Tooth Extraction Tips
A few tips to help you with extractions:
1) Use elevators first. I was once told that you should not put forceps on a tooth until it is at least grade 2 mobile. Obviously there are times when this is not possible but i made it my mantra midway through fifth year to always try and it has improved my success at taking out teeth immeasurably. In my opinion all teeth should be loosened with elevators, including all lower teeth. I seem to remember being taught that the mandibular bone is too thick to elevate effectively but I have never found that the case and it really helps me with my extractions.
2) Use Luxators correctly. A Luxator should be used to create a space between the bone and tooth. Luxators are placed in a simillar position as Coupland Elevators but they are used differently. You should apply a firm but very controlled force between tooth and bone and make very small ossilating (wiggling) movement as you go to widen a space.
3) Once this space has been created get a Couplands Elevator into the space and elevate. A couplands is thicker and narrower than a luxator and will engage the fulcrum better. Couplands 1 should be used first and the sizes moved up as the space widens or if the Couplands is ineffective (example b). Avoid elevating with luxators which wll act like example (a) of the diagram. It is also dangerous to elevate with a luxator as they are likely to fracture because they are thinner than a couplands (though I’m sure we all do it a little bit)
Click image to see full size.
4) Once the tooth is grade 2 mobile or as best you can get it apply your forceps. You should know the root pattern and movement you are trying to achieve. I won’t go through it here unless someone requests it later. The main point is that the majority of the force should be down the long axis of the tooth so that and turning force is concentrating at the root apex.
5) Some teeth won’t come out in one go. If you have a lower 6 with converging roots it may just not come. If the tooth is crumbling to bits then it ain’t gonna happen. It’s not the end of the world, breaking the tooth can be part of the process to remove it. Of course it always best if you can assess the cases where this is the case and plan how you will break it but unfortunately it’s not always that easy.
6) A few common ways i choose (or not) to split teeth are:
a) Cow Horns on a lower molar can be used if the thing just won’t come with normal Lower Molar Forceps. You might get it out in one with these but a second best result is if the tooth decoronates and you are left with two seperated roots. These can usually be elevated with Luxator/Couplands combo.
b) If you get one root out but the other breaks on a lower molar you can use a cryers elevator to get it out. place the blade on the root at the furcation side of the tooth and try to engage and lift. Often the best way to do this is to nibble away some of the furcal bone until you have an application site. If cryers are not working on the furcal side of the root you can apply them to the other side and rotate the other way. Depending on the curve of the root this can work better.
c) Section the teeth. If I’m really having trouble gripping the tooth, either because it has snapped or it is very grossly decayed then i try to section the tooth above the gingiva without raising a flap. I’m not sure if this is frowned upon but i use it on occasion before resorting to an MOS (at least I’m being honest).
Often on a grossly decayed tooth you can use just a Luxator to split the tooth. Across the furcation for a lower molar and in a Mercedes sign for an upper seperating palatal and 2 buccal roots. If you can’t do this with luxator alone i cut into the tooth with a long tapered bur and section in the same shapes but taking care not to cut too far lingually on a lower or too deep. Once trough has been made a Couplands can be wedged in and rotated to split the tooth as desired.
d) If that doesn’t work it’s tme to do an MOS which I won’t discuss now.
Looking at those instructions they seem quite basic but I do hope that some people can extract some use out of them. The diagram I’ve used in this article is from “Tooth extractiona practical guide” By Paul Robinson. This is an excellent text to refer to for a more formal description of good extraction technique. It also goes through chair position and body position for extractions which are also very important.
Mostly getting good at extractions is about experience but a little theory never hurt. If anyone has any tips they would like to add please add a comment and i will edit the article to include them.
All the best
Chris
#1 by Nick at June 6th, 2009
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Great tips Chris, the only thing I’d mention is I’d personally wouldn’t use a luxator for sectioning teeth. The twisting motion needed is perfect for deforming and shearing their delicate tips – couplands are much stronger in this respect.
#2 by ChrisO'C at June 6th, 2009
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Good point well put forward Nick. I’ll edit it in the post so I look more clever!
#3 by Andy at June 7th, 2009
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Hey chris,
An interesting and useful post. just to add to Nicks’ comments, I find a straight Warwick James a much stronger instrument to section roots and just as a personal opinion, I also find it is a more suitable size to engauge a slot in roots. I sometimes have found couplands a tad large in this regard.
#4 by Phil at June 7th, 2009
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The teaching in 3rd year that we had was to use an elevator to loosen the tooth first, fine, but then comes the catch. You’re must have the convex part of the elevator against bone? This always confused me, how am I supposed to get a chunky couplands 1 elevator down a 0.2mm wide p.d.l space of a healthy periodontium?
Inevitably, in all but the most periodontially compromised of teeth, students are attempting extractions with forceps after some token wiggling with a couplands which often leads to fracture.
In fairness, this year quite a few of us have been able to use luxators. I used them on my elective so I felt confident using them and managed to convince a clincian to let me. The rest of my group then wanted to use them and I think everybody was taught how to by the end of the year. I understand that the 3rd years are being taught to use luxators as well now although that may be a lie because I heard it from a 3rd year and I couldn’t have told a luxator apart from a straight probe at that stage.
#5 by ChrisO'C at June 7th, 2009
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COPIED FROM ALEX’S COMMENT ON BLOG POST EXTRACTION PHOBIA!
I think they have started to show students how to use luxators- perhaps only the third year at the moment?
I would echo your comments about snapping teeth- it happens and please please if you’re a student snap the tooth and do the MOS whilst you have backup, i’m not saying do it on purpose but….. you’re a student for a reason learn! To those at Newcastle, DEC is the best place to snap a tooth, it doesn’t matter if you think it’s a failure. It’s actually a success because the more you practice the better you get (though you might have to put up with someone wingeing about having to do the MOS and stay a bit later than the rest of your group)
In VT you will have difficult extractions and as nice as your trainer/the other associates are they might not be able to help, they might not have done a MOS for ages, they might be in the middle of the day from hell. You might ring the local Oral surgery department as be told that the waiting list for a MOS is 2 years, and if you ring the emergency departement they will tell you that it’s not there to help out general dentists, only the great unwashed who couldn’t be bothered to get themselves to the dentist when their tooth broke 3 years ago, or worse when we accessed the lower 7 6 months ago and told them they had to get to a dentist, get on a waiting list or worse offered them student treatment which they then DNA’d and they turn up today asking for another of those root canal things, because they really don’t want to lose the tooth oh and some antibiotics too. (sorry rant over)
As for extractions, my first experience of pain, real toothachey pain was in third year where i assessed a patient who couldn’t think straight due to pulpitis, the supervisor suggested i give the anterior buccal infiltrations (having learnt how last week) before they went to radiology. I declined because i was scared, i couldn’t have been more stupid- there was no way i was going to hurt the patient she was in agony already, she would’ve been so grateful but because i was terrified i declined, and had to do an IDB the following day on cons. The moral being, have a go- the only way you’ll learn how to take out teeth is to feel around, look at the tooth, think about where it ‘wants’ to go. That tactile sensation is just built up with time. You need to find a method that works for you.
My method
lowers sit down, uppers lie down (S Makani) it’s good advice, it means you can transmit the force correctly (Dr Moore’s curve of power)
fingers either side to feel what’s going on, this maybe why my left arm often doesn’t work so well after an uppr left 6 XLA….
lowers- i don’t really use a luxator for molars, unless they’re separate roots. I couplands the life out of them, remembering to lift the tooth up- possibly trying to split the tooth (with my couplands. or cowhorns) i will often use forceps in a figure of 8 movement, often i find they want to come more lingually than we were taught. Cowhorns are fantastic for kids with spongey bone, not so good if the tooth is more broken down. 7’s and 8’s i find the cheeks annoying and couplands them out instead of forceps.
If you break something, try to see it, rinse it (ideally with saline) dry it, suction then wiggle it out with the luxator or cryers the hell out of the interseptal bone and lift it out that way.
lower premolars- be aware of distal hooks, again gentle wiggling often works better in my hands. Afrocarribean men frequently have double rooted lower fives.
upper premolars- beastly, hate them with a passion, 5’s can have two roots- it’s not just the 4’s that’ll break! loads of upwards force, if you see a good oral surgeon doing them they often seem to pull them out wiggling a little too, once they’re loose.
upper 6’s- i’m a weak and feeble female therefore i cannot push them out through the buccal bone with the shear force of my muscular forearms.
I start with a luxator (or straight warwick James) working up the buccal and palatal- good finger rest needed so as not to end up in the nose, wiggling up. then i couplands mesial and distal. then when it’s moving i’ll put the forceps on and push as hard as my not insignificant weight will allow, at this point the patient’s head will be lower than my elbow (sometimes they start to turn purple and you have to stop for a bit) I may also need the nurse to stablise the head for me.
once it’s out i look for the OAC, more likely in the lone standing unopposed tooth, but a monster abcess will erode into the sinus in a healthy 20 year old with plenty of maxillary bone. i’ve been qualified 2 years-ish and i’ve created 3 that were large enough to need a buccal advancement flap, one that was so big i thought i could see the floor of the orbit (bisphosphonate taking, renal dialysis patient with an allergy to penecillin and 4 pages of green repeat prescribtion)
upper 8’s- i’ve been qualified 2 years and i’ve never done a MOS on one, this worrys me. At some point i will but until then its luxator and couplands/cryers mesially for me, there are bent bayonets in my practice that are more like upper molars but with a bend in them, i like them alot.
bits of root- hmmm in hospital we chase them, in practice i often don’t. Tell the patient, radiograph and/or document, review the patient in 6 months it’ll come to the surface when you can flick it out- less morbidity for patient. (do not do this where there is swelling/cellulitis/you feel it’s wrong)
I sometimes wonder if we should start to be a little more conservative with our approach to bone- i have taken out an upper 6 with a chunk of buccal bone and the 5 and the 7 were still grade 1 mobile a year later. I’ve done a periotome extraction (preserving everything you can by trying to cut the pdl) it took 45 minutes to take out an upper central but the buccal bone was intact- for a delayed immediate implant. I know from reading dental town- another excellent web forum, for the Americans http://www.towniecentral.com/Dentaltown/SiteDefault.aspx
there are people out there taking out teeth under a microscope, to maintain as much as is possible. and alot say that they always section upper 6’s and 7’s
I’m not doing any of that but it does sometimes make me think am i doing the best by being quick?
ALEX
#6 by Ishtar at June 7th, 2009
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Just to clear up the whole 3rd year extraction thingy, we do use elevators (luxators, cryers, couplands and all) to help extract teeth as long as the clinician is confident you know why and how you’re using them! oh and lingual and palatal side elevating is not allowed as yet …. x
#7 by ChrisO'C at June 7th, 2009
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Good I wish we were allowed! Can’t say I’ve ever really done lingual elevating though. Not sure I’d fancy that. Occasionally go palatal on a 6. Thanks for the message
Chris
#8 by orange county cosmetic dentistry at July 2nd, 2009
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I was totally agree with this that teeth should be loosened with elevators, including all lower teeth.Keep posting!
florence
#9 by thomas at March 21st, 2010
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Chris, Could you please tell me the difference between a luxator and a couplands
#10 by ChrisO'C at March 21st, 2010
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Sure,
A luxator and a couplands might look very similar but they are designed to be used differently.
The luxator is for cutting bone and periodontal ligament and has a fine sharp end. They should be pushed around the tooth to open space for the couplands to enter.
A couplands is far thicker at the end and reinforced so it can take the bending forces of elevation without distorting. These should be your instrument of choice after the luxation to elevate the tooth.
However as I’m sure your aware most people use the luxator to both expand space and elevate. I do too and it works well to get the tooth out but it ruins your luxator. You bend the end (as it is not reinforced for the turning action) and it quickly becomes blunt. Used this way and once blunt a luxator is pretty much is just a fine couplands whcih is more likely to snap.
I would have a nice luxator and a blunted one in your practice as sometimes using you need a fine instrument to elevate but once you do the luxator becomes a bit useless for it’s real purpose.
Hope that helps
Chris
#11 by pooja at June 7th, 2010
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can you please tell the sequence of elevators used,, as in which is used 1st ,, do we loosen teeth alwayz with copland? what are movements of forceps.. any easy trick for doing extraction in exams? kindly post some video if u can,,
thanx
#12 by Andy at June 11th, 2010
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Pooja,
The usual sequence I use is a luxator used in a vertical direction with some lateral ‘rocking’ movement (but no twisting as you risk fracturing/bending it). Usually, when in work, I tend to place forceps on the tooth at this stage to test mobility and often am able to extract them at this stage. If further loosening is required, then you could continue with the luxator (used to cut the PDL), or progress to the Couplands elevators I, II and III in this order (they increase in size from I to III) working from mesial, to buccal, to distal. You use these in a vertical direction and also with a gentle rotation side to side in order to elastically expand the alveolar bone and progressively increase socket space between tooth and bone. Then extract the tooth with forceps. I don’t always use Couplands, but if you’re a student in an exam and have yet to master your technique, then I would advise using all three Couplands as this is the textbook technique and the safest way of extracting teeth without snapping them.
#13 by Tan at June 24th, 2010
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Never used luxators. I only use elevators for fractured roots and as luxators. Will have to try luxators out.
My routine for extraction is to aim for a good grip on the root – not the crown – with the forceps, “wiggle” to break the periodontal ligaments, then deliver the tooth.
When I was a student, one OMS demonstrated extraction of a a broken root flush at the alveolar crest- he pushed the beaks of the forceps between the mucosa and the alveolar bone (about 2mm below the alveolar crest) – “the bone will resorb anyway” – gripped the root through the alveolar bone, and wiggled the root out. But that was long before implants became routine.
#14 by Simon Templeman at June 28th, 2010
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Interesting to see the variety of techniques in use and I guess everyone will use some modification of the above but essentially what they know to be successful in their own hands.
Luxators I agree should be considered an aid to extraction or ’site preparation’ rather than a means to finally remove the tooth and this way you will avoid damaging these instruments and the patient.
On cowhorns, I find if applied with careful but firm force to lower molars, can also act to elevate the tooth and actually enable a fairly atraumatic technique, though a favourable root morphology is needed to achieve this.
I have until recently found upper bi-rooted premolars often snapped off the apical thirds of spindly roots, particularly 4’s due to the thick buccal bone around the canine tuberosity. This seemed to happen with the technique taught in 3rd year with apical and buccal force to extract. I have now found using stubby nosed, straight forceps to firmly grip the tooth and apply ligament-expanding movements followed by a gentle rotational and pulling (yes, I said pulling) motion once the tooth is grade 2 mobile. This works much better for me as I feel much more in control and haven’t broken a root yet doing this (for about the last 6-8months). I find premolar forceps often rock on the tooth and don’t grip well. Anyone else use a similar technique?