This method is commonly used for removing an infected or loose cheek tooth. It involves standing sedation of the horse, and the placement of a regional nerve block to numb the area, prior to attempts at extraction. In older horses with short, loose teeth, anesthesia may not be necessary. The procedure can range from manual removal of a very loose tooth in an old horse, to hours- long manipulation of a deeply embedded rear molar tooth.

The horse's mouth is opened using a speculum. Elevators are sharp, angled instruments that cut some of the attachments of the tooth to the socket. A molar spreader is a wedging instrument that creates space for the tooth to be extracted and helps start to loosen the very strong, deeper attachments of the tooth to the socket. A very large molar forceps specially made for particular upper and lower teeth is then used to grasp and hold the tooth. The tooth is twisted and rocked gently over a variable period of time.

Older horses have far less reserve crown (tooth embedded in the socket) and smaller teeth than younger horses. Loose cheek teeth in older horses fall out on their own or can be removed using one's hands in some cases. In young horses with longer teeth embedded in the socket, it can take 1-2 hours to remove a tooth standing.