Tooth extraction, or dental extraction, is arguably one of the most common procedures we perform in our clinics. We all learned the “Five Basic Movements” for extractions back in dental school, and we tend to apply them almost automatically. But have you ever stopped to ask yourself if these five movements truly represent the correct protocol for every tooth in every patient’s mouth?
The honest answer is: no, not always.
There are significant exceptions and subtle nuances that, if overlooked, can transform what should be a simple extraction into a grueling battle involving fractured bone and roots. Conversely, mastering these insights will enable you to extract even the most challenging cases with an unexpected ease and fluidity.
In this article, we’re going to revisit the five fundamental movements, and more importantly, we’ll unveil five core exceptions that will fundamentally shift your perspective and approach when you’re holding the forceps.
Firstly: The Fundamentals – The Five Movements We All Know by Heart
Before we delve into the exceptions, let’s quickly review the five classic movements we learn to expand the tooth socket and sever the periodontal ligament fibers:
1. Apical Pressure:
This is the first and most critical movement. After achieving a firm grip on the tooth with the forceps, your immediate action is to apply pressure towards the root apex. This maneuver shifts the tooth’s center of rotation to the furthest possible point, which significantly reduces the risk of root fracture and aids in expanding the surrounding bone.
2. Buccal Movement:
The second movement involves slowly and steadily moving the tooth towards the cheek (buccally). The secret here is to sustain the pressure for a few seconds once you reach the maximum range of motion. This sustained pressure is what truly facilitates the genuine expansion of the buccal plate of bone.
3. Lingual/Palatal Movement:
Following the buccal movement, you then slowly and steadily shift the tooth in the opposite direction, either lingually (towards the tongue) or palatally (towards the palate). Again, upon reaching the maximum range of motion, maintain the pressure for a few seconds.
4. Rotation:
This movement involves gently rotating the tooth around its long axis.
5. Delivery:
Once you perceive that the tooth has become easily mobile, gently withdraw it from its socket, typically in a buccal direction.
Great. That’s the theoretical knowledge we’re all familiar with. But where does the practical wisdom and crucial nuances come in?
Secondly: The Exceptions That Distinguish a Skilled Clinician
Not every tooth should be extracted using the same sequence or movements. There are specific scenarios where rigidly applying the standard five movements will inevitably lead to tooth fracture or a protracted, difficult extraction.
Exception 1: Lower Molars
The Challenge: When attempting to extract a lower molar, especially the first or second molar, initiating with a buccal movement as your primary action will often encounter fierce resistance. Why? Because you’re directly pushing against a remarkably thick bone structure known as the External Oblique Ridge. Your attempts to force the tooth in this direction can cause severe pain for the patient or even fracture the buccal plate.
The Correct Solution: For lower molars, reverse the rule! Begin with the lingual movement first. The lingual plate of bone is typically thinner and weaker, allowing the tooth to mobilize more easily in that direction. By first expanding the socket from the lingingual aspect, the subsequent buccal movement becomes considerably easier (1).
Exception 2: Single Conical Roots
Who Are They? Some teeth possess a root morphology that feels like a gift from above: a single, straight, conical-shaped root. The most common examples include the upper central incisor and the lower second premolar.
The Challenge: If you attempt to apply buccal and lingual movements to these teeth, you’re subjecting the root to unnecessary lateral stress that could easily fracture it, particularly if it’s slender.
The Correct Solution: These teeth don’t require all five movements. Three movements are often perfectly sufficient:
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Apical pressure to ensure a secure grip.
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Continuous, gentle rotation, alternating between clockwise and counter-clockwise. This rotational motion alone is often sufficient to sever all PDL fibers surrounding this conical root and expand the socket.
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Delivery of the tooth.
Simply put: conical root = rotation, not buccal/lingual (2).
Exception 3: Supernumerary Teeth
The Challenge: Supernumerary teeth, like a mesiodens, often possess unpredictable root morphology, but in most cases, their roots are short and conical.
The Correct Solution: Treat them exactly like single conical-rooted teeth. Just three movements: apical pressure, rotation, and delivery. Attempting buccal/lingual movements can easily fracture these short roots or cause them to “spin uselessly” within the socket.
Exception 4: Long-Standing Remaining Roots
The Challenge: Occasionally, you’ll encounter a root remnant from a previous extraction that has been lodged in the bone for months or even years.
The Correct Solution: This might be one of the easiest cases you’ll face. Over time, bone resorption naturally occurs around these roots, and the PDL space often widens. You’ll frequently find that you need nothing more than three movements—apical pressure, rotation, and delivery—to retrieve them. In many instances, a simple rotational movement alone is enough to dislodge them with minimal effort.
Exception 5: Buccally or Lingually Inclined Teeth
The Challenge: Occasionally, a tooth presents with a severe buccal or lingual inclination. If you attempt to apply traditional movements, particularly in the direction opposite to the inclination, the axis of movement will be highly unconventional. This could lead to collision with adjacent teeth or even fracture of the alveolar plate.
The Correct Solution: In these situations, always consider the “path of withdrawal.”
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If the tooth is buccally inclined: Most of your movement should also be in the buccal direction, perhaps with gentle rotation. You’re essentially extracting it along its natural path of inclination.
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If the tooth is lingually inclined: Then most of your movement should be in the lingual direction.
In essence, you simplify the movement, often focusing on a single primary direction combined with rotation, to avoid undue stress on adjacent teeth (3).
Conclusion: Extraction is an Art, Not Just Brute Force
The five primary movements for extraction form the indispensable foundation that every practitioner must master. However, the truly skilled clinician understands precisely when to intelligently deviate from these standard rules. Before you even grasp the forceps, meticulously examine the radiographs. Observe the root morphology, the tooth’s position within the jaw, and thoughtfully consider: what is the easiest and safest path for this tooth to exit its socket?
When you adopt this thoughtful approach and recall the five critical exceptions we’ve discussed, you’ll discover that extractions transform into a procedure that is notably easier, faster, and significantly safer for both you and your patient.
