This is the story of the only time that I, Dr David Chen, failed to extract a tooth. It happened during my first job in private practice shortly after I finished my general practice residency. I was working up in Scarsdale, NY and it’s been years since then but I still remember it vividly.
Now let me tell you what happened.
The story
The patient had gross caries (severe tooth decay) on tooth #6 which was his upper right canine. The tooth was deemed to be non-restorable which meant that we cannot save it. Doing a perfect filling, crown, and root canal wouldn’t even make a difference.
The only option left was a tooth extraction, which surgically removes the tooth from the mouth. Afterwards he would need to replace the tooth with either a bridge or an implant.
The extraction
As usual, I followed my protocol for taking out a tooth. I proceeded to apply the numbing gel (benzocaine) to the injection site and waited 2 minutes for the onset. Then I loaded up the syringe with 2% lidocaine with 1:100k epinephrine and gave the patient two carpules of it. After about 3-5 minutes the patient was thoroughly numb and I could proceed to the removal process.
The first thing I had to do was to release the periodontal ligament fibers (PDL) with a periosteal elevator. This is a sharp instrument which cuts and severs the PDL so that the tooth is no longer anchored to the gums.
The second step was to elevate the tooth with a 301 elevator. This instrument looks similar to a flat screwdriver except the tip is slightly curved in a c-shape. You use it to elevate the tooth and loosen it via luxation.
Under normal circumstances, after about 5 minutes of working the tooth with an elevator you should see movement. The tooth should be loosen and have some give to it. Once it is loose enough, you can grab it with some forceps to deliver the tooth.
Unfortunately in this situation, the tooth was still not loose even after 10 minutes of elevating with the elevator. At that point I tried to grab it with the forceps and twist it out but it would not budge at all. This canine was in there rock solid.
The bailout
It didn’t look like the tooth wanted to come out at all so I had no choice but to call for help. I had to run into the next room and ask my boss for help. He comes in and starts drilling away some of the bone that was surrounding the tooth and encasing it. It took him about 10 minutes after that for the tooth to be extracted.
Thankfully the situation was resolved but it was a defeat on my end. The good news was that mistakes and failures are good catalysts for learning. It led to me reflect on why I did not succeed and what I could do better next time.
The hardest tooth to extract
In my opinion, the canine is the most difficult tooth to extract. This statement does not merely come from that one isolated scenario of failing to take out the tooth. In fact, I’ve had to extract many more canines after that day. Luckily, I was able to complete the procedure successfully.
However, every single one of those canine extractions were extremely difficult. They were all more difficult than any other teeth that I had to remove. This is in comparison to the incisors, premolars, molars, and even some wisdom teeth! I often found myself struggling and taking more time to extract canines than any other teeth.
It wasn’t as if I was bad at tooth extractions but it had more to do with the anatomy of a canine tooth. That tooth is just inherently harder to take out and here are the reasons why.
- Has the longest root. Canines have the longest roots in the mouth. The length of this tooth is a lot longer than even the big molars. The longer the root the more stable the tooth is because it is deeply embedded into the bone. It is akin to removing a fence pole that is planted a foot into the ground vs 3 feet into the ground. The latter is significantly more difficult.
- Located in aesthetic zone. You also need to extract canines with a lot more caution because it is located in the aesthetic zone. It is towards the front of your mouth so you can’t roughly take it out and damage the bone or adjacent teeth!
- Curved root. Normally for anterior teeth you’re suppose to remove the tooth with twisting motions with forceps. If the canine’s roots are curved you will not be able to remove it by twisting because the curvature anchors it in. You will need to use buccal-lingual motions instead but that is a problem. This second type of motion can fracture the buccal plate which can cause aesthetic issues due to lack of bone later on.
- Can’t section the tooth. Molars are big teeth but they have multiple roots which means you can section the tooth into pieces. This allows for an easier removal process since you’re taking out individual sized smaller teeth. Canines only have one big long root so you can’t make it easier by taking it out in pieces.
All of these reasons coupled together make canines the hardest teeth to extract.
The lesson
To be quite honest, these days I try not to attempt any extractions for canines. I mostly refer them out to the specialist (oral surgeon) if they need to be extracted. The patients will have a more pleasant experience with the surgeon since they can extract the tooth quicker. The faster it comes out, the less post-operative side effects. That is better than having me struggle with the tooth.
However I will still do extractions on them once in awhile but only during emergencies. An example would be if the patient was in severe pain and the tooth needs to come out NOW. Aside from that, if they weren’t in pain, I would 100% refer them out.
Nonetheless, after all of my experiences with canines and other tooth extractions, I’ve learned a better way to extract teeth. The most important step in making extractions easier is by using the elevator more effectively.
The proper way to use an elevator is to continually slide it apically down the PDL space. You literally want to invade the ligament space. This is based on the principle of how two objects cannot occupy the same space at the same time.
This is also something that a lot of rookie or new grad dentists do not really comprehend. Most of them use clockwise twisting motions to elevate the tooth. While that can work, it is no where near as effective as if you applied apical force while doing twisting motions.
If you can put this tip into practice you should have an easier time with extracting teeth. After all, you’re supposed to be able to take out any tooth in the mouth with JUST an elevator. Grabbing the tooth with forceps is supposed to be the last 1% of the procedure.
Therefore if you had thoughts about your dentist putting his knee on your chest for leverage in taking out your tooth, you couldn’t be more wrong! Something is definitely not going well if they have to do that.
Anyway, that was my story but next time let me tell you about the time a rotary file separated inside of a canine during a root canal procedure. Then I was forced to change treatment plans by extracting the canine and doing a dental bridge instead.