Surgical Tooth Extractions

Dental procedure
Overview
A dilacerated root on this unrestorable lower molar tooth makes surgical extraction necessary.

Figure 1: A non-restorable lower molar tooth with a curved (dilacerated) root is less traumatically removed if the tooth is divided into pieces. Whether or not a surgical access flap is required to do this, the procedure is considered surgical if the tooth is sectioned into pieces.

Surgical tooth extractions (also called “open extractions”) are tooth removal procedures in which surgical access is required to completely remove a tooth. Even if the tooth is visible in the mouth without surgically exposing it, surgical techniques may be necessary to remove the tooth. This includes sectioning the tooth into two or more pieces, whether or not a soft tissue incision is made. Surgical extraction does not necessarily mean that the dentist removing the tooth has advanced training in oral surgery, and you will generally not be billed for surgical tooth extractions unless the tooth is sectioned into pieces, or an incision into soft tissue is made. Surgical tooth extractions include removal of impacted wisdom teeth (third molars), but this does not mean that all wisdom teeth requiring removal are required to be removed surgically.
Impacted wisdom teeth such as this require surgical tooth extractions to be removed without trauma.

Figure 2: A soft-tissue impacted lower wisdom tooth (third molar). Removal of this tooth is also less traumatic if the tooth is divided into pieces. Often, impacted teeth require a surgical access flap to be made in order to provide better visibility for the dentist.

Removal (extraction) of a tooth is prescribed if the tooth is too extensively damaged from decay (Figure 1) or trauma to be fixable, or if it is infected and the patient is not a candidate for endodontic (root canal) treatment. It is also frequently prescribed when the teeth of one or both dental arches are severely crowded, and straightening the teeth would require unnecessarily complex orthodontics with a potentially compromised treatment outcome.
A large cavity in this rotten molar tooth makes it unrestorable. The prognosis is considered "hopeless."

Figure 3: Decay (caries) extended into the roots of this tooth, which made it unrestorable. The prognosis was considered “hopeless.” Removal (extraction) was recommended. Because so little intact tooth structure remained, and the tooth had been endodontically treated (note the white root canal fillings evident inside the roots), the procedure was anticipated to require surgical access.

Most commonly, either two or four bicuspid teeth are removed in such cases, and generally they are removed by “simple”, not surgical technique. 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 prognosis for the tooth (i.e. likelihood of long-term success) is not good. Wisdom tooth removal is frequently recommended, and ideally prescribed in the late teens to early twenties, if it is apparent that these teeth will not fit in the jaws in a normal bite relationship with normal gum tissue contours.

Extensively damaged teeth, and teeth with multiple curved roots frequently require extraction by surgical technique when removal is necessary. Teeth which have been endodontically treated and later need to be removed for some reason, frequently require surgical technique as their roots tend to be more brittle.

The process of surgical tooth extractions

Before a tooth is extracted

Atraumatic tooth extraction involves use of periotome to release gums from jawbone.

Figure 1: Here a periotome is shown in position in the ligament space on this study skull. Not showing the gums clearly demonstrates the gap that is present between a tooth and the tooth-supporting (alveolar) bone. The periotome is inserted as far into the ligament space as possible, to release the majority of the attachment fibers from the tooth.

When you have invasive dental procedures like tooth extractions done, the dentist will review your health history. If you have replacement joints (e.g. total knee, hip, 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 like warfarin (the generic name for Coumadin® and others), or drugs that inhibit platelet aggregation like clopidogrel (the generic name for Plavix®), 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 like Valium®; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication, such as Versed®. Your dental plan may not pay benefits toward sedation.

The following describes a typical steps involved in surgical tooth extractions. 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.

Incision and flap elevation to expose tooth

If the tooth is not visible, or is only partly visible in the mouth, it will be necessary to gently expose the tooth by elevating a surgical flap. An incision is made, and the gum tissues are gently reflected to expose the tooth.

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 very atraumatically with a thin-bladed instrument called a periotome (Figure 1).

It may be necessary to remove enough bone from around the tooth to allow its removal (full- and partial-bony impactions). This is generally done with a surgical handpiece that is specially designed for the removal of bone.

Safety net

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.

Sectioning of the tooth

Whether or not a surgical access flap is required to expose the tooth, it may be necessary to section it into individual pieces to remove it safely and without trauma. That step would usually be accomplished next. How many pieces the tooth is divided into depends on many factors, including the number and shape of the roots, as well as any nearby anatomical features that may be of concern (like nerves).

Loosening and elevation of the tooth

An "elevator" is used to loosen the tooth and expand the bony socket.

Figure 2: Here an elevator is shown adapted to the back corner of the tooth. Not showing the gums clearly demonstrates that the elevator applies leverage between the tooth and tooth-supporting (alveolar) bone, so as to separate them.

The tooth is (or individual pieces are) loosened (luxated) within the socket by applying leverage with an instrument called an elevator. There are several types of elevators, depending on the shape 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 (Figure 2). When the tooth has been sectioned, the socket generally isn’t enlarged much, if any.

The tooth fragments are removed in an ordered sequence, that usually involves curved roots being removed last.

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 generally done when teeth are being removed as part of an orthodontic treatment plan.

Placement of an immediate dental implant (optional)

Certain teeth may be candidates for immediate replacement with dental implants. If no acute infection is present (i.e. one that has drainage and swelling), and the bony socket is intact, you and your dentist may plan for immediate placement of the dental implant upon removal of the tooth. A bone graft may be required simultaneously.

Hemostasis (control of 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 surgical tooth extraction
Dental periapical X-ray (radiograph) showing tooth decay (caries).

Early removal of the horizontally impacted wisdom tooth from this patient could have prevented the large cavity (arrow) that developed in the second molar. Following removal of the wisdom tooth, the patient required root canal treatment and a crown on the second molar. This involved four additional appointments, the discomfort of an infected tooth, and significant expense.

  • 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 dental arches.
  • Removal of teeth having a questionable long-term prognosis can lead to a much more successful treatment outcome.
  • Removal of wisdom teeth can prevent the start of periodontal disease, avoid damage to the adjacent molars, and promote a more “stable” dentition that is easier to maintain.
  • Surgical removal of teeth is generally less traumatic to the jaw bone than intact removal of the tooth. In some cases surgical removal can significantly reduce the risk of surgical complications like nerve injuries and development of an oroantral fistula (i.e. an opening between the mouth and maxillary sinus caused by removal of an upper back tooth).
Disadvantages and risks of surgical tooth extractions
  • If you are taking bisphosphonate medications (a drug to reduce the effects of osteoporosis), 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. These complications generally do NOT occur when wisdom teeth are removed. Replacement of wisdom teeth is generally not necessary.
  • 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 multiple teeth are lost, "loss of vertical dimension of occlusion" (bite collapse) can result. 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. These complications generally do NOT occur when wisdom teeth are removed.
  • Tooth removal requires the use of local anesthetic, which 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. If you feel you’re experiencing an abnormal amount, apply direct pressure to the area and call your dentist. Post-operative infections generally don’t occur in the first few days after the extraction. When they do occur, your dentist will evaluate you and may prescribe antibiotics.
  • 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. Surgical removal of the tooth can reduce the risk of nerve injury in some cases.
  • 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. Surgical removal of multi-root upper back teeth can significantly reduce the risk of creating a large opening into the sinus.
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, dental bridges, dental implants, orthodontics, removable dentures, and sedation.

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, a realistic evaluation of the restorability of the tooth needs to be taken into account before the cost, time, and potential discomfort of undergoing extensive procedures are invested. If the tooth requires extensive procedures to fix, and isn’t expected to have a good long-term prognosis (i.e. chance of success), extraction may be the better option.

In patients who are not appropriate candidates for tooth removal due (usually due to medical history or use of certain medications like bisphosphonates), root canal treatment of teeth with a poor prognosis as a temporary solution to pain or swelling may be the only reasonable option. The tooth may still need to be removed at a later date, if the patient becomes an appropriate 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 (either through tooth removal or root canal treatment) 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
This page was reviewed by members of our review board.

This page was last updated on June 8, 2016.

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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.

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

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

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

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

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

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

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.