Simple Tooth Extractions

Dental procedure
Overview
simple tooth removal - straight roots are best.

Teeth that have straight roots (see arrow) are generally the best candidates for simple tooth removal. They should also possess a tooth structure that is solid enough for the dentist to use dental instruments to grab and manipulate the tooth.

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.

Anesthetic

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

Simple tooth extraction: loosening attachment fibers

To start to loosen the tooth, the dentist uses special instruments to release the tooth’s attachment fibers (along the orange dashed line).

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

Simple tooth extraction: loosening, elevation, and delivery.

The dentist then uses an instrument called an “elevator” to further loosen the tooth. When the tooth is sufficiently loosened, forceps are used to “deliver” the loosened tooth.

The tooth is loosened (luxated) 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.

Forceps delivery

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.

Minimizing bleeding

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.

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.

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.
Other care that may be needed

The following procedures are all separate, billable procedures which may be recommended during or after the removal of teeth:

Bone grafting, to prevent shrinkage (resorption) of the bony socket after tooth removal; Fixed bridgework, to replace the tooth (or teeth), and prevent shifting of the remaining teeth; Dental implants, to replace the tooth (or teeth), preserve the bone and prevent shifting of the remaining teeth (while avoiding the need to alter any remaining teeth); Orthodontic treatment, to close spaces, straighten and align the remaining teeth; Removable dentures, to replace missing teeth; Sedation, to allow the procedure to be performed more comfortably—especially on anxious, fearful, or special needs patients.

Other treatment options

If your tooth is infected, and it is not feasible to fix it, there may be no practical option to removing it. Treatment of recurring infections of known cause with antibiotics may not be considered medically responsible. This is because the bacteria that cause infections can develop resistance to repeatedly administered antibiotics, and the infections may become very difficult or impossible to treat, resulting in a potential life threat.

Root canal (endodontic) treatment can be an alternative to tooth removal for infected teeth. However, an evaluation of the restorability of the tooth should be taken into account before the cost, time, and potential discomfort of undergoing a root canal procedure are invested. If the tooth requires extensive procedures to restore, and isn’t expected to have a good long-term chance of success, extraction may be the better option.

Endodontic treatment may be recommended for infected teeth that have a poor prognosis if the patient is not a candidate for tooth removal.

What if I do nothing?

Chronically infected teeth that have been recommended for removal can become acutely inflamed, resulting in severe pain, swelling, and numbness.

If the tooth that has been recommended for removal is infected, and the infection is not treated some other way (for example, endodontic therapy) the infection can spread and become life threatening. Infections of the upper teeth can ascend into the brain. Infections that cause swelling into the oropharynx can ultimately prevent air from reaching the lungs (suffocation). Infections can also spread along fascial planes of the neck toward the heart, lungs, and other organs with potentially grim implications.

If tooth removal has been recommended for orthodontic reasons, and the advice is not followed, a compromised orthodontic treatment outcome may result.

Author: Thomas J. Greany, D.D.S. / Editor: Ken Lambrecht

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This page was last updated on February 15, 2016.

Evidence-based information for dentists and dental school students

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Links to dental and medical journals

Intended for dentists and dental students, ToothIQ.com links to additional information from over 100 U.S. and international dental and medical journals. Disclaimer: Full-text articles are linked to, when available. Some links lead to content requiring payment. Symbyos is not compensated by the organizations or authors whose articles are linked to. Symbyos is not responsible for the content linked to from ToothIQ.com.

Information you may wish to read before making a decision on treatment

An Evaluation of Buccal Infiltrations and Inferior Alveolar Nerve Blocks in Pulpal Anesthesia for Mandibular First Molars
Jung, Il-Young, DDS, MSc, PhD, et al.
Journal of Endodontics
2008 34 (1): 11-13
Editor’s notes: This article describes a potentially useful technique for getting lower molars numb, which may be more comfortable than traditional methods.

Mythbusters and Wisdom Teeth
Dodson, Thomas B., DMD, MPH
The American Journal of Public Health
2008 98 (4): 581-582

A comparative study of cone-beam computed tomography and conventional panoramic radiography in assessing the topographic relationship between the mandibular canal and impacted third molars
Tantanapornkul, Weeraya, DDS, et al.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology
2007 103 (2): 253-259

A Decision Tree for Bone Graft Success
Smiler, Dennis G., DDS, MSD
Journal of Oral and Maxillofacial Surgery
2007 65 (9): 88

Graft Techniques to Augment the Implant Site—Methods to Minimize Patient Morbidity
Misch, Craig M., DDS, MDS
Journal of Oral and Maxillofacial Surgery
2007 65 (9)

Inhibition of Alveolar Osteitis in Mandibular Tooth Extraction Sites Using Platelet-Rich Plasma
Rutkowski, James L., et al.
Journal of Oral Implantology
2007 33 (3): 116-121

Not All bone Grafts Are Created Equal—What You Need to Know For a Better Outcome
Danek, Sofamor
Back.com web site
Last viewed: 9/23/2010
2007
Editor’s notes: Scholarly article from the orthopedic literature, with relevance to dentistry. © Medtronic, Sofamor Danek 2007.

Socket Grafting: A Predictable Technique For Site Preservation
Jackson, Brian J., DDS and Morcos, Iyad, DDS
Journal of Oral Implantology
2007 33 (6): 353-364

The Prophylactic Extraction of Third Molars: A Public Health Hazard
Friedman, Jay W., DDS, MPH
The American Journal of Public Health
2007 97: 1554-1559

The relationship of cigarette smoking to postoperative complications from dental extractions among female inmates
Heng, Christine K., DDS, MPH, et al.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology
2007 104 (6): 757-762

A Cochrane Systematic Review Finds No Evidence to Support the Use of Antibiotics for Pain Relief in Irreversible Pulpitis
Keenan, James V., DDS (FAGD), et al.
Journal of Endodontics
2006 32 (2): 87-92

Dental management of patients receiving oral bisphosphonate therapy: Expert panel recommendations
The Journal of the American Dental Association
2006 137 (8): 1144-1150
Notes: Association Report by American Dental Association Council on Scientific Affairs

Grafting of Extraction Sockets: When and How
Misch, Craig M., DDS, MDS
Journal of Oral and Maxillofacial Surgery
2006 64 (9): 8

Maxillary Molar Sinus Floor Intrusion at the Time of Dental Extraction
Jensen, Ole T. DDS, MS, et al.
Journal of Oral and Maxillofacial Surgery
2006 64 (9): 1415-1419

Single-Tooth Replacement: Is a 3-Unit Fixed Partial Denture Still an Option? A 20-Year Retrospective Study
DeBacker, Hein, DDS, MScD, et al.
International Journal of Prosthodontics
2006 19 (6): 567-573

Third-molar extraction as a risk factor for temporomandibular disorder
Huang, Greg J., DMD, MSD, MPH and Rue, Tessa C., MS
The Journal of the American Dental Association
2006 137: 1547-1554

Failed Root Canals: The Case for Extraction and Immediate Implant Placement
Ruskin, James D., DMD, MD, et al.
Journal of Oral and Maxillofacial Surgery
2005 63 (6): 829-831d

Indications for Elective Therapeutic Third Molar Removal: The Evidence Is In
Assael, Leon A., DMD
Journal of Oral and Maxillofacial Surgery
2005 63 (12): 1691-1692

Third molars associated with periodontal pathology in older Americans
Elter, John R., DMD, PhD, et al.
Journal of Oral and Maxillofacial Surgery
2005 63 (2): 179-184

Update on dry socket: A review of the literature
Torres-Cagares, D., et.al.
Medicina Oral, Patologia Oral y Cirugia Bucal (Ed. impresa)
2005 10 (1): 77-85
Editor’s notes: Article in Spanish. To translate this article, you can use online translation tools such as Google™ Translate (Beta) (http://www.google.com/translate_t) or AltaVista® Babel Fish Translator (http://babelfish.altavista.com/)

Postextraction Tissue Management: A Soft Tissue Punch Technique
Jung, Ronald E., Dr Med Dent, DMD, et al.
The International Journal of Periodontics & Restorative Dentistry
2004 24 (6): 545-553

Review of Pediatric Sedation
Cravero, Joseph P., MD, and Blike, George T., MD
Anesthesia & Analgesia
2004 99: 1355-1364

Strategies for management of single-tooth extraction sites in aesthetic implant therapy
Sclar, Anthony G., DMD
Journal of Oral and Maxillofacial Surgery
2004 62 (9): 90-105

Comparison of 3 bone substitutes in canine extraction sites
Indovina, Anthony Jr., DDS, and Block, Michael S., DMD
Journal of Oral and Maxillofacial Surgery
2002 60 (1): 53-58

Oral hygiene and postoperative pain after mandibular third molar surgery
Penarrocha, M., MD, PhD, et al.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology
2001 92 (3): 260-264

Long-term evaluation of estimates of need for third molar removal
Venta, Irja, DDS, PhD, et al.
Journal of Oral and Maxillofacial Surgery
2000 58 (3): 288-291

The not-so-harmless maxillary primary first molar extraction
Northway, William M., DDS, MS
The Journal of the American Dental Association
2000 131 (12): 1711-1720

Third molars and incisor crowding: when removal is unwarranted
Southard, T.E.
The Journal of the American Dental Association
1992 123: 75-79

Endocarditis Prophylaxis Information
American Heart Association web site
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Fabrication of Essix Retainers: A guide to making clear plastic retainers with provisional replacement teeth in them (PDF, 268K)
No author specified
Dentsply Raintree Essix web site
Last viewed: 9/24/2010
Editor’s notes: Manufacturer’s web site

White Paper on Third Molar Data (PDF, 476K)
American Association of Oral and Maxillofacial Surgeons Task Force
American Association of Oral and Maxillofacial Surgeons web site
Last viewed: 9/24/2010
Notes: A Task Force was convened by the American Association of Oral and Maxillofacial Surgeons in March 2007 to review the current literature with regard to selected aspects relating to third molars (wisdom teeth), and their removal. Databases reviewed included Ovid Medline, PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews. Case reports were excluded. This white paper summarizes the findings.

Background information

Full-mouth Tooth Extraction Lowers Systemic Inflammatory and Thrombotic Markers of Cardiovascular Risk
Taylor, B.A., et al.
Journal of Dental Research
2006 85 (1): 74-78
Editor’s notes: More evidence that cardiovascular risks associated with chronic periodontal disease end when the periodontal disease ends. This article does not advocate edentulating patients.

Implant Restoration of External Resorption Teeth in the Esthetic Zone
Block, Michael S., DMD and Casadaban, Michael C., DDS, MD
Journal of Oral and Maxillofacial Surgery
2005 63 (11): 1653-1661

Medical-Grade Calcium Sulfate Hemihydrate (Surgiplaster) in Healing of a Human Extraction Socket—Histologic Observation at 3 Months: A Case Report
Guarnieri, Renzo, MD, DDS, et al.
The International Journal of Oral & Maxillofacial Implants
2005 20 (4): 636-641

Human mineralized bone in extraction sites before implant placement: Preliminary results
Block, Michael S., DMD, et al.
The Journal of the American Dental Association
2002 133 (12): 1631-1638

Supernumerary Teeth—An Overview of Classification, Diagnosis and Management
Garvey, M. Therese B. Dent. Sc, D. Orth., M. Orth., M.Sc., FDS, et al.
Journal of the Canadian Dental Association
1999 65: 612-616

The Hopeless Tooth: When is Treatment Futile?
Harrison, John W., DMD, MS, et al.
Current Topics in Dentistry
1999 30 (12)
Notes: Originally published in Quintessence International

The Mandibular Incisive Foramen
Serman, N.J.
Journal of Anatomy
1989 167: 195-198

Clove (Eugenia aromatica) and Clove oil (Eugenol)
No author specified
U.S. National Library of Medicine web site
Last viewed: 9/23/2010

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