1. Cut the gingival attachment around the whole circumference of the tooth using either a No. 11 or 15 scalpel blade in a handle or a sharp luxator (Fig. 13.2).

2. Select a luxator of the appropriate size. Its concave surface should equal the curvature of the root being extracted. This is often a larger size than initially estimated. The instrument is held with the handle along the palm of the hand and the index finger resting on the shaft, with the tip of the finger close to the cutting end (Fig. 13.3). The fingertip functions as an emergency stop should you slip, thereby avoiding iatrogenic damage to surrounding structures. With an average-sized hand, this will leave the end of the handle resting against the wrist, where it can be gripped with the other fingers. This grip prevents the excessive force which can be applied if the handle end rests in the center of the palm, forming a straight line of force from the elbow!

3. The luxator is advanced into the gingival sulcus at a slight angle to the tooth, i.e. following the surface of the tooth, and pressed into the periodontal ligament space (Fig. 13.4). If the luxator is not inserted into the gingival sulcus in the described fashion, it is likely to slide over the margin of the alveolar bone and raise the gingiva off the bone. This will lacerate the gingiva rather than break periodontal ligament fibers!

4. The luxator is worked, applying gentle apical pressure, into the periodontal ligament space around the whole circumference of the tooth (Fig. 13.5). The sharp luxator will cut the periodontal ligament fibers. Once sufficient space has been created between the tooth and the alveolar bone, an elevator can be used. Some clinicians prefer to perform the whole extraction using luxators of increasing size, i.e. do not switch to elevators. This is acceptable procedure as long as the luxators are used in the correct fashion, i.e. in an apical direction, without rotation, to cut the periodontal ligament fibers. Luxators should not be rotated, as this will damage the fine end of the instrument.

5. The elevator (gripped in the hand in the same way as a luxator) is also worked circumferentially around the tooth, with a steady gentle rotational pressure held at each point for 10–15 s to fatigue the deeper periodontal fibers. Hemorrhage will be created at the same time, which adds hydraulic pressure to the process of breaking down the fibers. The other hand should be used to support the jaw and prevent any undue stress on the jawbone. In addition, the thumb and index finger of the other hand should be placed on the buccal and palatal/lingual aspect of the tooth root (around the alveolus of the tooth). This will allow tactile feedback as well as minimize iatrogenic damage should slippage occur with the elevator. As the periodontal ligament fibers break and the tooth begins to loosen, the elevator can be pushed further apically, and rotated more. It is essential to work around the whole circumference of the tooth. It is tempting to concentrate elevation at the points where the tooth is most mobile. The opposite should be performed, i.e. the elevator should be worked more in positions where the tooth is least mobile. When the tooth is loose in its socket, it is tempting to use extra force to speed up the extraction. Try to avoid this, as it usually results in fracture of the root, which then needs to be retrieved.

6. When the tooth is loose, it can be drawn out of the socket with fingers or forceps. In my experience, the use of dental forceps usually results in fracture of the apical portion of the root. I do not use them or recommend their use. However, if they are used, make sure that the forceps are applied as far apically as possible on the root and use gentle rotational force applied in a back and forth manner along the long axis of the tooth.

1. Cut the gingival attachment around the whole circumference of the tooth using either a No. 11 or 15 scalpel blade in a handle (Fig. 13.2B) or a sharp Extraktor (Fig. 13.2C).

2. Amputate the tooth crown at the cemento-enamel junction.

3. Select an Extraktor of the appropriate size. Its concave surface should equal the curvature of the mesial and distal surface of the root being extracted. This is often a larger size than initially estimated. The instrument is held in the same way as a luxator or elevator (Fig. 13.3).

4. The Extraktor is advanced into the gingival sulcus at a slight angle to the tooth, i.e. following the surface of the tooth, and pressed into the periodontal ligament space (Fig. 13.4).

5. The Extraktor is worked, applying gentle apical pressure, into the periodontal ligament space at the mesial and distal surfaces of the tooth root (Fig. 13.5). The instrument is also encouraged to slide buccally and palatally/lingually (Fig. 13.6) to cut periodontal ligament fibers around the whole circumference of the tooth. The spoon-shaped Extraktor is sharp at its apical termination but also on part of its lateral wings and will thus readily slide bucally and palatally/lingually. Extraktors are also of sufficient metal thickness to allow some rotation (unlike luxators).

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