Professor of Oral Surgery, King's College London; Honorary Consultant in Oral Surgery, King's College Hospital NHS Foundation Trust and Guy's and St Thomas' NHS Foundation Trust, London
Dental extractions are potentially an unpleasant experience that patients have to undergo. Not only are they losing a tooth that they may have invested significant costs in retaining, but fear and expectation of pain makes the encounter stressful and terrifying for most.
Dental extractions are the most common surgery undertaken worldwide, and usually on conscious patients, unlike other branches of surgery. Patients' most common fear of the dentist is the pain during and after surgery and the experience of injections, both guaranteed when undergoing extractions at the dentist.
Despite universities aiming to make undergraduate dentists able to undertake routine exodontia, ability remains limited. This may be due to foundation training limiting access to routine exodontia practice or a reluctance on behalf of dentists in general to undertake surgical interventions due to their high risk, patient sequelae or risk of complications, which are perceived as poor practice builders.
CPD/Clinical Relevance: This paper aims to provide some clinical tips and information that will assist practitioners in undertaking dental extractions.
Article
Vijay Bhargava
Dental extractions are a necessary and common requirement for the dental team. NHS oral surgery commissioning encourages primary care practitioners to provide routine ‘Tier 1’ dental extractions in practice. Those identified referring inappropriate cases may be provided with additional training opportunities.1 Why is it that some dentists will not routinely provide dental extraction services? There may be many answers including lack of education and training, fear and anxiety of managing patients undergoing high risk procedures due to team and personal stress, and/or the fear of litigation.
Education
Despite many universities aiming to make all undergraduate (UG) dentists able to undertake routine exodontia, ability remains limited.2 A substantial number of extractions are required to enable competency and, due to increasing pressures including staff:student ratios, patient choice and commissioning pressures, there is a reduction in the exposure of UGs to dental extractions.3
Another recently identified pressure is that foundation training may limit access to routine surgical practice or a reluctance on behalf of dentists in general to undertake surgical interventions due to their high risk, patient sequelae or risk of complications, which are perceived as poor practice builders.4
Patient fear and pressure
Dental extractions are the most common surgery undertaken worldwide, and usually on conscious patients, unlike other branches of surgery. Most patients' most common fear of the dental visit is the potential for pain during and after surgery and the experience of injections, both guaranteed when undergoing extractions.5
Dental extractions are probably one of the least pleasant experiences that patients have to undergo. Not only are they losing a potentially valued tooth, that some patients may have already invested significant costs in retaining, but pain and possible infection makes the encounter stressful and acute. A recent study highlighted the degree of poor acceptance and resultant depression from dental extractions.6
The surgical branch of dentistry is associated with the highest number of potential complications and thus litigation risk.7 However, with good planning and risk assessment of patient, medical and dental factors, these risks can be mitigated.8 In general, risk assessment and preparation for complications is key in minimizing difficulties and complaints, as stated by Benjamin Franklin, ‘By failing to prepare, you are preparing to fail’. This article aims to discuss some of the factors that should aid planning for, and undertaking, most extraction cases, with the provision of some useful clinical tips.
Assessment and planning
A failed extraction is one that is not carried out when needed or not completed satisfactorily. Before undertaking dental extractions, clinicians must assess the patient's need, the patient's (and their escort's) understanding and consent and the surgical risk, whilst being confident that the procedure is within their skill set and is appropriately supported by the immediate dental team, managed clinical network and commissioning team.
Diagnosis
Clinicians must ensure that a correct diagnosis is made and the related risk/benefits of treatment options are explained to the patient. It is crucial that extractions are not carried out for non-odontogenic pain (trigeminal neuralgia, post-traumatic neuropathy, headache conditions, including migraine and cluster headache-related conditions)9,10
Indications for surgery
Regarding indications for dental extraction, there are no national guidelines regarding routine exodontia indications. Therapeutic indications for all teeth include:
Unrestorable, due to caries or insufficient tooth structure for restoration;
Necrotic pulp, not amenable to root canal therapy (RCT) or failed RCT;
Teeth associated with otherwise non-treatable pathology (for example cyst);
Symptomatic or potentially symptomatic impacted or ectopic teeth (including supernumeraries);
Medical factors prophylactic extractions of poor prognosis teeth, ie pre IV bisphosphonate, pre-chemotherapy, pre-irradiation, pre-cardiac surgery;
One may consider orthodontic extractions as an additional indication for non M3M extractions.
Risk assessment
Patient factors
Limited site access due to restricted mouth opening may be due to temporomandibular joint disorders (TMDs) or previous surgery or trauma resulting in trismus.
Anxiety and behavioural problems may present as: a lack of co-operation due to behavioural issues or not having the capacity to consent; severe gag reflex; inability to anaesthetize site fully; or a history of difficult extractions or attempted extractions. The SDCEP guidance on conscious sedation in dentistry is of value here.12
Complex medical history, including anticoagulants, anti-resorptive medications, or a combination of uncontrolled co-morbidities, respiratory, cardiovascular, immune or endocrine diseases.
Patients at risk of increased bleeding: clinicians should follow the SDCEP guidance.13
Post-operative persistent bleeding is a rare complication.14 Results of a 5-year prospective study indicated that in 9.9% of 2,056 outpatients in whom post-operative bleeding was observed, inpatient treatment became necessary for three patients with a haemostatic disorder (von Willebrands disease and haemophilia A).15
Requirement for antimicrobial prophylaxis: follow the SDCEP guidance for prescribing.16
Medically-related osteonecrosis (MRONJ): clinicians should follow SDCEP guidance.17,18 There is increasing evidence that a more aggressive medical and surgical approach may be more appropriate.19
Diabetic patients: ensuring that diabetic patients have eaten prior to their appointments when medicating, and routine provision of a glucose drink or tea with sugar can ensure that the patient does not experience hypoglycaemic collapse during the procedure.
Hypertensive patients with systolic over 160 and diastolic over 100 should be referred to their GMP for management, however, if the extraction is urgent it may be undertaken to minimize stress and pain for the patient.
Ischaemic heart disease: if a patient has had a myocardial infarct or coronary artery bypass graft (CABG) or coil or stent procedure, or brittle angina, in recent months (3–6), elective extractions should be delayed.
A summary of medical complexities and their management for oral procedures is presented in a previous publication.20
Risk assessment dental factors
Anatomical features affecting exodontia (Figure 1)
There is strong evidence to suggest that patient extractions become increasingly difficult for patients over the age of 25–27 years of age, which is also associated with higher morbidity.21 This is likely to be associated with more rigid and/or dense bone, making mobilizing the tooth roots more challenging. In addition, the tooth roots will be fully formed, requiring deeper application points.
Figure 1. Anatomical features affecting exodontia.
The tooth factors can largely be determined from the radiographic examination, such as:
Number of roots although, in a two-dimensional radiograph, this is not always possible to determine;
Tooth-supporting structures, bone level, periodontal ligament widening, sclerosis or hypercementosis;
For a submerging and/or ankylotic tooth, CBCT images can be a useful adjunctive diagnostic tool in diagnosis, but cannot be recommended as a single diagnostic modality, as false positive results may be found;22
Last standing maxillary molars may be more prone to bone fractures;
Proximity to anatomical structures such as the maxillary antrum, especially if enlarged, or the inferior alveolar canal;
Heavily restored teeth, root canal treated teeth, post and crowned teeth are generally considered to be brittle and at risk of crown and/or root fracture.
Investigations
Radiographs are an essential part of risk assessment in dental extractions. However, all radiographic investigations should align with guidelines (IRMER23 and SendentexCT24):
Long cone periapical (LCPA);
Dental pantomogram (DPT) or panoral useful when the full dental anatomy cannot be visualized with LCPA;
Cone beam CT (CBCT) scanning could be used if justifiable in order to locate an ectopic tooth position or determine proximity to high risk anatomical features, such as the inferior alveolar nerve or maxillary antrum.
Indices to predict the difficulty of tooth removal
Indices to predict the difficulty of tooth removal have traditionally focused on mandibular third molars. The most notable scale being the modified Parant which can be applied to routine exodontia.25 Criteria of the modified Parant scale are as follows:
Easy I – Extraction requiring forceps only;
Easy II – Extraction requiring osteotomy;
Difficult III – Extraction requiring osteotomy and coronal section;
Difficult IV – Complex extractions (root section).
With dental implants being increasingly used to replace missing teeth, and the need to have as much healed bone as possible post extraction, the ‘flapless’ option is increasingly being used to preserve the gingival and bony architecture.
The authors recommend the use of the following classification (inspired by the ITI implant classification system)26 pre-operatively when presented with dental extractions:
Straightforward;
Advanced;
Complex.
Whilst some teeth are easily classified as non-surgical, eg a mobile incisor, and others definitely surgical, eg an impacted third molar, there is a grey area where a large number of teeth are potentially surgical, such as the endodontically treated molar.
Periapical radiograph of endodontically treated LL6
The periapical radiograph of LL6 demonstrates the features to suggest a possible surgical extraction (Figure 2):
Long divergent roots;
Bulbous apicies +/- ankyloses;
Endodontic treatment increases brittleness of the teeth;
Large coronal restoration;
Good interradicular and crestal bone;
Adjacent heavily restored teeth likely to fracture on elevating the adjacent teeth.
Figure 2. Peri-apical radiograph of endodontically treated LL6.
The tooth was delivered non-surgically with elevators and forceps, with an apical abscess as well as part of the buccal bone attached to the roots. This will undoubtedly leave a large buccal defect when the socket heals. Could this have been avoided with an elective surgical approach?
Figure 3. Clinical view of extracted tooth.
Adjunctive care
Local anaesthesia
There is a shift from routinely using inferior dental blocks (IDBs) for mandibular dentistry and palatal blocks in the maxilla by using 2% lidocaine or 4% articaine infiltration (buccal mental nerve infiltration (NOT a BLOCK)) plus supplementals if needed, including supracrestal, intra-ligamental and lidocaine lingual infiltrations. Arguably, for extractions a lower level of plural anaesthesia is required and LA is better achieved when compared with restorative dentistry.27
Local anaesthesia of suggested optimal LA practice for exodontia (Figure 4)
Analgesia
There is strong evidence to avoid the use of opiates or opioid drugs as they provide little in additional analgesia compared with Paracetamol and NSAIDs. Opiates also cause constipation and nausea along with other complications. Optimal analgesia is reported to be combined Paracetamol with Ibuprofen as they work synergistically, working extremely effectively for third molar surgery and other moderate pain-inducing dental procedures.28 Combined Ibuprofen (400–600 mg) plus Paracetamol (500 mg–1 g) has the lowest number needed to treat (NNT) compared with other commonly used analgesics, providing evidence of the effectiveness of this combination.29
Figure 4. Local anaesthesia of suggested optimal LA practice for exodontia. Adapted from a drawing by Andrew Mason of Unversity of Dundee.
Antibiotics
Prophylactic antibiotics are not required during routine dental extractions in healthy patients.30 The use of antibiotic therapy without appropriate indications can result in the development of resistant organisms. However, a clear trend is seen in which practitioners overprescribe antibiotics, as well as medications in general. The current evidence questions the benefits of prophylactic antibiotic therapy for patients undergoing dental extractions confirmed by a recent prospective randomized controlled trial (PRCT).31
Antibiotics are ONLY indicated if drainage of a locally spreading infection is not achieved after extraction (SDCEP and FGDP AMS guidelines 2012).
Chlorhexidine
Increasing sensitivity to chlorhexidine-containing products has led to many Hospital Trusts limiting surgical wound irrigation with chlorhexidine although, as yet, there is no national guidance. There is weak evidence to support peri-operative use of oral rinse chlorhexidine to reduce dry socket incidence but the benefit is minimal and potentially can cause anaphylaxis in fresh bleeding sockets.31
Consent
Clinicians must now ensure that patients are aware of any ‘material risks’ involved in a proposed treatment, and of reasonable alternatives, following the judgement in the case Montgomery v Lanarkshire Health Board (2014).32 The patient must be aware of alternative treatments and their risks and benefits. Appropriate information and time must be given for the patient to give informed consent, along with financial implications for patients paying for treatment (immediate and future costs). Most dentists undertake verbal consent for conscious LA procedures. However, if there are risks attendant with the procedure (nerve injury, oro-antral communication (OAC), etc), written consent may be more appropriate, which of course is essential if the patient is undergoing sedation or general anaesthetic.
Patient positioning
Patient positioning is very important for the comfort of the dental team, surgical access and patient comfort. Exodontia has traditionally been performed by operators in a standing position, and the patient's head is usually just above the operator's waist height. When removing mandibular teeth, the patients are best seated upright. This allows direct vision to the respective teeth. Maxillary teeth are best approached with the patients positioned supine on the dental chair.
Operator factors
Operator factors may be either:
A lack of required surgical equipment: equipment must be appropriate and prepared in accordance with regulations (COSH, NHS England);
Inexperience and/or insufficient support: if this is the issue then further training must be sought rather than subject the patient to a procedure that is likely to fail.
Techniques
One can change to the next classification peri-operatively if the tooth being extracted is more complicated than anticipated as follows.
Straightforward exodontia
This may have one or more of the following features; a periodontally involved tooth or, with significant apical pathology, single-rooted, with a degree of pre-operative mobility or favourable root morphology.
PLAN A – requiring elevators or luxators and forceps only
The key factor in this decision-making is being fully equipped in terms of instrumentation (Table 1). This list does not include luxators, which are now the ‘go to’ instruments for bone maintaining dental extractions. Luxators are ever ‘expanding’ in range, to include many different diameters, angles and materials.
Couplands I, II, III
Warwick James straight, left and right
Cryers left and right
Mitchell's Trimmer
Howarth's Periosteal Elevator
Rake or Minnesota Retractor
Suturing instruments
Halstead Mosquito forceps
Surgical Straight Handpiece with sterile saline with round and fissure burs
Full selection of dental forceps suitable for every tooth/root
LUXATORS (Courtesy of the Directa Luxator catalogue (Figure 5))
The diameters range from 1–5 mm, with straight, curved, reverse curved, inverted and dual-edge varieties. The 1 mm diameter is commonly used for small root tips, whilst the 3 mm is the most useful for single-rooted teeth. The authors have struggled to find an appropriate scenario to use the 5 mm luxators, and advise caution with inappropriate positioning of this instrument. They are specially designed as periodontal ligament knives with fine tapering blades that compress the alveolar bone, cut the membrane and gently ease the tooth from the socket with a minimum of tissue damage. The handles are designed to maximize support and minimize excessive forces being applied. Undergraduates are often taught that these instruments should not be used palatally due to the risk of damage to soft tissue. This is true for maxillary molars, as the greater palatine vessels are in close proximity.
Figure 5. Luxators (Courtesy of the Directa Luxator catalogue).
However, palatal application of luxators in the pre-maxillae for the removal of incisors, canines and premolars can be invaluable. The bone here is usually abundant and, with appropriate finger rest support, it can make this an effective technique to mobilize the commonly fractured incisor, canine or premolar that has lost the buccal wall subgingivally. This technique also preserves the buccal bone that can be mobilized or lost with buccal application of instruments. It is never recommended to use luxators or elevators lingually.
The authors advise against the horizontal placement of these instruments, even though the manufacturers provide a manual instructing their use in this way. There may be a high risk of damage to the adjacent tooth or restorations, as well as soft tissue, if the instrument passes through lingually or palatally.
Stainless steel luxators will become softer after continued heat sterilization cycles and the metal can wear. Figure 7 demonstrates metal fatigue of luxators. They require regular sharpening to maintain their effectiveness with a sharpening stone. Figure 8 shows a sharpening stone having just sharpened the same luxator as shown in Figure 7.
Figure 6. How NOT to use a luxator.Figure 7. Metal fatigue of a luxator.Figure 8. A sharpening stone having just sharpened the same luxator as shown in Figure 7.
Newer titanium nitride-coated stainless steel luxators may avoid the need for polishing in the future. It should be noted here that luxators are used to expand the bone space between the periodontal ligament and tooth root(s), while elevators (Coupland) are used to lift the tooth from the periodontal membrane. Both of these are used prior to forceps application (Figures 9–12). Whilst luxators can aid dental extractions, they are not suitable for all teeth. Care must be exercised with luxators in the extraction of third molars. There is an increased risk of either lingual plate fracture for lower third molars and buccal/tuberous fractures for upper third molars. This may also apply for first and second molars, particularly if roots are splayed or close to the maxillary antrum. Two-dimensional radiography often has the limitation of not allowing the clinician to visualize the palatal roots. Whilst 3D imaging is not recommended in most cases, clinicians should be mindful of splayed or additional roots.
Figure 9. Peri-apical radiograph of upper right second premolar requiring orthodontic extraction.Figure 10. Use of angled luxator palatally: note finger support protecting adjacent teeth and palatal positioning of instrument.Figure 11. One point contact, carefully selected forceps.Figure 12. Coupland elevators are still the elevator of choice for mandibular and maxillary molars.
Forceps extraction
Forceps extraction is often the first choice for routine simple extractions of multi-rooted teeth after initial elevation with luxators. The forceps are positioned beneath the cemento-enamel junction on the root surface with one-point contact to achieve traumatic extraction.
Forceps should be chosen for the appropriate tooth and applied, ideally ensuring one point contact with the blades as far apical on the root surface as possible. This minimizes the risk of coronal fracture. They should be parallel to the long axis of the tooth, and a gentle supported and controlled pressure should be applied. This is maintained until the expanded site ‘gives’ ie you feel some positive movement, not to be confused with buccal bone fracture. If achieved, a circular motion can be used, migrating to a conical movement for a single-rooted tooth or figure of eight movement for a multi-rooted tooth. Once mobile, a wrist twist action can be used to disengage the apical portion of the roots. Excessive forces should be avoided for risk of TMJ displacement, jaw fracture or buccal wall fracture.
This series of images demonstrates the removal of an upper left second molar using the Cowhorn principles, ‘beak to cheek’. It is important to note the forces being positioned on the roots beneath the cemento-enamel junction (Figures 13–16).
Figure 13. DPT indicating upper left second molar unrestorable caries.Figure 14. Positioning forceps.Figure 15. Forceps engaged with appropriate finger support.Figure 16. Mobilized tooth: note root position of forceps.
Elevators and forceps only go so far and, once a plateau point has been reached without successful exodontia, an operator decision should be made to move on to Plan B, if suitably experienced and equipped to do so. This decision-making ideally should be made within the first few minutes of attempting non-surgical exodontia.
PLAN B – requiring a surgical handpiece and sterile saline to, if possible, flaplessly decoronate and section root(s), if appropriate
If the cemento-enamel junction is visible, sectioning horizontally is useful to remove the crown or carious portion of the tooth. The pulp space then acts as a good guide for sectioning the roots. The ‘Y’ section for maxillary molars allows the three roots to be divided and elevated individually.
Another technique that can be used for the maxillary molar would be to section through the cemento-enamel junction only, dividing the mesio-buccal and disto-buccal roots from the crown. The crown and attached palatal root can then be removed as one piece, leaving the two buccal roots to then be removed individually. These may require sectioning from each other.
Mandibular molar roots can be sectioned in a bucco-lingual direction (Figure 17). Sectioning with the surgical handpiece and fissure bur creates a point of weakness to allow elevators to perform the final sectioning and mobilization of the roots. This prevents the need for the drill to go through too far buccally or lingually/palatally, therefore avoiding soft tissue damage. Care should be taken to ensure that the surgical handpiece does not contact the soft tissues. Avoidance of high speed handpieces for surgical dissection of teeth is important as there are increasing reports of surgical emphysema.33,34,35,36
Figure 17. Mandibular molar roots can be sectioned in a bucco-lingual direction.
If the inter-radicular bone can be preserved, this will allow better socket healing. However, if it is not possible to deliver the roots, then part or all of the inter-radicular bone can be sacrificed to allow access to the roots. Curved elevators can be useful to deliver sectioned roots. Inter-radicular bone is the preferred bone to be removed, as opposed to buccal bone, that would leave the site resorbed post-operatively.
If the cemento-enamel junction of the tooth in question is not visible, or if the roots are subgingival or subcortical, then a buccal flap is recommended. This can be extended to a 2-sided or last resort 3-sided flap if absolutely essential for access and vision.
Conclusion
Having a sequential plan for complexity for any dental extraction helps manage most cases. There will, however, always be false positives that will challenge the most experienced operator. Knowledge, equipment, experience, and awareness of personal limitations are all essential for successful exodontia and optimal patient care.
