Preparation and patient positioning
Good visualization of the surgical field and prevention of complications (such as fainting) depend on proper positioning. The patient is seated upright or semi-reclined in the dental chair, with the backrest and headrest slightly tilted back.
The dentist stands to the right and front. With their left hand, they stabilize the alveolar process, retracting the lip or cheek. A specific forceps grip is used for the upper jaw: the hand is rotated with the back of the hand facing the physician, the index and middle fingers are placed between the handles, the thumb grasps one handle from the outside, while the ring and little fingers grasp the other. The ends of the handles must rest firmly against the palm, ensuring control when advancing the instrument beneath the gingiva.
Immediately before extraction, the preparation stage is performed: a periosteal elevator or a narrow blunt instrument is used to detach the circular ligament from the tooth neck. This prevents mucosal tearing during root retrieval.
Instruments
Instrument selection depends directly on the root anatomy of the tooth and its location.
- Straight forceps: used for incisors and canines (with wide or narrow beaks).
- S-shaped forceps: used for premolars and molars. The bend helps avoid interference from the lower jaw during lateral movements. For molars, the beaks are asymmetric: the outer beak has a spike for engagement between the buccal roots, while the inner (palatal) beak is flat or semi-rounded.
- Third molar forceps: feature short, broad beaks with rounded ends.
- Forceps with horizontal handles: the working part is bent at a right angle. They have a low profile and are ideal when the patient has restricted mouth opening.
- Straight elevator: the handle, shaft, and beak (trough-shaped) lie on the same axis. It works on the lever principle and is used for single-rooted teeth and separated roots.
Stages and biomechanics of extraction
The procedure consists of five sequential steps:
- Placement of forceps. The crown is positioned between the buccal and oral beaks. The axes of the instrument and the tooth must coincide.
- Advancement. The instrument is gently moved subgingivally with a hand motion down to the neck of the tooth. If the crown is destroyed, the forceps are applied directly to the alveolar margins (capturing 2–3 mm of bone).
- Fixation (clamping). The tooth and forceps must function as a single lever arm. If fixation is weak, the forceps will slip; if excessive, they will crush the crown.
- Luxation (luxation and rotation). Movements must be smooth. The initial, gentlest movement is directed toward the path of least resistance (toward the thinner socket wall).
- Extraction (traction). Performed downward and outward only after complete rupture of the periodontal fibers. Premature extraction risks damaging antagonist teeth.
Features of extracting various tooth groups
Root anatomy dictates the direction of luxation:
- Incisors: Have a single cone-shaped root. The primary movement is rotation. If this is ineffective, rocking movements toward the labial and palatal sides are added.
- Canine: The root is massive and triangular in cross-section. The alveolar walls are thick. Considerable force is required. A combination of rocking and rotation is used. The first movement is outward.
- Premolars: Roots are compressed laterally; the first premolar often has thin, bifurcated roots. Luxated very smoothly (outward, then inward) to prevent root tip fracture.
- First molar: The outer wall in this area is reinforced by a thick zygomaticoalveolar crest. Therefore, the first luxating movement is performed in the palatal direction (an exception to the general rule).
- Second and third molars: The first movement is classic — toward the buccal side (since the outer wall here becomes thinner than the inner wall again).
Briefly: answers to topical questions
Which nerves innervate the maxillary teeth and require blockage prior to extraction?
Innervation of the maxillary teeth is supplied by branches of the maxillary nerve:
- Superior anterior alveolar branches (rami alveolares superiores anteriores) — innervate the incisors and canines.
- Superior middle alveolar branch (ramus alveolaris superior medius) — innervates the upper premolars.
- Superior posterior alveolar nerves (nn. alveolares superiores posteriores) — participate in the innervation of the posterior maxillary teeth; in the absence of the superior middle alveolar branch, the premolars receive sensory innervation from the superior posterior alveolar nerves.
What local complications can occur directly during maxillary tooth extraction?
The following local complications may arise directly during the maxillary tooth extraction procedure:
- Root fracture — improper forceps placement can lead to root fracture during luxation.
- Pushing a tooth root into the maxillary sinus — occurs due to improper advancement of forceps or a straight elevator.
- Alveolar process fracture — during upper molar extraction, detachment of the posterior alveolar process, part of the maxillary tuberosity, or a portion of the maxillary sinus floor along with adjacent teeth may occur.
For the extraction of which teeth and roots are bayonet forceps used?
Bayonet forceps are used to extract tooth roots and teeth with destroyed crowns. This instrument is used for the extraction of:
- Roots of maxillary molars, including fused roots (forceps with wide beaks are used).
- Separated roots of molars (forceps with narrower beaks are used).
- Maxillary incisor roots (as an alternative to straight converging forceps).
- Teeth with destroyed crowns.
Class and exam questions
In which direction is the initial luxation movement directed in the maxilla?
Toward the path of least resistance of the bone tissue. In most cases, this is the external (buccal) wall of the alveolus, as it is thinner than the palatal wall. The main exception is the first molar, where the buccal bone is thickened.
What is the main rule when applying forceps?
The longitudinal axis of the forceps beaks must strictly coincide with the longitudinal axis of the tooth. Failure to follow this rule leads to root fracture during luxation.
What is a straight elevator used for in the upper jaw?
It is used for extracting single-rooted teeth, retrieving separated roots of multi-rooted teeth, and for teeth located outside the dental arch.
How to properly hold forceps when extracting upper teeth?
A special grip is used: the hand is rotated with the back facing the physician, the index and middle fingers are placed between the handles, the thumb grasps one handle externally, and the ring and little fingers grasp the other. The end of the instrument rests firmly against the palm.
What else to study on this topic
- Complications during tooth extraction (root fracture, detachment of the maxillary tuberosity)
- Mandibular tooth extraction: differences in biomechanics
- Use of angular and bayonet elevators
- Anatomy of the zygomaticoalveolar crest and its clinical significance
- Technique for extracting teeth with a completely destroyed crown
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Other topics in "Chapter 14. Tooth Extraction"
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