Surgical Tooth Extractions
What are Surgical Tooth Extractions?
Surgical tooth 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.
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.
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
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 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 a typical steps involved in surgical tooth extractions. 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.
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.
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
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.
Some advantages and benefits of Surgical 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 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).
Potential 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.
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