Simple Tooth Extractions
What are Simple Tooth Extractions?
Simple tooth extractions are tooth removal procedure that can be accomplished from above the gums using traditional elevator and forcep instruments. It is a process of removing teeth without the need of surgical techniques, which are call surgical tooth extractions.
Generally, teeth that are candidates for simple tooth extractions have straight roots and enough solid tooth structure extending through the gums to grasp and manipulate with the instruments. “Simple” implies that the tooth is not cut into pieces and no incision is made in the gum tissues to gain access to the tooth.
Simple tooth extractions are prescribed if teeth are too extensively damaged from decay or trauma to be fixable, or if they are infected and the patient is not a candidate for root canal treatment (endodontics). Simple tooth extractions are also frequently prescribed when the teeth in one or both jaws are severely crowded, and straightening the teeth would require unnecessarily complex orthodontics with a compromised treatment outcome. Most commonly, either two or four bicuspid teeth are removed in cases of significant crowding.
Sometimes the decision to remove a tooth is based on cost, if the procedures required to restore it would involve significant expense. This is especially true if the likelihood of long-term success is not good.
The process of Simple Tooth Extractions
Before a tooth is extracted
When you have invasive dental procedures like tooth extractions done, the dentist will review your health history. If you have replacement joints (for example, total knee replacement, hip replacement, etc.), you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure.
If you take blood thinning medications or drugs that inhibit platelet aggregation, particularly if you take either with aspirin, your dentist and/or physician may require you to suspend those medications temporarily to have any oral surgical procedures, including simple tooth extraction. This is due to the possibility for prolonged bleeding from tooth extraction sites.
If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication. Your dental plan may not pay benefits toward sedation.
The following describes the typical simple tooth extraction process in detail. Your procedure may vary from the procedure described.
The tooth to be removed is usually anesthetized by injecting local anesthetic around the nerve(s) that supply sensation to the tooth. Discomfort from the injection can be minimized by use of a topical numbing gel for a minute or two prior to the injection.
Release periodontal ligament fibers
Teeth are not normally fused to bone. Instead, they have a shock-absorbing ligament that suspends them from the bony tooth socket. The ligament is called the periodontal ligament, and the first step in removing a tooth is to release it. This can be done without trauma with a thin-bladed instrument called a periotome. To prevent the tooth from being swallowed or inhaled when it is removed, dentists will often place a “safety net” of gauze in the back of the mouth.
Loosening and elevation of the tooth
The tooth is loosened within its socket by applying leverage on the tooth with an instrument called an elevator. There are several types of elevators, depending on the type and size of tooth to be removed, and its location in the mouth. The tooth’s bony housing is somewhat pliable, like a green tree branch, and elevation enlarges the tooth socket enough to remove the tooth.
If the tooth has multiple or twisted roots, it can be very loose, and still not be removable without sectioning it into individual pieces. In that case, the extraction is considered surgical, not “simple,” and a different billing code is used to report the extraction for benefits coverage. Generally, the cost of a surgical extraction is greater than the cost of a simple extraction. If the tooth is not sectioned into pieces, and no incision is made, the extraction is simple, not surgical. This is true regardless of the credentials of the doctor removing the tooth.
When the tooth is sufficiently loosened, a forceps is adapted to the tooth to remove it from the jaw. Forceps resemble pliers, with specially designed jaws for the type of tooth being removed. Used correctly, the forceps merely “delivers” the loosened tooth. It is usually not used to apply heavy forces to the tooth.
Ridge preservation via socket graft (optional)
If the tooth being removed is going to be replaced (for example, with a dental implant or fixed bridge), the dentist may recommend placing bone graft material in the tooth socket to significantly decelerate the bone resorption process and preserve the height and width of the bony ridge at its pre-extraction level. If ridge preservation is not done, the height and width of the bony ridge will immediately begin to deteriorate with the healing process. This procedure is not done for orthodontic extractions.
Placement of an immediate dental implant (optional)
Certain teeth may be candidates for immediate replacement with dental implants. If no acute infection is present (no drainage and swelling), and the bony socket is intact, you and your dentist may plan for immediate placement of a dental implant upon removal of the tooth. A bone graft may be required simultaneously.
When the tooth is out, the dentist will apply pressure directly to the tooth socket to minimize any bleeding. There are no major arteries in tooth sockets, so bleeding is generally minimal anyway.
Post-operative instructions and care
Your dentist will give you specific post-operative instructions, taking into account your unique medical and dental situation. Oral, written, and/or video instructions are helpful. Although they may seem simple at the time of your appointment, questions frequently come up later.
Some advantages and benefits of Simple Tooth Extractions
Removal of infected teeth eliminates the source of the infection, and generally brings fairly rapid relief from pain and swelling.
Removal of teeth from severely crowded dental arches provides more space in which to move the remaining teeth to straighten and better align the teeth from the upper and lower jaws.
Removal of teeth having a questionable long-term prognosis can lead to a much more successful treatment outcome.
Potential disadvantages and risks of Simple Tooth Extractions
- Dry socket (osteitis) is a risk of tooth extraction, brought on by premature loss of the blood clot. There are ways to minimize the likelihood of developing a dry socket.
- If you are taking bisphosphonate medications (a drug to reduce the effects of osteoporosis and treat certain cancers), you may be required to go off of the medication for a period of time prior to the removal of one or more teeth. If your tooth is infected and painful, ask your dentist about having the tooth endodontically treated (i.e. root canal) to eliminate the infection, even if you plan to have it removed later. Bisphosphonates decrease the blood circulation in the head and neck bones, possibly enough to impair healing and invite infection following surgical procedures like tooth extractions. This is especially true if you receive the medication intravenously, or are also taking immunosuppressive drugs like corticosteroids.
- If you have a history of radiation treatment that may have involved the head and neck, you may be at risk for developing osteoradionecrosis following surgical procedures like tooth removal. Essentially, this means “bone death” secondary to radiation, which destroys small blood vessels that supply the bone.
- Loss of the teeth without compensating for the missing tooth in some way (e.g. moving the other teeth orthodontically, replacing the tooth with a dental implant, fixed bridge, or removable denture) can lead to shifting of the remaining teeth, improper alignment of the upper and lower teeth, and increased bite forces on the remaining teeth. A “domino effect” can result, in which overloaded remaining teeth crack or chip and require dental treatment.
- If multiple back teeth are lost, “loss of vertical dimension of occlusion” (bite collapse) can result. In this condition, the lower jaw rotates closer to the upper jaw than it should. Taken to the extreme, this can lead to excessive muscle contraction forces in the chewing muscles, which become shorter; reduction in lower face height, which changes the appearance; chronic chapping and cracking of the lips and corners of the mouth (angular cheilitis); improper nutrition and subsequent digestive issues.
- Tooth removal requires the use of local anesthetic, which (although generally minor) has risks of its own. Your dentist can provide you with specific information.
- Tooth removal, like any surgical procedure, has general post-surgical risks: pain, swelling, bruising, bleeding, and infection. Most of the early symptoms (pain, swelling, bruising) can be managed with anti-inflammatory medications (check with your physician or dentist before taking any unprescribed medications). Your dentist may provide other specific instructions for addressing your symptoms following tooth extractions. Most of the time, dentists will prescribe pain relievers for tooth extraction procedures, but the specific medication will depend on the age and health history of the patient. Bleeding after an extraction is normally minimal.
- Tooth removal in a few areas of the mouth can be accompanied by the risk of nerve injury. If this occurs, the worst case scenario includes permanent numbness in the area supplied by the injured nerve. The incidence of this is relatively low, but you should discuss the possibility with your dentist ahead of time.
- Removal of upper back teeth is accompanied by the risk that a hole may be opened into the maxillary sinus. It is generally easy to tell with a dental X-ray what the likelihood of a sinus exposure is, and if it occurs, the problem is normally easy to fix. However, fixing the problem may add cost to the tooth extraction procedure.
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