Working with minor oral surgery, like tooth extractions and surgical flap creation, is often a daily bread-and-butter procedure in many dental clinics. And while we perform these tasks almost every day, the devil, as they say, is always in the details. A tiny mistake—perhaps an incorrect chair adjustment or an ill-calculated incision with a scalpel—can quickly transform a seemingly simple procedure into a complication or issue that we could absolutely do without.
That’s precisely why we’ve compiled 10 golden tips and crucial insights for you in this article. Consider it a quick checklist, a timely reminder of those fundamental principles that truly differentiate “good” work from “ideal” work in extractions and flap procedures.
1. Proper Patient Positioning: Get That Chair Right
Before you even pick up an instrument, the very first thing you need to perfect is the patient’s position in the dental chair. Correct positioning doesn’t just grant you better visibility; it also allows you to leverage your body’s strength efficiently, saving your back from unnecessary strain.
When Working on Lower Teeth (Mandibular):
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Ensure the mandibular occlusal plane is parallel to the floor.
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Crucially, the mandible itself should be at or slightly below your (the doctor’s) elbow level. This ergonomic setup enables you to effectively utilize your arm and shoulder strength during extraction, rather than relying solely on finger pressure.
When Working on Upper Teeth (Maxillary):
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Recline the chair so the maxilla forms an approximate 45-degree angle with the floor.
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The maxillary level should ideally be higher than your elbow, ensuring direct and clear visibility.
2. Your Stance Matters Too (Operator’s Position)
It’s not just about positioning the patient; your own stance is equally critical.
The general rule dictates that for most extractions, you’ll position yourself in front of the patient. The single exception to this is when extracting lower right molars. For these specific cases, the ideal position for you is to stand behind the patient, roughly at the 11 o’clock position. This stance provides superior visibility and significantly greater control over your forceps.
3. Upper Molar Forceps: The Only “Right and Left” Pair
Almost all the forceps we commonly use are ambidextrous – they work equally well for both sides. However, there’s one notable exception: the Upper Molar Forceps. This is the only pair designed with a distinct configuration for the right side and a separate one for the left.
Why is this the case? Because the beak designed to go towards the palate is typically smooth, while the beak intended for the buccal side features a pointed projection. This projection is designed to fit precisely between the buccal roots. Using the incorrect side will prevent the forceps from achieving a secure grip on the molar.
4. Upper 8th Molar Extraction: Different Tools for Different Tasks
The upper 8th molar (wisdom tooth) is often a special case. You might use the standard Upper Molar Forceps for it, or alternatively, a different, somewhat curved scissor-like forceps known as the Jockey Forceps or Bayonet forceps.
When to use the standard Upper Molar Forceps? If the wisdom tooth is well-erupted, has a large crown, and its roots are clearly divergent.
When to opt for the Jockey Forceps? If the tooth has a small crown, or its roots are fused and exhibit a conical shape, or if the access is simply too restricted for the standard forceps.
5. Upper Canine Extraction: The King of Long Roots
The upper canine is renowned for its exceptionally long and robust root. You can choose to extract it using straight Upper Anterior Forceps, or you might prefer the Upper Premolar Forceps, which feature a slight curvature. The choice here is entirely yours, depending on what feels most comfortable and provides you with the easiest access to the tooth.
6. Post-Extraction Bleeding: Reassure Your Patient
This is often the primary concern for patients after an extraction. It’s crucial to help them understand what’s normal and what’s not. The key message you absolutely must convey is: “It’s perfectly normal, madam/sir, to have a metallic, bloody taste in your mouth for up to 24 hours. This is typically minor bleeding mixed with saliva. The important thing is that there shouldn’t be overt, frank bleeding. Therefore, it’s strictly prohibited to rinse or spit forcefully today, as this could dislodge the protective blood clot that covers the wound.”
7. The Secret to Flap Success: Stick to the Bone (Sub-periosteal Elevation)
When creating a surgical flap, especially a full-thickness flap, your objective isn’t merely to lift the gingiva.
The Correct Technique: As you elevate the flap with a periosteal elevator, ensure your instrument stays firmly against the bone. Your goal is to lift both the gingiva and the periosteum as a single, intact layer. Why? Because the periosteum is essentially the “healing factory”—it’s incredibly rich in blood vessels and cells that are vital for efficient wound healing. When you preserve it intact and meticulously reposition it, healing is significantly faster and far superior (1).
8. Red Lines for Mandibular Flaps (Critical Considerations)
The mandible is rich with crucial nerves and blood vessels that demand your careful attention.
Lingual Side: Absolutely avoid inserting a bur or any sharp instrument towards the lingual aspect, especially in the molar region. Always leave approximately 1 mm of intact lingual plate bone as a safety barrier to protect the vital lingual nerve. Injury to this nerve is a significant complication.
Premolar Region: Completely avoid making any vertical incisions in this area. Why? To prevent severing the mental nerve, which exits from the mental foramen. If a vertical incision is necessary, place it either anterior to the canine region or far posterior, beyond the premolars.
Around the 7th Molar: Be extremely mindful when raising a flap in this area, as the facial artery and vein traverse through the vestibule. Any laceration to these vessels could lead to severe hemorrhage.
9. Red Lines for Palatal Flaps (Palatal Flap Considerations)
Surgical work on the palate is exceptionally sensitive due to the presence of large nerves and blood vessels.
The Golden Rule: Any incision on the palate must be a horizontal incision, running parallel to the teeth, such as a gingival crest incision or a sulcular incision. Absolutely avoid vertical incisions to prevent severing the Greater Palatine Nerve Bundle, which runs longitudinally, or the Nasopalatine Nerve Bundle, which exits from behind the incisors. Lacerating these nerve bundles can result in severe bleeding and permanent loss of sensation (2).
10. Suturing: Knot Placement Matters (Infection Prevention)
You’ve sutured the wound? Excellent. But there’s one small, yet crucial, detail that makes a significant difference in preventing infection.
The Correct Placement: Always position the suture knot laterally—for instance, towards the buccal side—and never directly over the incision line. Why is this important? Because the knot provides an ideal nidus for the accumulation of food debris and bacteria. By keeping it away from the open wound, you substantially reduce the risk of infection and make it easier for the patient to maintain oral hygiene.
