes bone overlying impacted teeth or roots during surgical extraction.
• Also used to section tooth roots.
• Always used with copious sterile saline irrigation to prevent thermal bone necrosis.

3.8 Surgical Handpiece

• Function: Drives the surgical bur at appropriate speed with external irrigation.
• Low-speed handpiece used for bone work (unlike high-speed air turbine — NOT used in surgery
due to risk of surgical emphysema).

⚠ WARNING: NEVER use an air turbine handpiece during surgical extraction — air
can be forced into tissues, causing surgical emphysema or air embolism.

3.9 Haemostatic Agents

• Gauze Pack: Biting pressure for 30 minutes achieves haemostasis by pressure.
• Resorbable Gelatin Sponge (Gelfoam): Placed in socket to stimulate clot formation.
• Oxidised Cellulose (Surgicel): Haemostatic gauze that dissolves over days.
• Tranexamic Acid (5%) mouthwash: Used in anticoagulated patients.

3.10 Suture Materials and Needle Holders

• Needle Holder (Webster/Mayo): Holds the suture needle to close the flap.
• Tissue Forceps (Adson's): Holds soft tissue during suturing.
• Suture Scissors: Cuts suture after tying.
• 3-0 Vicryl (resorbable): Used for most flap closures — does not need removal.
• 3-0 Silk (non-resorbable): Used where slower healing is expected; must be removed at 7 days.
 4. DENTAL FORCEPS — IDENTIFICATION, DESIGN & TOOTH
ALLOCATION

Each type of dental forceps is specifically designed for a particular tooth or group of teeth. Correct
identification of forceps depends on the shape and angulation of the beaks, the angle of the handles,
and the presence of a bayonet offset.

HOW TO IDENTIFY FORCEPS — GENERAL RULES

1. Handle angle: Upper forceps have handles that are roughly in line with the beaks. Lower
forceps have handles at RIGHT ANGLES to the beaks.
2. Beak shape: Upper anterior forceps have fine, narrow beaks. Upper molar forceps have a
pointed beak on one side for the buccal root. Lower molar forceps have both beaks pointed
for mesial and distal roots.
3. Left vs Right (upper molars): The pointed beak faces buccally. Hold the forceps upright
— if the pointed beak is to the RIGHT, it is for the RIGHT upper molar.
4. Bayonet forceps: Used for upper premolars and posterior teeth requiring offset access
(long handles angled away from teeth).

4.1 Upper Jaw (Maxillary) Forceps

Forceps No. 1 — Upper Incisors and Canine (Anterior)

• Design: Straight handles and straight beaks. Narrow beaks that are symmetrical on both sides.
• Identification tip: Beaks are straight and narrow, handles align with the beaks (no angulation).
• Used for: Upper central incisors, lateral incisors.
• Technique: Buccal-palatal luxation followed by rotational movement for single conical roots.

Forceps No. 2 — Upper Canine

• Design: Wider beaks than No. 1 to accommodate the larger canine root.
• Used for: Upper canine (longest root in the mouth).
• Technique: Buccal-palatal rocking with eventual rotation as the root is conical.

Forceps No. 76N (Bayonet / Ash No. 76) — Upper Premolars

• Design: Bayonet-shaped (S-shaped offset). Narrow symmetrical beaks. Handles are offset from
beaks to provide access to the posterior region.
• Identification tip: S-shaped profile when viewed from the side. No pointed beak — both beaks
are rounded.
• Used for: Upper first and second premolars.
• Technique: Buccal-palatal rocking. NO rotation (upper premolars have two roots — bifid roots —
rotation causes fracture).
 ⚠ WARNING: Do NOT rotate upper premolars — they often have two roots. Rotation
will fracture the roots. Use buccal-palatal rocking only.

Forceps No. 94 (Upper Right Molar) and No. 95 (Upper Left Molar)
• Design: Bayonet-style handles. One beak is POINTED (for the buccal bifurcation) and one beak
is ROUNDED (for the palatal root).
• Identification tip — No. 94 (Right): When holding the forceps with beaks pointing away from
you, the pointed beak is on the RIGHT side.
• Identification tip — No. 95 (Left): The pointed beak is on the LEFT side.
• Used for: Upper first and second molars.
• Technique: Buccal and palatal rocking, then figure-of-eight movement to disengage three roots;
deliver buccally.

🧠 MNEMONIC: Upper Molar Forceps: 'Right beak = Right molar'

Hold forceps upright, beaks pointing away.
Pointed beak to YOUR RIGHT → Forceps No. 94 → Upper RIGHT molar
Pointed beak to YOUR LEFT → Forceps No. 95 → Upper LEFT molar

Forceps No. 67 (Cow-Horn / Upper Molar Roots)

• Design: Both beaks are pointed (cow-horn shaped).
• Used for: Elevating upper molar roots, especially roots of upper third molars.

Forceps for Upper Third Molars (Wisdom Teeth)

• Design: Similar to upper molar forceps but with shorter beaks for access to the distal region.
• Used for: Erupted upper third molars. For impacted ones, surgical extraction with flap is required.

4.2 Lower Jaw (Mandibular) Forceps

Forceps No. 74 (Lower Anteriors — Incisors and Canines)

• Design: Handles meet at RIGHT ANGLES to the beaks. Fine, narrow, symmetric beaks.
• Identification tip: The sharp right-angle bend distinguishes lower forceps from upper.
• Used for: Lower central incisors, lateral incisors, lower canine.
• Technique: Labial-lingual rocking. Rotation can be used for canine (single conical root).

Forceps No. 74 — Lower Premolars

• Design: Similar to lower anterior but with slightly wider beaks.
• Used for: Lower first and second premolars.
• Technique: Buccal-lingual rocking. Slight rotation acceptable (single root).
Forceps No. 73 (Lower Molar Forceps)
• Design: Right-angle handles. BOTH beaks are POINTED (bifid/bicuspid tips) to engage the
buccal and lingual bifurcation of lower molars.
• Identification tip: Both beaks are pointed/notched — this is UNIQUE to lower molar forceps. It is
SYMMETRICAL (same on both sides — used for both left and right lower molars).
• Used for: Lower first and second molars.
• Technique: Buccal-lingual rocking using equal force on both sides, then figure-of-eight
movement; deliver buccally or lingually.

Forceps No. 79 (Cow-Horn Lower Molar Forceps / Cryer/Read Forceps)

• Design: Right-angle handles. Both beaks are sharply pointed and curved, resembling cow horns
— designed to penetrate the bifurcation of lower molars.
• Identification tip: Very prominent pointed beaks that curve inward toward each other.
• Action: When squeezed, the pointed beaks penetrate into the buccal and lingual bifurcation and
act as a wedge to force the tooth out occlusally (squeezing action).
• Advantage: Reduces risk of root fracture by distributing force at the furcation.

Forceps for Lower Third Molars (Wisdom Teeth)

• Design: Right-angle handles; wider beaks for access. Some have additional curves.
• Used for: Erupted lower third molars (impacted ones need surgical extraction).

Forceps Tooth / Arch Beak Design Identification Key

No.

No. 1 Upper incisors Straight, narrow, symmetrical Straight handles + straight narrow
beaks

No. 2 Upper canine Wider than No. 1 Straight, wider beaks

No. 76N Upper premolars S-shaped offset, symmetrical Bayonet (S-shape) — no pointed
(Ash) rounded beaks beak

No. 94 Upper RIGHT molar Pointed beak on RIGHT Pointed beak to right when held
(buccal) upright

No. 95 Upper LEFT molar Pointed beak on LEFT Pointed beak to left when held
(buccal) upright

No. 67 Upper molar roots Both beaks pointed (cow- Both pointed — no offset handles
horn)

No. 74 Lower Right-angle handles, narrow 90-degree handle-beak angle

anteriors/premolars beaks

No. 73 Lower molars (both Right-angle handles, BOTH Both beaks pointed = lower molar
sides) beaks pointed

No. 79 Lower molars (cow- Sharply curved inward- Very prominent curved beaks,
horn) pointing beaks squeezing action

★ EXAM TIP: KEY EXAM POINT: Lower forceps always have handles at right angles
to the beaks. Upper forceps handles are roughly in line with the beaks. Upper MOLAR
forceps have ONE pointed beak (for the bifurcation). Lower MOLAR forceps have
BOTH beaks pointed.
 5. EXTRACTION TECHNIQUE FOR EACH TOOTH GROUP

The technique varies depending on the root morphology, number of roots, and position in the arch.
Understanding root anatomy is essential to selecting the correct movement to avoid complications.

5.1 Upper Anterior Teeth (Incisors & Canine)

Anatomy: Single, conical roots (incisors shorter; canine longest — up to 27mm).

• Forceps: No. 1 (incisors), No. 2 (canine)
• Anaesthesia: Buccal infiltration + palatal infiltration (nasopalatine/greater palatine nerve).
• Elevator: Straight elevator (Warwick-James or Coupland's) applied mesially.

Technique Steps:
25. Loosen the gingiva with a luxator or periosteal elevator.
26. Place elevator mesially to widen the periodontal ligament space.
27. Apply forceps — beaks apically below the gingival margin.
28. Firm apical pressure first (seating the beaks).
29. Labial-palatal rocking movements (labial force slightly greater — thinner buccal plate).
30. Rotation applied gradually (root is conical — rotation widens socket).
31. Deliver labially (direction of least resistance).

⚠ WARNING: Nasal floor is close to upper incisors. Excessive apical force can push
roots into the nasal cavity. Monitor depth of beak placement.

5.2 Upper Premolars

Anatomy: Usually two roots (buccal and palatal) — can be fused or bifid. First premolar most
commonly has two roots.
• Forceps: No. 76N (Bayonet / Ash)
• Anaesthesia: Buccal infiltration + palatal infiltration.
• Elevator: Straight elevator applied mesially first.

Technique Steps:
32. Apply luxator in the periodontal space to sever PDL fibres.
33. Apply straight elevator mesially.
34. Apply bayonet forceps with beaks below gingival margin.
35. Apical pressure to seat beaks.
36. Buccal-palatal rocking ONLY — NEVER rotate.
37. Deliver buccally.
 ★ EXAM TIP: Upper premolars are the most commonly fractured teeth during
extraction because of their bifid roots. Never rotate — always buccal-palatal rocking
only.

5.3 Upper Molars

Anatomy: THREE roots — one palatal (largest/strongest) + mesiobuccal + distobuccal. Roots

may be divergent. Close to maxillary sinus.
• Forceps: No. 94 (right molar), No. 95 (left molar)
• Anaesthesia: Posterior superior alveolar nerve block + greater palatine block + middle superior
alveolar.

Technique Steps:
38. Loosen all gingival attachments completely.
39. Apply correct molar forceps — pointed beak engages buccal bifurcation, rounded beak on palatal
root.
40. Firm apical pressure to seat beaks into furcation area.
41. Buccal force first (thicker palatal plate resists movement more), then palatal — alternating, slow,
and controlled.
42. A figure-of-eight movement disengages the three roots.
43. Deliver buccally (in the direction of the buccal furcation).

⚠ WARNING: Upper molars are immediately adjacent to the maxillary sinus (floor of
antrum). Excessive apical force or root fracture may result in oro-antral
communication (OAC). Verify root fragments are not displaced into the sinus.

5.4 Lower Anterior Teeth (Incisors & Canine)

Anatomy: Single roots; lower incisors are the smallest teeth. Thin alveolar plate.
• Forceps: No. 74
• Anaesthesia: Inferior alveolar nerve block OR bilateral mental nerve block + lingual infiltration.

Technique Steps:
44. Luxate PDL space with luxator.
45. Apply elevator mesially.
46. Apply No. 74 forceps, beaks as far apically as possible.
47. Labial-lingual rocking (labial force greater — thinner buccal plate).
48. Rotation for lower canine (single conical root).
49. Deliver labially.
 5.5 Lower Premolars

Anatomy: Single root, round cross-section; first premolar root may curve distally.
• Forceps: No. 74 (lower premolar pattern)
• Anaesthesia: Inferior alveolar nerve block + long buccal nerve infiltration.

Technique Steps:
50. Luxate and elevate with straight elevator.
51. Apply lower premolar forceps.
52. Buccal-lingual rocking with slight rotation.
53. Deliver buccally.

5.6 Lower Molars

Anatomy: TWO roots (mesial and distal). Mesial root is wider with two canals. Roots close to
inferior alveolar nerve. Dense cortical bone (mandible is much denser than maxilla).
• Forceps: No. 73 or No. 79 (Cow-Horn)
• Anaesthesia: Inferior alveolar nerve block + long buccal nerve block.

Technique Steps — No. 73:

54. Thorough loosening of gingival cuff.
55. Apply elevator distally (Warwick-James curved) to loosen.
56. Apply No. 73 forceps — both pointed beaks engage the buccal and lingual bifurcation.
57. Firm apical seating pressure.
58. Buccal-lingual rocking with equal, controlled force — NO rotation (two roots).
59. Figure-of-eight movement to disengage roots.
60. Deliver buccally or lingually.

Technique Steps — No. 79 (Cow-Horn):

61. Pointed beaks are forced into the buccal and lingual furcation.
62. Squeezing the handles together drives the tooth out occlusally.
63. Useful when tooth is extensively broken down.

5.7 Lower Third Molars (Wisdom Teeth)

Lower third molars are the most challenging extractions due to variable impaction depth, root
morphology, proximity to the inferior alveolar nerve, and dense mandibular bone.

Impaction Classifications (Winter's Classification):

• Mesioangular: Most common. Tooth tilted mesially. Easiest to remove.
• Vertical: Tooth upright. Moderate difficulty.
 • Distoangular: Tooth tilted distally. Most difficult — root goes deeper into ramus.
• Horizontal: Tooth lying horizontally. Requires bone removal and sectioning.

🧠 MNEMONIC: Winter's Impaction — 'MaV DiH'

Ma — Mesioangular (Most common)
V — Vertical
Di — Distoangular (most Difficult)
H — Horizontal

Surgical Extraction of Impacted Lower Third Molar:

64. Inferior alveolar nerve block + long buccal block.
65. Incision: Ward's incision (distal releasing incision + sulcular incision along 2nd molar).
66. Elevate mucoperiosteal flap with Molt elevator.
67. Remove buccal/distal bone with surgical bur and copious irrigation.
68. Section tooth (mesiodistal division): separate crown from root.
69. Elevate crown first, then roots using Cryer elevators.
70. Debride socket, smooth sharp bone edges with bone file.
71. Irrigate with saline.
72. Suture flap with 3-0 vicryl — interrupted sutures.
 6. COMPLICATIONS OF TOOTH EXTRACTION

Complications can be classified as intra-operative (occurring during extraction) or post-operative

(occurring after extraction). Early recognition and management of complications is crucial.

🧠 MNEMONIC: Intra-operative Complications — 'FRIEND'

F — Fracture of tooth (root or crown)
R — Root displacement (into sinus/soft tissue)
I — Injury to adjacent teeth or structures
E — Excessive bleeding / vessel damage
N — Nerve damage (inferior alveolar/lingual/mental)
D — Dislocation of the jaw (TMJ)

🧠 MNEMONIC: Post-operative Complications — 'DISHAB'

D — Dry socket (Alveolar Osteitis)
I — Infection (post-extraction alveolitis / osteomyelitis)
S — Swelling and Trismus
H — Haemorrhage (primary/reactionary/secondary)
A — Alveolar nerve damage (paraesthesia)
B — Broken jaw (mandible fracture)

6.1 INTRA-OPERATIVE COMPLICATIONS

6.1.1 Fracture of the Tooth (Crown or Root)

Causes:
• Carious, heavily restored, or brittle teeth
• Hypercementosis (excess cementum on root surface)
• Curved or divergent roots
• Excessive uncontrolled force
• Dense alveolar bone

Management:
73. Stop. Assess the size and position of the fragment.
74. If the root fragment is large and accessible: continue elevation with apical or Cryer elevators.
75. If the root fragment is small (< 3mm), near the apex, with no associated pathology, and not near
the sinus: leave in situ (inform patient, document, review).
76. If the root is near the sinus or in the sinus: refer to oral surgery.
77. Always inform the patient and document in notes.
 ★ EXAM TIP: A retained root tip < 3mm with no pathology, not near vital structures =
acceptable to leave. Always document, explain to patient, and arrange follow-up X-
ray at 6 months.

6.1.2 Displacement of a Root into the Maxillary Sinus (Oro-Antral Communication)

Most common with: Upper premolars and upper molars (roots in close proximity to sinus floor).
Signs of Oro-Antral Communication (OAC):
• Blood-tinged air bubbling through the socket
• Positive nose-blow test (air exits through socket when patient blows through nose with mouth
closed)
• Patient feels air movement in the socket

Management:
78. If OAC is small (< 2 mm): promote clot formation, prescribe antibiotics + nasal decongestant,
avoid nose-blowing. May close spontaneously.
79. If OAC is > 2 mm: surgical closure with a buccal advancement flap (Rehrmann flap).
80. If root is displaced into sinus: refer to oral/maxillofacial surgery — Caldwell-Luc procedure may be
needed.

⚠ WARNING: Never perform aggressive probing of the socket to search for roots
when OAC is suspected — this enlarges the communication.

6.1.3 Displacement of Tooth into Soft Tissues or Infratemporal Fossa

• Upper third molars can be displaced into the infratemporal fossa.
• Lower third molars can be pushed lingually into the pterygomandibular space.
Management:
• STOP applying force immediately.
• Do not blindly probe — this pushes the tooth deeper.
• Refer to oral surgery for planned retrieval under controlled conditions.

6.1.4 Injury to Adjacent Teeth

• Adjacent tooth loosened, extracted accidentally, or restoration fractured.
• Caused by improper elevator use (fulcrum must be bone, NOT adjacent tooth).
Prevention:
• Always use alveolar bone as the fulcrum, not the adjacent tooth.
• Check for crowns, bridges, and implants on adjacent teeth before starting.

6.1.5 Fracture of the Alveolar Bone (Tuberosity Fracture)

• The maxillary tuberosity (bone behind upper third molar) can fracture as a block with the tooth.
Risk factors:
• Large, fused upper molar roots
• Hypercementosis
• Adjacent wisdom tooth already extracted (tuberosity unsupported)
Management:
• If the bony fragment is small and detached: remove it.
• If large tuberosity fractured: do NOT force extraction — stop, splint, and allow healing over 6–8
weeks, then re-extract.

6.1.6 Fracture of the Mandible

• Rare but serious — occurs with excessive force, especially during lower third molar surgery.
• Risk factors: Osteoporosis, large impacted wisdom teeth occupying most of the ramus.
Management: Immediate referral to oral-maxillofacial surgery for fixation (IMF or plates).

6.1.7 Haemorrhage During Extraction

Causes:
• Local: Damaged blood vessels in the socket, laceration of gingiva, excessive bone removal.
• Systemic: Anticoagulant therapy, haemophilia, thrombocytopenia, liver disease.

Management:
81. Apply gauze pack with pressure for 15–30 minutes.
82. Suture bleeding vessels or socket if necessary.
83. Apply bone wax to intra-osseous bleeders.
84. Place resorbable haemostat (Gelfoam, Surgicel) in socket.
85. Prescribe tranexamic acid mouthwash (5%) for anticoagulated patients.
86. Refer to hospital if bleeding uncontrolled — IV tranexamic acid, FFP, or platelet transfusion.

6.1.8 Nerve Damage

Inferior Alveolar Nerve (IAN):
• Risk during lower molar surgery — especially lower third molars.
• Presents as: paraesthesia (tingling), hypoaesthesia (numbness), or anaesthesia of the lower lip,
chin, and lower teeth on the affected side.
Lingual Nerve:
• Lies on the floor of mouth, medial to mandibular third molar.
• Damage causes numbness of the ipsilateral half of the tongue + altered taste.
Long Buccal Nerve:
• Damage causes numbness of buccal mucosa — usually transient.
Mental Nerve:
• Damage during premolar or anterior mandibular surgery.
Management:
• Transient nerve injury (neuropraxia): Reassure patient; most resolve within 8–12 weeks.
• Persistent injury (> 3 months): Refer to specialist for neurological assessment; consider
microsurgical repair if axonotmesis or neurotmesis.

6.1.9 Dislocation of the Temporomandibular Joint (TMJ)

• Can occur if excessive downward force is applied to lower jaw during extraction.
• The condyle dislocates anteriorly out of the glenoid fossa.
Presentation: Inability to close the mouth; jaw locked open.
Management:
87. Bimanual reduction (Hippocratic technique): Thumbs on lower molars, fingers under chin.
88. Push jaw down and backward simultaneously.
89. Apply head bandage for 24 hours; soft diet.

6.2 POST-OPERATIVE COMPLICATIONS

6.2.1 Dry Socket (Alveolar Osteitis / Fibrinolytic Alveolitis)

Dry socket is the most common post-extraction complication. It occurs when the blood clot in the socket
breaks down prematurely (fibrinolysis), leaving bare bone exposed.

Incidence: 1–5% of all extractions; 20–30% of lower third molar extractions.

Risk Factors (Predisposing Factors):

• Smoking: Most significant risk factor — nicotine causes vasoconstriction + fibrinolysis.
• Female sex: Oestrogen promotes fibrinolysis.
• Oral contraceptive use: Increases fibrinolysis.
• Poor oral hygiene and infection.
• Traumatic extraction.
• Lower third molars (dense bone = poor blood supply).
• Excessive rinsing or drinking through a straw post-extraction.

Pathophysiology:
Normally, a blood clot forms in the socket within minutes of extraction. This clot acts as a scaffold for
healing. In dry socket, fibrinolysis (breakdown of fibrin) destroys the clot. Bacteria (especially
Treponema denticola) and activated plasminogen promote fibrinolysis. Bare bone becomes exposed to
oral environment → inflammation and severe pain.

Clinical Features (Presentation):

• Onset: 2–4 days post-extraction (not immediately after).
• Pain: Severe, throbbing, radiating to ear, temple, and eye — disproportionate to the appearance.
• Socket: Empty socket with bare/white bone visible. No blood clot present.
 • Halitosis: Foul smell from socket due to bone inflammation and necrosis.
• No pus: Dry socket is NOT an infection (though secondary infection can occur).

Management:
90. Do NOT curette — this destroys remaining healing tissue and worsens pain.
91. Gentle irrigation of socket with warm saline or chlorhexidine to remove debris.
92. Pack the socket with an obtundent dressing (Alvogyl / BIPP — Bismuth Iodoform Paraffin Paste).
93. Change dressing every 2–3 days until socket heals from the base upward.
94. Systemic analgesics: NSAIDs (ibuprofen 400mg TDS) ± weak opioid.
95. Antibiotics only if secondary infection present (metronidazole 400mg TDS x 5 days).
96. Smoking cessation counselling.

DRY SOCKET vs INFECTION — KEY DIFFERENCES

Dry Socket: Bare bone visible, severe throbbing pain (days 2–4), no pus, no fever, halitosis.
Post-extraction Infection: Pus present, swelling, fever, raised WBC, pain worsening after
day 5.

★ EXAM TIP: Dry socket: Pain AFTER day 2 (not immediately). Empty socket, bare
bone, NO pus. Tx = Alvogyl/BIPP dressing. DO NOT curette.

6.2.2 Post-operative Haemorrhage

Classification:
• Primary haemorrhage: Occurs at the time of extraction (intra-operative).
• Reactionary haemorrhage: Within first 24 hours, as the vasoconstrictor (adrenaline) in LA wears
off.
• Secondary haemorrhage: 7–10 days post-extraction, due to infection eroding a blood vessel.

Management (for reactionary or delayed bleeding):

97. Remain calm. Sit patient upright.
98. Remove clot with suction/gauze.
99. Apply firm pressure with gauze pack for 15–20 minutes.
100. Infiltrate with LA + adrenaline (vasoconstriction).
101. Suture the socket if gingival bleeding.
102. Apply Surgicel/Gelfoam if intra-osseous.
103. If uncontrolled: prescribe tranexamic acid 500mg TID; refer to hospital.

6.2.3 Post-extraction Infection / Alveolar Osteitis

• Presentation: Swelling, erythema, purulent exudate from socket, fever, raised WBC, pain
worsening after day 5.
• Organism: Mixed oral flora, often including anaerobes.
Management:
 104. Drainage: Irrigate socket, curette granulation tissue if required.
105. Antibiotics: Amoxicillin 500mg TDS x 5 days + Metronidazole 400mg TDS x 5 days.
106. Chlorhexidine mouthwash 0.2% BD.
107. Analgesics.

6.2.4 Swelling and Trismus (Lockjaw)

• Swelling: Expected after surgical extractions, especially lower third molars. Peaks at 48–72
hours, resolves by day 7.
• Trismus: Limited mouth opening due to inflammation of masticatory muscles (particularly medial
pterygoid after lower molar surgery).
Management:
• Ice packs first 24 hours (15 min on/15 min off)
• NSAIDs (ibuprofen) for anti-inflammatory effect
• Warm packs after 48 hours
• Jaw physiotherapy (mouth-opening exercises) — 'coin exercises'
• Antibiotics if infection contributing to trismus

6.2.5 Oro-Antral Fistula (OAF) — Post-operative

• Definition: A persistent epithelialised tract between the oral cavity and maxillary sinus,
developing from an untreated OAC.
• Features: Regurgitation of fluids through the nose, sinusitis, and nasal discharge.
Management:
• Surgical closure: Rehrmann buccal advancement flap (most common).
• Alternative: Palatal rotation flap for larger fistulas.
• Treat associated sinusitis before surgical closure.

6.2.6 Paraesthesia / Altered Sensation

• Inferior Alveolar Nerve: Numbness of lower lip and chin.
• Lingual Nerve: Numbness + loss of taste on ipsilateral tongue.
Management:
• Reassure patient — most cases (neuropraxia) resolve within 8–12 weeks.
• Neurosensory testing (cotton wool, sharp probe) at follow-up visits.
• B-vitamins (thiamine, B12) may support nerve recovery.
• Persistent cases > 3 months: refer to oral surgery specialist.

6.2.7 Osteoradionecrosis (ORN)

• Definition: Exposed necrotic bone in the jaw following extraction in a patient who has received
radiotherapy to the jaw region.
• Mechanism: Radiation destroys osteocytes and the blood supply → hypovascular, hypoxic bone
→ unable to heal after trauma.
Risk:
 • Greatest within 2 years of radiotherapy
• Mandible more susceptible than maxilla
Prevention:
• Ideally extract compromised teeth before radiotherapy.
• If post-radiotherapy extraction is unavoidable: hyperbaric oxygen therapy (20 pre-op + 10 post-op
dives) to promote neovascularisation.

6.2.8 Medication-Related Osteonecrosis of the Jaw (MRONJ)

• Definition: Exposed necrotic bone following extraction in patients on bisphosphonate therapy (IV
more dangerous than oral) or anti-RANKL drugs (denosumab).
Prevention:
• Drug holiday (2 months off bisphosphonate) before elective extraction — discuss with prescribing
physician.
• Minimise trauma; promote primary closure.
 7. POST-EXTRACTION INSTRUCTIONS AND CARE

Post-extraction instructions are critical to prevent complications. Always provide written instructions in
the patient's language.

Immediate Post-Extraction (First 24 Hours):

108. Bite firmly on gauze pack for 30 minutes.
109. Do NOT rinse the mouth for 24 hours (dislodges clot).
110. Do NOT use a straw (negative pressure dislodges clot).
111. Do NOT smoke (fibrinolysis — dry socket risk).
112. Eat soft, lukewarm food on the opposite side.
113. Avoid strenuous activity (raises blood pressure → bleeding).
114. Some oozing is normal — does not require alarming.

After 24 Hours:
115. Warm saline rinses (1 teaspoon salt in glass of warm water) three times daily.
116. Resume gentle brushing around the socket.
117. Continue prescribed antibiotics (if given) for the full course.
118. Take analgesics as prescribed — do not wait for pain to become severe.

Return to Clinic if:

• Persistent severe pain after day 2 (suspect dry socket)
• Bleeding not controlled with pressure
• Swelling increasing after day 3
• Fever > 38°C
• Numbness / tingling persisting > 24 hours

POST-EXTRACTION INSTRUCTIONS SUMMARY

Bite gauze 30 min → No rinsing 24h → No smoking → No straws → Soft diet
Warm saline rinse after 24h → Complete antibiotics → Return if dry socket/swelling/fever
8. QUICK REFERENCE — TOOTH-BY-TOOTH SUMMARY

Tooth Roots Forceps Elevator Movement Key Risk

Upper central 1 (single, No. 1 Straight/ Labiopalatal + Root into

incisor conical) Coupland rotation nasal cavity

Upper lateral 1 (may curve No. 1 Straight Labiopalatal ± Root

incisor distally) rotation fracture
(curved
apex)

Upper canine 1 (longest No. 2 Straight Labiopalatal + Labial bone

root) rotation fracture

Upper 1st Usually 2 No. 76N (Ash) Straight Buccal-palatal Root

premolar (bifid) ONLY fracture (2
roots)

Upper 2nd 1 (usually) No. 76N (Ash) Straight Buccal-palatal OAC (near
premolar ± rotation sinus)

Upper 1st molar 3 (2 buccal + No. 94 Warwick- Buccal-palatal OAC, root

1 palatal) (right)/95 (left) James + figure-of-8 fracture
curved

Upper 2nd molar 3 (may be No. 94/95 Warwick- Buccal-palatal Tuberosity

fused) James + figure-of-8 fracture
curved

Upper 3rd molar Variable Upper wisdom Straight/ Distal force, Tuberosity
(fused/conic forceps Cryer rotation fracture,
al) OAC

Lower 1 (thin, flat) No. 74 Coupland's Labiolingual ± Adjacent

central/lateral rotation tooth injury
incisor

Lower canine 1 (long, No. 74 Straight Labiolingual + Dense labial

round) rotation plate

Lower 1st 1 (may No. 74 Straight Buccal-lingual Root tip

premolar curve) + rotation fracture

Lower 2nd 1 No. 74 Straight Buccal-lingual —

premolar + rotation

Lower 1st molar 2 (mesial + No. 73 or No. Cryer/ Buccal- IAN

distal) 79 Warwick lingual, NO damage,
curved rotation root fracture

Lower 2nd molar 2 (may be No. 73 or No. Cryer/ Buccal- IAN damage
fused) 79 Warwick lingual, NO
curved rotation

Lower 3rd molar Variable, Surgical (flap Winter's Surgical IAN/lingual

curved + bur) Crossbar/Cr sectioning nerve, dry
yer socket
9. MNEMONICS AND EXAM TIPS — RAPID REVISION

🧠 MNEMONIC: Indications for Extraction — 'CRAFTS-P'

C — Caries (unrestorable)
R — Radiotherapy preparation
A — Abscess (unresolvable periapical)
F — Fracture (unrestorable tooth fracture)
T — Tumour / cyst treatment (tooth in field)
S — Supernumerary / orthodontic space
P — Periodontal (advanced bone loss)

🧠 MNEMONIC: Dry Socket Risk Factors — 'STOMP'

S — Smoking (No. 1 risk factor)
T — Trauma (difficult extraction)
O — OCP / Oestrogen (oral contraceptive pill)
M — Mandibular third molars (most common site)
P — Poor oral hygiene / Pre-existing infection

🧠 MNEMONIC: Post-extraction Instructions — 'No BRASS'

No — No rinsing for 24 hours
B — Bite on gauze for 30 minutes
R — Rest and avoid strenuous activity
A — Avoid alcohol and hot drinks
S — Stop smoking
S — Straws prohibited (negative pressure)

★ EXAM TIP: FORCEPS EXAM SHORTCUT: 'Upper = inline handles; Lower = right-
angle handles. Upper molar = ONE pointed beak; Lower molar = BOTH beaks pointed.
Left vs Right upper molar = pointed beak side tells you the side.'

★ EXAM TIP: COMPLICATIONS TO ALWAYS MENTION IN EXAMS: Dry socket, OAC

(oro-antral communication), IAN damage, haemorrhage
(primary/reactionary/secondary), root fracture, infection.

GOLDEN RULES OF FORCEPS TECHNIQUE

1. Beaks BELOW the gingival margin — grip tooth at CEJ or below.
2. Apical pressure FIRST to seat beaks before any rocking.
3. Slow, controlled, deliberate movements — NEVER jerk or twist rapidly.
4. Rotation ONLY for single, round, conical roots (upper anteriors, canines, lower
canines/premolars).
5. NEVER rotate multi-rooted teeth (upper molars, lower molars, upper premolars).
6. Deliver in direction of least resistance — usually buccally.

END OF NOTES — TOOTH EXTRACTION

Prepared for Health Professions Students — East Africa