• Perineural nerve blocks (dental blocks)

• Adequate sedation

• Molar spreaders (in various degrees of angulation)

• Molar extraction forceps

• Variety of fulcrums

• Anesthetic agent: Lidocaine 2%, mepivacaine 2%, or bupivacaine 0.75%

• Inadvertent removal of the incorrect tooth

• Fracturing the tooth such that intraoral extraction becomes impossible

• Inadvertently leaving dental fragments within the alveolus, which could subsequently sequester

• Sedate sufficiently to allow perineural analgesia.

• Additional sedation may be necessary.

• Place the full-mouth speculum and light source such that the tooth to be removed can be adequately visualized.

• Apply the molar spreaders to the interdental space caudal to the affected tooth. Slowly apply force to drive the wedges together. NOTE: This takes time and should not be rushed. The handles of the instrument can be taped together to reduce operator fatigue. This stage can take up to 20 minutes or longer (Figure 1).

• Apply the molar spreaders to the interdental space rostral to the affected tooth. Use the same technique as above.

• Elevate the gingiva on all sides of the tooth (Figure 2).

• DO NOT APPLY MOLAR FORCEPS UNTIL THE TOOTH IS DEMONSTRABLY LOOSE. At this stage, the alveolus will be bleeding readily and “squishing” sounds can be heard when the tooth is manually grasped and rocked.

• Apply molar extraction forceps (Figure 3). Insert fulcrum to allow the handles of the instrument to be moved toward the occlusal surface of the tooth. DO NOT ROCK THE INSTRUMENT IN A DORSOVENTRAL DIRECTION. If molar forceps application has occurred at the correct time, pressure against the fulcrum will result in elevation of the tooth from the alveolus as a single, intact unit. (Figure 4).

• Remove from the mouth and check that the specimen is intact.

• Check the alveolus manually and radiographically for retained fragments.

• Pack alveolus if necessary. A variety of products are available, such as iodine-soaked gauze and plaster of Paris. The author currently recommends a Silastic pack (Splash Putty Pak, regular putty, firm setting (European distributor: EMDAR BV, El Arnhem, The Netherlands; North American distributor: Discus Dental Inc., Culver City, CA).