Simple extractions are so called because the tooth or root is removed whole from the dental arch without involving tooth sectioning, flap raising or bone removal. Any or all of these additional techniques may be required during a surgical extraction. Whether the tooth is still vital or has died from any associated infection, local anaesthesia will always be required to numb the surrounding gingivae at least, even for a simple extraction.
The specific instruments, equipment and medicaments that may be required for a simple extraction are shown in Table 17.1.
Forceps are the instruments most frequently used to extract a tooth, and are handled by being pushed along the sides of the root to sever the periodontal membrane. Once a reasonable position has been achieved, the root is gripped and gentle wrist movements are employed to gradually loosen the tooth in the socket. The forceps are gradually worked further towards the apex of the tooth until it is loose enough in the socket to be removed. In effect, then, a tooth is actually extracted by being pushed out of the socket, rather than being pulled out of it, as most people would assume.
Table 17.1 Specific instruments, equipment and medicaments that may be required for a simple extraction
Item Function
Forceps Range of sterile hand instruments used to grip a tooth or root at its neck before applying appropriate wrist actions to loosen the tooth/
root in its socket during the extraction procedure. Various designs are available for use on upper or lower teeth, and for each individual tooth Luxators Sterile hand instruments used to widen the socket and sever the
periodontal ligament attachment
Elevators Sterile hand instruments used to prise the tooth/root out of the socket. Various patterns are available – Cryer’s, Warwick James’, Winter’s
Fine-bore aspirator Disposable suction tip used to suck away all blood and maintain good moisture control during the procedure; also useful for sucking and holding tooth debris so that it can be removed from the mouth safely Haemostats Gelatine sponges or oxidised cellulose packs, which are inserted
into the socket after extraction to aid blood clotting and achieve haemostasis – can be used with or without a suture
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Unnecessary force during extractions often results in tooth or root fracture, although this can also occur anyway with grossly carious teeth.
Forceps are designed in various patterns, to be used individually for each type of tooth. Upper tooth forceps tend to have their handles and blades roughly in line with each other, whereas lower tooth forceps tend to be at right angles to each other for ease of access to the lower arch (Figure 17.1).
Multi-rooted molar tooth forceps have blades which are shaped like beaks so that they can grip the furcation area between the roots, but single-rooted tooth forceps are smooth (Figure 17.2).
The most common patterns of forceps are shown in Figure 17.3.
•
Upper incisor and canine forceps are straight with single rounded blades and have both wide and narrow patterns.•
Upper root forceps are similar in appearance, with narrow, straight blades.•
Upper premolar forceps have slightly curved handles and single rounded blades.•
Upper left molar forceps have curved handles and a beaked blade to the right of the instrument, and a rounded blade to the left to grip the buccal roots and the palatal root respectively (many dental nurses identify upper molar forceps by the mantra ‘beak to cheek’).Upper pattern, with handles and blades in line
Lower pattern, with blades at right angles to handles Cross-hatching on handles
allows a firm grip
Figure 17.1 Upper and lower pattern of forceps.
Beaked blade for multi-rooted teeth
Smooth blade for single rooted teeth
Figure 17.2 Blade detail of forceps.
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•
Upper right molar forceps have curved handles and the beaked blade is to the left of the instrument.•
Upper bayonet forceps have extended handles and angled blades to gain access to third molars, or have angled pointed blades to gain access to fractured roots.•
Lower anterior forceps have single, rounded blades at right angles to the handle that are particularly useful for extracting lower premolars.•
Lower root forceps are similar, with narrow and straight blades that are also particularly useful for extracting small or crowded incisors.•
Lower molar forceps have beaked blades at right angles to the handles, to grip the furcation of the two roots.•
Lower ‘cowhorn’ forceps have curved and pointed blades at right angles to the handles, to grip the furcation of lower molar teeth.•
Smaller versions of most patterns exist, for deciduous tooth extractions.Similarly, elevators are available in a variety of patterns and are used to gradually sever the periodontal membrane and loosen the tooth in the socket (Figure 17.4). They are specifically used to elevate retained roots and impacted teeth, where adequate access to the root or tooth is not possible with conventional forceps, or where the angle of elevation required to loosen the root or tooth is not possible with forceps.
(a) (b)
(c)
Figure 17.3 Extraction forceps. (a) Upper straight, root, premolar. (b) Upper left and right molar, bayonets. (c) Lower anterior, root, molar, cowhorns.
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The more common types are as follows.
•
Cryer’s elevators are available as left and right patterns, but can be used on either side of the mouth, depending whether they are engaged mesially or distally – the tips are triangular shaped and pointed.•
Winter’s elevators have a similar blade design as Cryer’s, but have a corkscrew style handle to give more leverage.•
Warwick James’ elevators are available as left, right and straight patterns – the tips are a similar shape to the round blade of forceps.Alternatively, the dentist may choose to use one of a variety of luxators (Figure 17.5) that are available and are used in a similar fashion to an elevator but with greater effect, as the tips are sharper and finer
Cryer’s elevator
Winter’s elevator
Warwick James’ elevator
Figure 17.4 Types of elevators.
Figure 17.5 Luxator.
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and therefore more easily pushed into the periodontal space between the root and the bony socket.
It is possible to extract practically any tooth using a luxator alone, and many dentists are able to do so.
A single-bladed chisel is also available for splitting multi-rooted teeth, called a Coupland’s chisel and available in sizes 1, 2 and 3 (Figure 17.6).
Difficult extractions can be quite exhausting for the dentist and the patient, and it often helps both for the dental nurse to actually support the patient’s head or mandible during the extraction. In this way, the dentist is not wasting energy by rocking the patient’s head rather than loosening the tooth, and it also allows the patient to relax more, rather than trying to hold their head still for the dentist.
Upon removal of the tooth, the dentist squeezes the socket walls together, places a bite pack over the socket, and instructs the patient to bite on it for 10 min to help to achieve haemostasis (stop the bleeding). After treatment, the patient is not dismissed until the bleeding has ceased and postoperative advice has been given. A suitable bite pack can be made from a cotton wool roll and gauze sheets, as shown in Figure 17.7.
Figure 17.6 Coupland’s chisels – sizes 1, 2, 3.
Figure 17.7 Bite pack construction.
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Role of the dental nurse during the procedure
The dental nurse should have a full working knowledge of each instrument likely to be used, including the full range of forceps available, to ensure the ability to provide close support and assistance to the dental team during the procedure.
Each instrument will be sterile and bagged, and should be carefully opened without touching it and then handed to the dentist handles first, while holding the tips still within the sterile pouch – this is the ‘no-touch’ technique (Figure 17.8). In this way, infection control is maintained.
As with any dental procedure, all the required instruments and equipment will have been made ready before the procedure begins and laid out in their bags, close to the dental chair for easy access but not in full view of the patient – this is likely to increase their anxiety.
The dental nurse will anticipate the dentist with regard to the instruments required and their order of need, and safely pass them as required using the ‘no-touch’ technique described above.
Throughout the procedure, the dental nurse will monitor the patient for any signs of distress (such as feeling pain) and notify the dentist accordingly. A calm, reassuring manner is required to put the patient at their ease and this must be adapted for the various types of patient that may be treated – whether a child, an adult or elderly person, or a patient with special needs. When treating patients from different ethnic backgrounds, it is very useful to have a friend or family member present to interpret as necessary.
As the forceps, luxators and elevators used have to be pushed into the tooth socket, the dental nurse may also be required to stabilise the patient’s head or mandible so that the dentist’s efforts are not wasted. The purpose of the support should be briefly explained to the patient beforehand.
Surgical field considerations
Whichever technique is used to extract a tooth or root, the procedure is considered a surgical one, as bleeding will definitely occur and the tissues of the patient’s oral cavity will be breached by the instruments used. If the working area is not treated as a sterile field during the procedure, there is a potential risk of cross-infection occurring and this is more likely with oral surgery procedures than with any other in dentistry.
Figure 17.8 No-touch technique of passing forceps.
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Consequently, the following special precautions are taken.
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Sterile bagged instruments – all instruments to be used must have been individually sterilised and bagged before the procedure, unlike restorative instruments that are bagged together.•
PPE for the dental team – over and above the usual PPE requirements for dental procedures, surgical gowns or single-use plastic aprons should be used to prevent blood contamination of the uniform.•
Disposable items – wherever possible, disposable items should be used to prevent cross- infection, including aspirators, scalpel blades, needles, suture needles, etc.•
Contamination policy – any single-use items and materials that are opened but not used during the procedure should be disposed of anyway, to avoid their possible contamination and then spread of infection by resealing and using at a later date.•
Suction equipment – must be run through immediately after the procedure with the required disinfectant solution to remove all traces of blood from its inner workings, rather than at the end of the session as usual.•
Operative field – should be assumed to be blood contaminated and wiped down thoroughly with sodium hypochlorite (bleach) or another accepted decontaminant.•
Equipment coverage – items such as the dental chair will obviously be reused and are not ster- ilisable, so they must be covered before the procedure with a single-use impervious membrane, to prevent blood contamination.•
Sterile field – the oral cavity and its immediate vicinity will be regarded as a sterile field during the procedure, and any team member who is not wearing suitable PPE should not enter it nor pass instruments into it without using a ‘no-touch’ technique.The aspects of infection control and Health and Safety that are relevant to these procedures, especially cleaning methods, infection control and sterilisation, are fully discussed in Chapters 4 and 8. They are summarised below.
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All sharps are carefully disposed of in the sharps box – this includes local anaesthetic needles.•
All autoclavable items are placed in a washer-disinfector unit or an ultrasonic bath, and decontaminated thoroughly before being placed in the autoclave for sterilisation.•
All contaminated waste is placed in hazardous waste sacks – this includes all the impervious covers used as barriers on equipment items.•
All surfaces are disinfected using the correct solution.Pre- and postoperative instructions
Often, the patient will request information regarding the procedure itself in advance, and the dental nurse is ideally suited to allay their fears by giving advice beforehand as follows.
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Local anaesthesia will always be necessary for an extraction.•
The procedure will not be painful, as adequate local anaesthesia will be given.•
If a surgical procedure is being undertaken, sutures will be necessary.•
Patient must take all medication as normal before the procedure unless the dentist informs them otherwise, except for aspirin which prevents blood clotting and could cause postoperative bleeding.•
Patient must have a light snack 2 h before the procedure, to avoid fainting.•
Full postoperative instructions will be given in writing, so the patient does not have to remember them.•
If the patient is a nervous adult or child, they should be escorted by a reassuring and competent adult.539
After the procedure a full list of postoperative instructions should be given verbally and in writing (Figure 17.9). It is important that the patient understands that most postoperative complications occur because of disturbance to the blood clot which forms in the area, and that they should avoid this happening wherever possible. Postoperative instructions should include the following points.