Quartz 4

L1 Introduction to Practice Oral Surgery 2026

41 min read

Introduction to Practical Oral Surgery 2026123

Course Overview

  • Course Title: Practical Oral Surgery 2026

Course Structure and Timing

This module has been moved forward in the semester based on student feedback to allow for earlier exposure to the Extraction Clinic. The session includes a didactic lecture followed by hands-on practical exercises using specialized models for tooth extraction and suturing.

  • Course Code: DENT5310
  • Instructor: Dr. Richard Hague
  • Students must complete mandatory hand hygiene modules and submit certificates to Michelle Lewis before clinical sessions.

About the Instructor4

Professional Background

  • Clinical Focus: General Dentist with an interest and significant experience in Oral Surgery.
  • Academic Role: Covering the Oral Surgery Module on behalf of Dr. Helen Grady.
  • Availability: Working day is Tuesday.
    • Occasional sessions may also be held on Wednesdays.
    • Email responses may not be same-day due to clinical commitments four days per week.

Clinical Appointments

  • Principal Dentist: All Saints Dental Group in Rockingham.
  • Surgical Privileges: Private General Anaesthetic (GA) surgery at Southbank Day Surgery.
    • This South Perth facility is the same one students will attend during their fourth year.

Session Outcomes5

By the end of this session, participants should be able to:

Clinical Referral and Assessment

  • Appropriately refer a patient to the student extraction clinic.
  • Be aware of factors that complicate extractions.

Anaesthesia and Instrumentation

  • Understand local anaesthetic techniques and doses as they apply to oral surgery.
  • Understand local anaesthetic pharmacology and dosing strategies relevant to oral surgery
  • Describe the instruments required for simple exodontia.

Surgical Principles and Techniques

  • Understand the principles of mechanics for simple exodontia.
  • Explain the biomechanical principles of tooth extraction
  • Demonstrate safe extraction techniques on models
  • Perform suturing on relevant anatomical models
  • Demonstrate the safe use of luxators and forceps.
  • Demonstrate the safe use of sutures.

This course is designed to provide a comprehensive overview of the fundamental principles and clinical techniques essential for successful minor oral surgery in a general practice setting.

Course Objectives and Learning Outcomes

By the end of this program, participants should be able to:

  • Assessment and Planning: Accurately assess patients for oral surgical procedures, identifying potential risks and complications before they arise.
  • Surgical Technique: Demonstrate proficiency in basic surgical skills, including flap design, bone removal, and tooth division.
  • Complication Management: Implement effective strategies for managing common intra-operative and post-operative complications.
  • Instrumentation: Select and utilize appropriate surgical instruments for specific procedures with confidence.

Core Curriculum Components

  1. Patient Evaluation

    • Medical history review and risk stratification
    • Radiographic interpretation and surgical mapping
    • Informed consent and legal considerations

  2. Surgical Fundamentals

    • Aseptic technique and operatory setup
    • Local anesthesia optimization for surgical cases
    • Soft tissue management and suturing techniques

  3. Exodontia and Beyond

    • Management of impacted teeth
    • Root fragment recovery
    • Alveoloplasty and site preservation

Practical Application

The 2026 curriculum emphasizes hands-on experience and case-based learning to ensure that theoretical knowledge translates directly into clinical competence. Each module includes interactive components designed to simulate real-world surgical challenges.

Chance

GO DIRECTLY TO JAIL

DO NOT PASS GO, DO NOT COLLECT $200

Compliance

These criteria are non-negotiable and constitute a "go to jail situation" if violated.

Extraction Clinic

All patients must meet specific clinical criteria to have extractions performed by DMD students.

Patient Eligibility Criteria6

Clinical Contraindications and Restrictions

  • Tooth and Volume Restrictions
    • No impacted teeth.
    • Do NOT book for extraction of more than 3 teeth at any one time.
      • No wisdom teeth that are inverted (upside down) or canines positioned in the nasal region.
        • Root fragments may exceed the 3-tooth limit but require prior tutor consultation.
  • Medical and Treatment History
    • No patients requiring sedation.
    • No patients requiring antibiotic (AB) cover.
      • No patients unable to tolerate treatment sounds and stimulation.
        • Antibiotic cover cases are excluded due to coordination difficulties.
    • No patients who have had previous Radiotherapy (RT) to the head and neck.
    • No patients on anti-resorptive agents (e.g., Bisphosphonates or Prolia).
    • No patients on immunosuppressants (e.g., Azathioprine or Methotrexate).
  • Medication Management (Anticoagulants and Anti-platelets)
    • Warfarin: Patients must have their INR checked within 24 hours prior to the extraction. The patient must bring their INR results to the appointment. - Acceptable INR range is up to 4.0, though 3.5 is preferred.
    • Dual Therapy: No patients on DUAL anti-platelets (e.g., Aspirin and Clopidogrel) or DUAL anti-coagulants (e.g., Aspirin and Rivaroxaban). - These patients experience significant oozing and represent the highest risk for haemostasis failure.
    • Single Therapy: It is acceptable to book patients on a single anti-platelet or a new oral anti-coagulant (Aspirin OR a NOAC). - Includes apixaban, rivaroxaban, and dabigatran; local haemostatic measures are sufficient.

Extractions and Prosthodontics7

Clinical Coordination and Scheduling

  • Bridge Sectioning: If bridge sectioning is required before extraction(s), ensure this is completed prior to the patient attending the extraction clinic.
    • The clinic is not equipped for extensive handpiece work; sectioning can take up to 1 hour, leaving no time for the extraction.
  • Session Capacity: Each chair in the extraction clinic can accommodate two patients per session. Each appointment duration is 1 hour 45 minutes.
    • Students should expect initial appointment durations of 80–90 minutes including waiting times and documentation.

Prosthetic Considerations

  • Denture Insertion: Immediate complete and partial dentures can be inserted in the extraction clinic.
  • Follow-up Care: Review appointments must be organized by the usual student clinician in a CC session.
  • Patient Informed Consent: Patients must be warned that if the prosthesis fails to fit, there is limited corrective action that can be taken within the extraction clinic setting.

Referral Process for Non Eligible Patients89

If a patient does not meet the standard eligibility criteria, follow these protocols:

Consultation and Internal Review

  1. Speak to the tutor covering the clinic on the proposed appointment date (e.g., for cases involving multiple teeth).

Referral to E Block

  1. For standard specialist referrals, use the following Titanium workflow: 3. Select “Add a new waitlist entry” 4. Select “Oral Surgery” 5. Select “Referral to Specialist” 6. Add all relevant clinical information.

Urgent Referrals

  1. If the case is urgent, complete the referral on Titanium first. The student clinician must then go IN PERSON to E Block with the patient details and the specific reason for urgency.

    • Note: If the referral is not found on Titanium, the request will be immediately rejected.

  2. Time-Sensitive Referrals: For patients on Prolia or other anti-resorptives requiring extraction in a narrow therapeutic window, follow the urgent referral protocol (Titanium + In-person).

  3. Waitlist Context: With approximately 2,500 patients on the waitlist, urgent referrals should not be routine.

Patients who do not meet the specific criteria for the Extraction Clinic must be managed through alternative referral pathways. It is essential to ensure that these patients are directed to the appropriate service to receive necessary care.

Referral to Oral Surgery (OS) and Oral & Maxillofacial Surgery (OMFS)

For patients requiring specialist intervention, referrals should be directed to the OS/OMFS departments. This includes cases involving:

  • Complex surgical extractions beyond the scope of the student clinic.
  • Patients with significant medical comorbidities that require a hospital setting.
  • Suspicious lesions or pathology requiring urgent assessment.

Referral to the Primary Care Oral Surgery (PCOS) Service

The PCOS service is available for patients who require minor oral surgery that can be performed in a primary care setting but is too complex for general dental practice.

  • Submission Process: All PCOS referrals must be submitted via the Vantage Rego electronic referral system.
  • Documentation: Ensure all relevant clinical notes and high-quality radiographs are attached to the electronic referral to avoid delays in processing.

General Principles for Referrals

When redirecting a patient, clinicians must:

  1. Clearly explain to the patient why they are not eligible for the student Extraction Clinic.
  2. Provide an estimated timeframe for the alternative referral, if known.
  3. Ensure the patient’s immediate pain or infection is managed appropriately before they leave the clinic, or provide a clear plan for emergency care while they await their referral appointment.

Assessing Complexity

Patients should be able to be positioned in the dental chair according to operator needs.

  • Patients with severe kyphosis or inability to extend their neck may be unsuitable due to access difficulties.
  • Patients prone to anger management issues should be avoided for student treatment.

Treatment Tolerance and Environment

  • Patients should be tolerant of longer procedures, especially in the beginning of the clinical training phase.
  • Patients must understand that this is student treatment and a learning environment.

Sensory and Behavioral Considerations

  • Patients should be able to tolerate dental treatment with associated sights, sounds, and stimulation.
  • Ideally, patients should be able to undergo dental treatment without making loud noises or causing distractions to the operator.

Root Morphology: Dilacerations

  • Assess for dilacerations or evidence of dilacerations.
  • Note that some curvature of the root is acceptable for treatment.

Root Morphology: Hypercementosis

  • Assess the apical ligament space and trace it out thoroughly.
  • Be aware of teeth presenting with bulbosities or areas of hypercementosis, as these increase extraction complexity.

Periodontal Ligament Space: Ankylosis

  • Assess the apical ligament space and trace it out.
  • Be aware of teeth where the periapical ligament space is obliterated; this indicates a high risk of ankylosis.

Radiographic Case Review

Consider the radiographic presentation of teeth 36 and 35 when assessing the complexity for extraction.

Case Study: Complex Multi-Rooted Extractions (85-Year-Old Patient on Prolia) case

An 85-year-old patient on Prolia (denosumab) was referred for extraction of teeth 35 and 36.

  • Tooth 35: Presented with gross caries, hypercementosis (mid-root bulbosity), and disappearing PDL space. Required drilling past the bulbosity for mobilization.
  • Tooth 36: Appeared ankylosed with extremely long roots. Required sectioning halfway down the roots to achieve mobility. This case demonstrates how radiographic signs of ankylosis and hypercementosis necessitate surgical intervention and specialist management.

When assessing the complexity of a surgical extraction, several tooth-specific variables must be evaluated to determine the likely difficulty of the procedure and the potential for complications.

Crown Condition and Structural Integrity

  • Extensive Caries: Large carious lesions can significantly weaken the crown, making it prone to fracturing under forceps pressure.
  • Large Restorations: Teeth with extensive amalgams or composite builds often lack the structural integrity of a sound tooth.
  • Pre-existing Fractures: Cracks or fractures in the crown increase the likelihood of the tooth crumbling during extraction.

Endodontic Status and Material Changes

  • Root Canal Treatment: Endodontically treated teeth are notoriously brittle. The loss of internal moisture and the presence of obturation materials make these teeth more likely to shatter rather than luxate cleanly.

Root Morphology and Anatomy

  • Number of Roots: Multi-rooted teeth (especially those with divergent or widely spread roots) provide greater resistance to extraction.
  • Root Curvature: Significant dilaceration (sharp bends) or hooked roots can trap the tooth in the alveolar bone, often requiring bone removal or tooth sectioning.
  • Root Length and Shape: Long, slender roots are at a higher risk of apical fracture compared to short, conical roots.
  • Hypercementosis: Excessive cementum formation at the apex creates a bulbous root end that is wider than the coronal portion of the root canal, physically preventing a simple vertical extraction path.

Periodontal and Bone Relationship

  • Periodontal Ligament (PDL) Space: A wide PDL space often facilitates easier movement, whereas a narrow or obliterated PDL space suggests a more difficult extraction.
  • Ankylosis: Fusion of the root to the bone eliminates the PDL space entirely, necessitating surgical bone removal to “trough” around the tooth.
  • Bone Density: Increased bone density (sclerosis) or thick cortical plates (especially in the mandible) provide less “give” during luxation, increasing the risk of root fracture.

“Informed consent is a person’s decision, given voluntarily, to agree to a healthcare treatment, procedure or other intervention that is made:

  • Following the provision of accurate and relevant information about the healthcare intervention and alternative options available; and
  • With adequate knowledge and understanding of the benefits and material risks of the proposed intervention relevant to the person who would be having the treatment, procedure or other intervention.

At the Commission, we believe informed consent is a key quality and safety issue.”

— Australian Commission on Safety and Quality in Health Care

  • ==Voluntary: Given without coercion==
  • ==Informed: Based on adequate knowledge of benefits and material risks==
  • ==Specific: Relevant to the proposed intervention and available alternatives==

Risk Communication Balance

While informed consent requires disclosure of material risks, clinicians must avoid clouding patient judgment with extremely rare complications (e.g., death from local anaesthesia) for simple procedures, as this may inappropriately influence treatment decisions.

Clinical Communication Examples

  • “Like with all minor surgery there are some common things that might occur afterwards including bleeding, bruising, swelling, pain and infection”

  • For patients on anticoagulants:

    • “Because you take [drug name] we usually find things are a little more oozy afterwards, and you might be prone to more significant bruising. It can sometimes look quite severe, almost like you’ve been in a boxing ring. I’m sure you know how easily you bruise when you knock your arm…”

Procedure Specific Risks202122

  • This is the part that we tailor to the specific procedure.

  • Example: Upper teeth close to the maxillary sinus

    • “This tooth is close to your sinus. Your sinus is this big hollow space inside your cheek. Sometimes the tooth is actually forming part of the floor of this sinus. This means that when I remove it, a hole can be left behind between the sinus and the extraction site.”
    • “If this happens we might need to give you some extra instructions and maybe put in some extra stitches. If it is small it will often close itself. Very rarely it might be significant and in which case we might need to refer you to a specialist to manage.”

Risks to Adjacent Structures

  • This is the part that we tailor to the specific procedure:

  • Example: Teeth with large cavities, restorations, or adjacent crowns

    • “Sometimes when we take out teeth, we can find that the tooth next door is compromised. This is sometimes only obvious when we either start to move or remove the tooth.”
    • “This can sometimes mean that the …[point to x-ray] on this tooth can come off. If this happens we may usually be able to stick it back on or replace it with a temporary solution. Sometimes you might need to come back another day for more dental treatment.”

Case Study: Unexpected Prosthesis Failure During Extraction

A long-standing patient presented for extraction of tooth 17, reporting a "niggle" adjacent to the extraction site. The patient had recently undergone implant placement in Turkey against clinical advice. Prior to extraction, the patient was warned that the implants could not be assessed (prosthesis design prevented probing and palpation). During forceps application and initial movement, a three-unit implant bridge became mobile and subsequently detached completely upon extraction of the 17. Because the conversation regarding potential damage to adjacent structures had occurred pre-operatively, the patient understood the situation and accepted referral back to the original provider for remediation.

Learning point: Pre-operative warning about adjacent tooth/implant compromise prevents the appearance of excuse-making if damage occurs.

Specific surgical procedures carry unique risks that must be disclosed to the patient during the consent process. These risks are categorized by the nature of the surgery and the anatomical structures involved.

Risks Associated with Extractions and Minor Oral Surgery

  • Damage to Adjacent Teeth: This includes the risk of chipping, loosening, or displacing existing restorations or natural teeth adjacent to the surgical site.
  • Fracture of the Alveolar Bone: Potential for localized bone fractures during the application of force.
  • Oro-Antral Communication (OAC): Specifically for upper posterior teeth, there is a risk of creating an opening between the oral cavity and the maxillary sinus.
  • Displacement of Roots: Roots or tooth fragments may be displaced into the maxillary sinus or other deep anatomical spaces.
  • Jaw Fracture: Although rare, the mandible or maxilla may fracture during difficult extractions.

Nerve Injuries and Sensory Disturbances

Nerve damage is a significant risk, particularly in the mandible, and can result in temporary or permanent altered sensation (paresthesia, dysesthesia, or anesthesia).

  • Inferior Alveolar Nerve (IAN): Risk of numbness or tingling to the lower lip and chin on the affected side.
  • Lingual Nerve: Risk of altered sensation to the tongue, which may also affect the sense of taste.

Post-Operative Complications

  • Dry Socket (Alveolar Osteitis): Localized pain and delayed healing due to the loss of a blood clot in the extraction site.
  • Infection and Sequestra: Potential for post-operative infection or the later exfoliation of small bone fragments.
  • TMJ Stress: Aggravation of pre-existing Temporomandibular Joint issues or new onset of jaw stiffness and clicking due to prolonged opening or pressure during the procedure.

Pre Operative Safety and Identification

The Dental Surgery Safety Checklist Tool is an abridged and adapted version of the WHO safety checklist. It is mandatory for all patients and must be completed via TOHM – eForms – Dental Surgery Safety Checklist Tool – Students.

Before Procedure: Patient Identification

Performed at the dental chair by the Dentist or Dental Clinic Assistant (DCA) to confirm: - Use verbal confirmation for identity; be cautious as common names like "John Smith" may result in the wrong patient responding.

  • Surname
  • First Name
  • Address
  • Date of Birth (DOB)

Before Procedure Commences: Time Out

A collective confirmation by dental staff and students to ensure the following:

  • Staff Introductions: All team members have introduced themselves.
  • Patient & Procedure Verification: Dentist confirms patient name and the specific procedure to be performed.
  • Procedure Briefing: Outline of the procedure and discussion of any specific concerns.
  • Consent & History: Confirmation that consent has been received and medical history (including allergies) is completed.
  • Readiness: Confirmation that essential radiographs, instruments, and equipment are available.

Dental Surgery Safety Checklist23

Before Patient Leaves Clinic: Procedure Completion

Final steps performed by the Dentist or Student:

  • Confirmation: Confirm the completed procedure with the patient.
  • Post-Operative Care: Discuss post-procedure effects and management strategies.
  • Emergency Protocols: Advise the patient on how to contact OHCWA in an emergency.
  • Discharge: Direct the patient back to Reception (assisted by the DCA if available).

Documentation Requirements

  • Student Name and Signature
  • Tutor Name and Signature

Critical Timing

Complete each section of the checklist at the appropriate time during the appointment, rather than retrospectively at the end of the session, to prevent errors such as extracting teeth already removed decades prior.

Tooth Identification24

Dental panoramic radiograph (OPG) displaying the full dentition with the overlay text “Which tooth?” used for clinical identification practice.

  • Trace the PDL space on radiographs to identify anomalies like ankylosis or hypercementosis before commencing treatment.

Case Study: Communication Breakdown in Treatment Planning

A referral requested extraction of teeth 36 and 37, but clinical review revealed the patient required full mouth clearance. This necessitated extensive consultation with the patient and referrer to align the treatment plan. Always verify referrals against clinical findings as they may underestimate required treatment.

Local Anaesthesia25

Local Anaesthetics

A quick recap…

Local Anaesthetic Considerations

75KG Reference

Dosage Guidelines by Weight26

LA DrugMaximum Dose (mg/kg)Maximum Dose of Anaesthetic (mg) (75kg)Weight of anaesthetic in a 2.2ml carpule (mg)Weight of adrenaline in a 2.2ml carpuleMaximum number of 2.2mL carpules based on LA drug max dose (weight dependant)
Lidocaine 2% (1:80,000)7500 (525mg but absolute max dose 500mg)44mg27.5mcg11.36
Articaine 4% (1:100,000)7500 (525mg but absolute max dose 500mg)88mg22mcg5.68
Bupivicaine 0.5% (1:200,000)2150 (175mg absolute max dose)(comes in 20mL ampoule) – 100mg(comes in 20mL ampoule) - 100mcg30mL (1.5x20mL ampoule)
Mepivicaine 3%Not stated in AUS (Other countries 4.4)Adult: Maximum 6.6ml66mg-3 (absolute maximum for adult)

Manufacturer Guideline Changes

Note: Septodont recently changed UK instructions for Mepivacaine from 6.6 to 4.4 mg/kg without notification, highlighting the importance of checking current local guidelines.

*Stated figures are taken from TGA Therapeutic Guidelines V4 – correct as of January 2026. As per TGA “stated maximums do not take into account vasoconstrictor”.

Common Anaesthetic Agents2728

Lidocaine 2% (20 mg/mL) with Adrenaline 1:80,000 (12.5 micrograms/mL)

  • Maximum mg/kg dose of local anaesthetic: 7 mg/kg
  • Approximate maximum volume for a 70 kg adult: 24.5 mL
  • Approximate maximum volume for a 20 kg child: 7 mL

Mepivacaine 3% (30 mg/mL)

A maximum mg/kg dose is not specified in the Australian product information. The Australian product information specifies:

  • Child 3 to 6 years: maximum 1.8 mL
  • Child 6 to 14 years: maximum 2.7 mL
  • Adolescent 14 to 17 years: maximum 4.4 mL
  • Adult: maximum 6.6 mL

Articaine 4% (40 mg/mL) with Adrenaline 1:100,000 (10 micrograms/mL) or 1:200,000 (5 micrograms/mL)

  • Maximum mg/kg dose of local anaesthetic: 7 mg/kg
  • Approximate maximum volume for a 70 kg adult: 12.25 mL
  • Approximate maximum volume for a 20 kg child: 3.5 mL

*Source: TGA online

Product Information: Lignospan Special (ARTG ID 49328)

  • Sponsor: Specialites Septodont Pty Ltd
  • Ingredients: Adrenaline (epinephrine), lidocaine hydrochloride monohydrate
  • Licence Status: Registered (A)

Qualitative and Quantitative Composition

Component2.2 mL Cartridge1.8 mL Cartridge
Lidocaine hydrochloride monohydrate44 mg36 mg
Adrenaline (epinephrine) (as acid tartrate)27.5 µg22.5 µg
Sodium chloride14.3 mg11.7 mg
Potassium metabisulfite2.64 mg2.16 mg
Disodium edetate0.55 mg0.45 mg
Sodium hydroxide solution(to adjust pH)(to adjust pH)
Water for injection q.s. ad2.2 mL1.8 mL

Clinical Particulars

  • Indications: Production of local anaesthesia in routine dental procedures and oral surgery via infiltration and nerve block techniques. Recommended for oral surgery requiring prolonged duration of anaesthesia and haemostasis.
  • Administration: Use the lowest dosage that results in effective anaesthesia for the planned treatment.
  • Note: For single patient use only. Contains no anti-microbial agent. Discard unused contents.

Clinical Relevance of Dosing29

Clinical Significance of Dosing

  • Generally Not Critical:

    • Routine restorative work usually requires only 1 to 2 carpules.
    • Simple extractions typically require 1 to 2 carpules.

  • Critical Exceptions:

    • Dental Clearances: Extracting multiple teeth in different quadrants (e.g., an upper clearance may require 5+ carpules).

    • Vulnerable Populations: Small patients, frail elderly individuals, or adolescents (e.g., orthodontic extractions).

    • Management: Dosages and timings must be calculated. Consider whether to administer all local anaesthetic at once or in stages.

      • Phase treatment for clearances (e.g., right side then left side) to allow metabolic clearance between quadrants.
      • Consider using Lidocaine rather than Articaine for multiple extractions to preserve “wiggle room” for supplemental injections.

Anatomical Targets for Anaesthesia30

Required Anaesthetic Coverage

To achieve complete anaesthesia for oral surgery, the following must be targeted:

  • The tooth itself
  • The surrounding alveolar bone
  • The circumferential gingival tissues

Common Error

Forgetting palatal/lingual infiltration often results in patient pain despite apparent lip anaesthesia.

Nerve Blocks Required31

Case Example: Removal of Tooth 38

To successfully anaesthetise for the removal of a lower left third molar (38), the following blocks are required:

  • Left Inferior Alveolar Nerve Block (including the Lingual Nerve)
  • Left Long Buccal Nerve Block

Patient Sensation During Extraction323334

Pressure vs. Pain

Local anaesthesia is designed to eliminate pain, but it does not necessarily remove the sensation of pressure during an extraction. It is important to manage patient expectations regarding this distinction.

Troubleshooting Inadequate Anaesthesia

If a patient experiences pain during an extraction, consider the following factors:

  1. Injection Technique:

    • Did the block miss the target (e.g., IANB)?
    • Was it a partial miss (e.g., successful IANB but missed lingual nerve)?

  2. Local Environment:

    • Is the area infected or inflamed? (Lower pH in these tissues can reduce the efficacy of the anaesthetic agent).

  3. Anatomical Variations:

    • Are there accessory innervations (e.g., mylohyoid nerve involvement in lower first molars)?
    • Mylohyoid Supplementation: If suspected, supplement with 0.5 cartridge lingual to the tooth.

It is essential to manage patient expectations regarding what they will feel during a surgical procedure. While local anaesthesia effectively eliminates pain, other physical sensations remain present.

Sensory Perception Under Local Anaesthesia

  • Pain vs. Pressure: Local anaesthetics block the transmission of pain (nociception), but they do not typically block the mechanoreceptors responsible for sensing pressure and movement.
  • Proprioception: Patients will still feel the sensation of the tooth being moved, the pressure applied to the jaw, and the vibration of surgical instruments.

Communication Strategies

  • Pre-operative Warnings: Always inform the patient beforehand that they will feel “pushing, pulling, and pressure.”
  • Distinguishing Sensations: Advise the patient that while pressure is normal, sharp or stinging sensations are not. This helps the clinician determine if additional anaesthesia is required or if the patient is simply reacting to the physical force of the extraction.
  • Reassurance: Constant communication during the procedure helps reduce patient anxiety when they encounter these non-painful but potentially distressing sensations.

Extraction Principles Access3536

Core Philosophy of Surgical Access

In oral surgery, successful extraction often relies on a fundamental principle: make the hole bigger or the tooth smaller.

Core Philosophy

The fundamental principle of exodontia is to make the hole bigger or the tooth smaller, always with the caveat of ensuring minimal trauma to the patient.

Methods for Improving Access

  • Increasing Space (Making the Hole Bigger)

    • Reflecting a mucoperiosteal flap to expose the underlying bone.
    • Strategic removal of alveolar bone (troughing) to create a purchase point or reduce resistance.
      • Simple exodontia: Use forceps to expand the socket (make the hole bigger)
      • Complex exodontia: Use a surgical handpiece to remove bone (make the hole bigger)

  • Reducing Resistance (Making the Tooth Smaller)

    • Sectioning the tooth into individual roots.
    • Removing portions of the crown that impede the path of withdrawal.
      • Complex exodontia: Section the tooth into smaller pieces (make the tooth smaller)

Clinical Application

By applying these principles, the clinician reduces the amount of force required for extraction, thereby minimizing the risk of root fracture or damage to the surrounding alveolar process.

To achieve a successful extraction, the clinician must ensure adequate access to the tooth and its surrounding structures. This involves both visual and physical considerations.

Visual and Physical Access Requirements

  • Direct Visualization: Clear sight of the tooth, the gingival margin, and the surrounding alveolar bone is essential to monitor the progress of the extraction and avoid trauma to adjacent tissues.
  • Instrument Placement: There must be sufficient space to allow for the correct seating of elevators and forceps without interference from lips, cheeks, or neighboring teeth.
  • Light Source: Proper illumination of the oral cavity is mandatory to identify root morphology and any potential complications during the procedure.

Soft Tissue Management

  • Retraction: Use of appropriate retractors (e.g., Austin, Minnesota, or finger retraction) to protect the buccal mucosa and tongue.
  • Flap Reflection: In cases where simple access is insufficient, a surgical flap may be required to expose the underlying bone and root structure.

Patient Positioning

  • Maxillary Extractions: The patient should be reclined so that the maxillary occlusal plane is at an angle of approximately 60 to 90 degrees to the floor.
  • Mandibular Extractions: The patient should be positioned more upright so that the mandibular occlusal plane is parallel to the floor when the mouth is open.

Extraction Mechanics and Principles3738

The fundamental objective of tooth extraction is to either make the hole bigger or the tooth smaller, ensuring the procedure is completed with minimal trauma.

Scope of Current Session

This session focuses exclusively on simple exodontia. More advanced and difficult surgical procedures will be covered in a later session.

Lever and Fulcrum39

Mechanical Advantages of Levers

  • A fulcrum serves as a support at a specific point around which a lever turns.
  • Utilizing a long lever arm provides a significant mechanical advantage.
  • To reduce the amount of force required for extraction, the effort arm must be longer than the resistance arm; increasing this length further diminishes the necessary effort.
  • Cryer elevators utilize this principle by engaging the alveolar bone as a fulcrum to lift retained roots.

Wedge Principle40

Application of Wedge Forces

  • A wedge is designed to overcome a larger resistance at right angles to the applied effort.
  • This principle can be used to displace a tooth occlusally through two primary methods:

Forceps Application

Apical pressure with forceps drives the tooth into the socket to expand the periodontal space, facilitating easier removal.

  • Wedging the instrument along the long axis of the tooth.
  • Delivering consistent apical pressure using forceps.
    • Luxator insertion between the tooth and socket wall creates a wedging force that dilates the socket.
    • When applied successfully, the wedging force often causes the tooth to "pop" from the socket.

Wheel and Axle Principle414243444546

Rotational Force Application

  • In the wheel and axle principle, effort is applied to the circumference of a wheel. This action turns the axle, generating the necessary force to raise a weight.
  • In a clinical context, the tooth (or root) is engaged by the instrument and rotated out of the socket.

The wheel and axle principle is a powerful mechanical advantage used in oral surgery, primarily through the application of specialized elevators. This principle transforms rotational motion into a high-force output to displace a tooth or root from its socket.

Mechanical Application

  • The handle of the instrument serves as the wheel.
  • The shank and working tip of the instrument serve as the axle.
  • A small movement at the circumference of the wheel (the handle) produces a powerful rotational force at the axle (the tip).

Clinical Implementation

  • This principle is most commonly utilized with the Cryer elevator (often referred to as “East-West” elevators).
  • It is specifically designed for the removal of a root when the adjacent socket is empty, providing a space for the root to be displaced into.

Proper Technique for Cryer Elevators

  1. The tip of the elevator is placed into the empty socket of a multi-rooted tooth (typically a mandibular molar).
  2. The point of the elevator is positioned against the remaining root or the interradicular septum.
  3. The handle is rotated, causing the tip to engage the root and elevate it occlusally.

Force Distribution

  • The force is applied perpendicular to the long axis of the root.
  • Because this principle generates significant force, clinicians must exercise extreme caution to avoid fracturing the alveolar bone or damaging adjacent structures.

Risks and Precautions

While the wheel and axle principle is highly effective, its misuse can lead to surgical complications.

  • Excessive Force: The mechanical advantage is so great that the surgeon may not feel the amount of pressure being exerted on the bone.
  • Mandibular Fracture: In cases of dense bone or weakened jaw structures, aggressive use of the wheel and axle motion can lead to a fracture of the mandible.
  • Fulcrum Selection: Never use an adjacent tooth as a fulcrum when applying this principle, as it will likely result in the accidental luxation or extraction of the healthy tooth.

Instrument Design and Variations

  • Cryer Elevators: Feature a triangular blade set at an angle to the shank. They come in pairs (left and right) to accommodate different sides of the mouth and different socket orientations.
  • Crossbar Elevators: These instruments feature a handle perpendicular to the shank, which significantly increases the mechanical advantage of the wheel and axle.

Clinical Warning

Due to the extreme force generated by crossbar handles, many oral surgery programs discourage their use by novice practitioners to prevent avoidable bone trauma.

Summary of Mechanical Advantage

The efficiency of the wheel and axle is determined by the ratio of the radius of the handle to the radius of the axle (the shank/tip).

  • A larger handle diameter increases the mechanical advantage.
  • The surgeon should use controlled, deliberate rotations rather than sudden movements.
  • Always ensure the tip is properly seated in the interradicular space before applying rotational force to ensure the energy is directed toward the root rather than the buccal or lingual cortical plates.

Educational Resource Luxation Technique4748

Video Demonstration

For a visual guide on the proper application of luxation techniques in oral surgery, please refer to the following instructional video:

Instrument Identification

  • ==Luxator: Thin, narrow blade designed to sever periodontal ligament fibers along the long axis of the root. Creates wedging force without adjacent tooth contact.==
  • ==Coupland Chisel/Elevator: Broader tip designed for rotating and lifting; may pressure adjacent teeth.== )

Core Principles of Luxation

Luxation is the process of displacing a tooth from its socket using specific instruments and controlled forces. This technique relies on the mechanical advantage of the elevator to expand the alveolar bone and sever the periodontal ligament attachments.

Mechanical Advantages in Extraction

  1. Lever Principle
  • The elevator acts as a first-class lever.
  • The fulcrum is typically the alveolar bone crest.
  • Force is applied to the handle to move the tooth (the load) in the opposite direction.
  1. Wedge Principle
  • The tip of the elevator is inserted into the periodontal ligament space.
  • As the instrument is advanced, it acts as a wedge, expanding the socket and displacing the tooth occlusally.
  1. Wheel and Axle Principle
  • Rotating the handle of the elevator transmits force through the shank to the blade.
  • This rotational force is used to lift the root out of the socket once sufficient space has been created.
  1. Advantages of Luxators over Elevators
  • No contact with adjacent teeth
  • Less traumatic to bone
  • Reduced post-operative swelling and infection risk

Procedural Steps for Effective Luxation

  • Access and Positioning: Ensure clear visibility and stable finger rests. The non-working hand must support the alveolar process to tactilely monitor the expansion and protect surrounding soft tissues
  • ==Grip and Control: Hold in dominant hand with handle in palm. Beginners should extend the index finger down the shank toward the tip for precise control, while advanced operators may rest the finger on the handle.==
  • ==Insertion: Insert tip into gingival margin, angle along long axis of root, and advance with a gentle rocking motion and apical pressure to sever PDL fibers.==.
  • Initial Purchase: Seat the blade of the elevator into the periodontal ligament space, usually on the mesio-buccal or disto-buccal aspect.
  • Controlled Force Application: Use gentle, repetitive movements. Avoid using adjacent teeth as a fulcrum unless they are also slated for extraction, as this can cause unintended damage or subluxation of healthy teeth.
  • Expansion of the Alveolus: Gradually increase the space by working the instrument around the circumference of the root, focusing on areas with the least resistance.

Safety Considerations

  • Always apply force away from vital structures (e.g., maxillary sinus, mandibular canal).
  • Maintain constant control of the instrument to prevent “slippage,” which could result in soft tissue lacerations or puncture wounds.
  • If the tooth does not yield to moderate pressure, reassess the need for a surgical approach (guttering bone or sectioning the tooth) rather than applying excessive force.

Beginner Safety Critical

==Never luxate palatally or lingually as a beginner. Blood and saliva create slip hazards; uncontrolled instruments can lacerate the palatal artery or penetrate the floor of the mouth. Use only on buccal surfaces until tactile control is developed.==

  • The handles are curved to facilitate better access to the posterior regions of the mouth.
  • The beak profile is similar to anterior forceps but features a slight curvature.

Instrument Identification Upper Forceps4950515253

Anatomy of Forceps

Forceps consist of three primary parts: beaks (the gripping surface), the hinge (pivot point), and the handles (grip). While hinges are generally universal, beaks and handles vary based on the specific tooth and operator handedness.

Upper Straight Forceps Variations

  • Number 29 Upper Straight Forceps: A standard-length instrument designed for the extraction of maxillary anterior teeth.
  • Number 107 Upper Straight (Short) Forceps: A variation of the straight forceps featuring shorter beaks or handles, utilized for specific access requirements in the upper jaw.
  • A stumpy variant of the straight forceps is specifically available for extracting canines.

Universal Upper Forceps (No. 150)

The No. 150 forceps is a versatile instrument designed for the extraction of maxillary teeth. Its design allows it to be used across various quadrants of the upper arch.

  • Primary Application: Extraction of maxillary incisors, canines, and premolars.
  • Design Features:
    • Slightly curved handles for ergonomic grip.
    • Symmetrical beaks that meet at the tips.
    • Beaks are curved to adapt to the convex surfaces of the maxillary tooth roots.
  • Clinical Note: Often referred to as the “Universal Upper” because it can be used for almost any maxillary tooth if necessary, though specialized forceps are often preferred for molars.

Maxillary Anterior Forceps (No. 1)

These forceps are specifically engineered for the single-rooted teeth located in the anterior segment of the maxilla.

  • Primary Application: Maxillary central incisors, lateral incisors, and canines.
  • Design Features:
    • Straight handles and straight beaks.
    • The beaks are non-overlapping and designed to grasp the cervical portion of the root.
    • Provides a direct line of force for rotational movements during extraction.

Maxillary Premolar Forceps (No. 150S)

The 150S is a variation of the universal forceps, scaled specifically for smaller anatomy or pediatric cases, but primarily utilized for premolars in adult patients.

  • Primary Application: Maxillary premolars and occasionally smaller anterior teeth.
  • Design Features:
    • Similar geometry to the No. 150 but with a more compact size.
    • Beaks are designed to fit the narrower dimensions of premolar roots.
    • Provides excellent tactile sensitivity during luxation.

Maxillary Molar Forceps (No. 53R and 53L)

Maxillary molars require paired forceps due to the asymmetrical root anatomy (two buccal roots and one palatal root).

  • Primary Application: Maxillary first and second molars.
  • Design Features:
    • Right (53R): Designed for the upper right quadrant.
    • Left (53L): Designed for the upper left quadrant.
    • Beak Configuration: One beak features a pointed projection (the “horn”) designed to fit into the buccal furcation, while the other beak is smooth and rounded to cradle the single palatal root.
  • Identification Tip: When holding the forceps with the beaks pointing away from you, the pointed “horn” will be on the side corresponding to the buccal surface of the tooth.

Maxillary Third Molar Forceps (Bayonet)

  • ==Bayonet Forceps: Characterized by a severe deviation in the beak angle to provide access to the posterior maxilla (8s).==

  • These are often referred to as "Hawks" due to their beak shape.

  • Key Identification Rule: The projection (pointed beak) must always go toward the cheek (buccal side) to engage the furcation.

  • Note for clinicians: Left-handed variants exist and must be specifically requested if needed.

Instrument Identification Lower Forceps545556

<Figure: Number 73 Lower Molar (Hawks) Forceps showing a full view of the instrument and a close-up of the beak.>

Lower Universal Forceps (No. 151)

The No. 151 is a versatile instrument designed for the extraction of mandibular teeth. Its design features allow for effective engagement of various tooth types in the lower arch.

  • Design Characteristics

    • Beaks are curved downward to allow access to the mandibular teeth.
    • The beaks meet at the tip but have a space between the shanks to prevent crushing the crown.
    • The handles are usually straight or slightly curved to provide a comfortable grip and leverage.

  • Clinical Applications

    • Used primarily for mandibular incisors, canines, and premolars.
    • Can be used for mandibular roots if they are sufficiently supragingival.
    • Often referred to as the “Universal” lower forceps because of its utility across multiple tooth types.
      • Lower Fine Forceps: A smaller variant of the universal design specifically for narrow roots.

Lower Molar Forceps (No. 17 and No. 23)

Mandibular molars require specific forceps designs to accommodate their multi-rooted anatomy, specifically the bifurcation between the mesial and distal roots.

Lower Hawks Forceps

  • Features beaks on both sides (buccal and lingual) to engage both furcations of mandibular molars simultaneously.

  • No. 17 Forceps

    • Designed specifically for mandibular molars with intact crowns.
    • Features pointed beaks that are designed to fit into the bifurcation of the molar roots on both the buccal and lingual sides.
    • The handles are straight, and the beaks are set at an angle to the handle to provide proper mechanical advantage in the posterior mandible.

  • No. 23 Forceps (Cowhorn Forceps)

    • Distinctive sharp, pointed, horn-shaped beaks.
    • Specifically designed for mandibular molars where the furcation is accessible.
    • Mechanism of Action: When the handles are squeezed, the pointed beaks seat into the bifurcation, using the furcation as a fulcrum to “pump” or lift the tooth vertically out of the socket.
    • Care must be taken to avoid damaging the maxillary teeth when the tooth is released from the socket.

Safety Precaution

Never place fingers between forceps handles; shattered teeth or sudden instrument closure can cause severe crush injuries. - Technique: Squeeze handles while rocking buccal-lingual; tips approximate to act as a wedge between furcal bone and root. - Outcome: Often results in a sudden "pop" extraction or may crack the tooth into fragments. - Indication: Best utilized when the furcation is exposed due to bone loss. - Caution: High risk of tooth fracture; requires clinical experience.

Operator Positioning57

Ergonomic Importance

Ergonomic positioning prevents career-limiting musculoskeletal injury and optimizes force transmission.

*Assuming ambidextrous chair is setup.

General Positioning Guidelines58

  • Stand to the dominant hand side and in front of the patient when extracting maxillary and mandibular non-dominant hand teeth.

  • For the mandibular dominant hand side, stand to the dominant hand side.

  • Left-handed operators: For maxillary teeth and mandibular right teeth, stand in front and to the left of the patient. For mandibular left teeth, stand behind and to the left of the patient.

  • Note: Not all practices have ambidextrous chairs; verify equipment capabilities when seeking employment.

Maxillary Teeth Extraction Positioning59

Right-Handed Operator Positioning

  • Operator Standing Position:

    • In front and to the right of the patient.

  • Patient Positioning:

    • Positioned at elbow height.
    • Head tipped 30 degrees up.
      • Operator approaches from the front with direct vision.
      • Non-dominant hand supports the alveolus and provides tactile feedback; assistant can stabilize the head/maxilla.

Mandibular Teeth Extraction Positioning6061

Mandibular Left Teeth (Right-Handed Operator)

  • Operator Standing Position:

    • In front and to the right of the patient.

  • Patient Positioning:

    • Can be positioned a little lower than elbow height.
    • Tipped back slightly more than for maxillary teeth.

Mandibular Right Teeth (Right-Handed Operator)

  • Operator Standing Position:

    • Just behind and to the right of the patient.

  • Patient Positioning:

    • Can be positioned a little lower than elbow height.
    • Tipped back slightly more than for maxillary teeth.

Critical Safety: Mandibular Stabilization

The mandible is free-floating (unlike the maxilla). The non-dominant hand must stabilize the jaw to prevent dislocation, particularly in patients with lax temporomandibular joints. - Request patient tilt chin up for visualization of second molars.

- ==Caution: Requires leaning across patient—maintain proper posture to avoid strain.==

Audio Appendix

Additional Audio Content

The following sections from the lecture audio did not correspond to any heading in the main document.

Post-Extraction Assessment and Immediate Management

Following extraction, systematic assessment of both the extracted tooth and socket is mandatory:

Tooth Assessment:

  • Verify root apices are intact
  • If fractured, estimate remaining root length to determine retrieval necessity

Socket Assessment:

  • Oroantral Communication: Look for bubbling, air movement, or “big black hole.” Small perforations on the buccal wall of palatal root sockets may be subtle and require good illumination.
  • Soft tissue trauma: Check for crushed or torn mucosa engaged by forceps (particularly lingual/palatal surfaces)
  • Alveolar bone: Identify loose bone fragments; stabilize with sutures if necessary
  • Tooth fragments: Check socket rim for retained fragments (commonly disto-lingual corners) attached to gingiva; remove with spoon curette
  • Haemostasis: Assess bleeding intensity (normal oozing vs. torrential hemorrhage indicating arterial damage)

Post-Operative Instructions

Provide both written instructions and verbal explanation tailored to the individual patient.

Immediate Care:

  • Bleeding: Small amounts normal; swallow blood rather than spitting
  • Gauze protocol: Ice-cold water on sterile gauze, roll up for small gaps, place directly on socket, bite with pressure for 20 minutes (30–45 minutes if anticoagulated). No talking or physical exertion during pressure application.
  • Escalation: If bleeding continues, replace with fresh gauze for 45 minutes, then 1 hour. If persistent, seek emergency care.

Pain Management:

  • Anaesthetic wears off within hours; expect soreness
  • Regular paracetamol and ibuprofen (if no contraindications) taken prophylactically
  • Pain peaks at 3–5 days then improves; worsening pain after initial improvement suggests infection or dry socket

Wound Care:

  • No rinsing today; warm salt water rinses from tomorrow
  • If sutures placed: dissolvable type (2–3 weeks), may fall out sooner, brush away if dangly
  • Dispose of bloody gauze in plastic bag then bin

Smoking Cessation:

  • Avoid physical smoking process for several days (use nicotine patches instead) to reduce dry socket risk

Emergency Contacts:

  • Provide specific contact hours and after-hours facilities

Emergency Management in the Extraction Clinic

Most Common Emergency: Vasovagal syncope (fainting)

Recognition:

  • Patient reports feeling dizzy, faint, or unwell
  • Lips turn blue (cyanosis)
  • Sudden loss of consciousness may occur mid-sentence

Immediate Management:

  1. Chair position: Whack chair fully back (beyond 90 degrees if necessary) to get head lower than heart
  2. Protection: Prevent sliding (friction of clothing usually sufficient); protect arms from chair mechanisms if jerking occurs
  3. Summon help: Send for tutor immediately
  4. Recovery: Once consciousness returns, maintain 45-degree elevation, provide sugary drink (lemon effervescent electrolyte) or jelly beans via saliva ejector straw
  5. Monitoring: Do not sit patient fully upright immediately (risk of recurrent syncope)

Other Emergencies:

  • Palpitations: Get tutor immediately (may be adrenaline-related)
  • Hyperglycemia: Schedule diabetic patients early morning; ensure they’ve eaten
  • Asthma: Know location of Ventolin inhaler
  • Seizures/Cardiac/Stroke: Follow emergency protocols; summon help immediately

Case Study: Vasovagal Syncope in a Young Patient

A 20-year-old nursing student received an inferior alveolar nerve block and buccal infiltrations for restorative work. She stated, “I don’t feel good, I think I’m going to faint.” Despite the clinician placing the syringe down, she lost consciousness within seconds, arms flopping, followed by small tonic-clonic movements (not a full seizure).

Management: Chair immediately tipped back, arms protected from chair mechanics, cold compress applied to forehead. Recovery was rapid with reperfusion. Patient was embarrassed but opted to continue treatment rather than return for re-injection. The episode illustrates the importance of watching patients closely after local anaesthetic administration, as syncope can occur without warning even in young, healthy individuals.

Additional Safety Notes:

  • Magnification: Do not use loupes initially for extractions; binocular vision difficulties may increase risk of patient injury. Introduce magnification only after developing basic tactile skills.
  • Documentation: Discuss with supervising tutor whether specific incidents require formal reporting.

Footnotes

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