Dental extraction explained

Dental extraction
Icd9:-
Specialty:Oral and maxillofacial surgery, Periodontics[1]

A dental extraction (also referred to as tooth extraction, exodontia, exodontics, or informally, tooth pulling) is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes impacted wisdom teeth (wisdom teeth that are stuck and unable to grow normally into the mouth) cause recurrent infections of the gum (pericoronitis), and may be removed when other conservative treatments have failed (cleaning, antibiotics and operculectomy). In orthodontics, if the teeth are crowded, healthy teeth may be extracted (often bicuspids) to create space so the rest of the teeth can be straightened.

Procedure

Extractions could be categorized into non-surgical (simple) and surgical, depending on the type of tooth to be removed and other factors.

Assessment and special investigations

A comprehensive history taking should be performed to find out the pain history of the tooth, the patient's medical history and the history of previous difficult extractions.[2] The tooth should be assessed clinically i.e. checked visually by the dentist. Pre-extraction radiographs are not always necessary but are often taken to confirm the diagnosis and hence appropriate treatment plan. Radiographs also help in visualising the shape and size of roots which are beneficial in planning the extraction. All this information will aid the dentist in foreseeing any difficulties and hence preparing appropriately.

Obtaining consent from patient

In order to obtain permission from patient for extraction of tooth, the dentist should explain that other treatment options are available, what is involved in the dental extraction procedure, the potential risks of the procedure and the benefits of the procedure. The process of gaining consent should be documented in clinical notes.

Giving local anaesthetic

Before extracting a tooth, the dentist would deliver local anaesthetic to ensure the tooth and surrounding tissues are numb before they start the extraction. There are several techniques to achieve numbness of the tooth including

The two most commonly used local anaesthetics in the UK are lidocaine and articaine.[3] Prior to injection, topical anaesthetic gel or cream, such as lidocaine or benzocaine, can be applied to the gum to numb the site of the injection up to a few millimetres deep. This should reduce the discomfort felt during the injection and thus help to reduce patient anxiety.

Removal of tooth

During extraction, multiple instruments are used to aid and ease the removal of the tooth whilst trying to minimally traumatise the tissues to allow for quicker healing.Extraction forceps are commonly used to remove teeth. Different shaped forceps are available depending on the type of tooth requiring removal, what side of the mouth (left or right) it is on and if it is an upper or lower tooth. The beaks of the forceps must grip onto the root of the tooth securely before pressure is applied along the long axis of the tooth towards the root.

Different movements of the forceps can be employed to remove teeth. Generally, while keeping downwards pressure attempts to move the tooth towards the cheek side (buccal) and then the opposite direction (palatal or lingual) are made to loosen the tooth from its socket. For single, conical-rooted teeth such as the incisors, rotatory movements are also used. A 'figure of eight' movement can be used to extract lower molars.

Instruments used are summarised below:

!Name!Type of instrument!Use!Area of use!Unique features
LuxatorLuxatorTear PDL around tooth AnywhereSharp blade
CouplandElevatorexpand socket and lift AnywhereNumbered 1-3 from most narrow to wide
Warrick JamesElevatorExpand socket and lift toothAnywhereRight left and straight
CryersElevatorExpand socket and lift toothAnywhereRight and left with sharp tips
Upper straightForcepRemove teethUpper canine to canineStraight handle
Upper anteriorForcepRemove teethUpper anteriors and premolars
Upper molarForcepRemove teethUpper 1st/2nd/3rd molarsOne pointed end to engage buccal furcation
Upper bayonetForcepRemove teethUpper 3rd molarsCurved handle and tip to reach 3rd molars
Upper rootForcepRemove teethUpper retained/fractured rootsNarrow tips
CowhornForcepRemove teethLower molarsThin tips to engage furcation of broken down molars
Lower anteriorForcepRemove teethLower anteriors and premolars90 degree bend handle
lower molarForcepRemove teethLower 1st/2nd/3rd molars2 beak tips to engage furcations
Lower rootForcepRemove teethLower retained/fractured rootsNarrow tips to engage roots

In terms of operator positioning when removing a tooth, the patient is placed more supine when extracting an upper and more upright when extracting a lower. This is to allow direct vision for the operator during the procedure. A right handed operator will stand to the front of the patient and to their right when removing any upper teeth or lower left teeth. However, they will stand behind the patient and to the right when extracting a lower right tooth.[4]

Dental elevators can be used to aid removal of teeth. Various types are available that have different shapes. Their working ends are designed to engage into the space between the tooth and bone of the socket. Rotatory movements are then made to dislodge the tooth from the socket. Another similar looking but sharper instrument that can be used is a luxator; this instrument can be used gently and with great care to cut the ligament between the tooth and its boney socket (periodontal ligament).

Achieving haemostasis

Biting down on a piece of sterile gauze over the socket will provide firm pressure to the wound. Normally this is sufficient to stop any bleeding and will promote blood clot formation at the base of the socket.[5]

Moreover, the patient must be inhibited from eating and drinking hot food in the first 24 hours. Using straw for drinking is also prohibited due to the negative pressure it can produce which will lead to removal of a newly formed clot from the socket.

The source of any bleeding can either be from soft tissues (gingiva and mucosa) or hard tissue (the bony socket). Bleeding of soft tissues can be controlled by several means including suturing the wound (stitches) and/ or using chemical agents such as tranexamic acid, ferric sulphate and silver nitrate. Bony bleeding can be arrested by using haemostatic gauze and bone wax. Other means of achieving haemostasis include electrocautery.

Reasons

Medical/Dental

Orthodontic

Aesthetics

Types

Extractions are often categorized as "simple" or "surgical".

Simple extractions are performed on teeth that are visible in the mouth, usually with the patient under local anaesthetic, and require only the use of instruments to elevate and/or grasp the visible portion of the tooth. Typically the tooth is lifted using an elevator, and using dental forceps, specific tooth movements are performed (e.g. rocking the tooth back and forth) expanding the tooth socket. Once the periodontal ligament is broken and the supporting alveolar bone has been adequately widened the tooth can be removed. Typically, when teeth are removed with forceps, slow, steady pressure is applied with controlled force.

Surgical extractions involve the removal of teeth that cannot be easily accessed or removed via simple extraction, for example because they have broken under the gum or because they have not erupted fully, such as an impacted wisdom tooth. Surgical extractions almost always require an incision. In a surgical extraction the dentist may elevate the soft tissues covering the tooth and bone, and may also remove some of the overlying and/or surrounding jaw bone with a drill or, less commonly, an instrument called an osteotome. Frequently, the tooth may be split into multiple pieces to facilitate its removal.

Common risks after any extraction include pain, swelling, bleeding, bruising, infection, trismus (not being able to open as wide as normal) and dry socket. There are additional risks associated with the surgical extraction of wisdom teeth in particular: permanent or temporary damage to the inferior alveolar nerve +/- lingual nerve, causing permanent or temporary numbness, tingling or altered sensation to the lip, chin +/- tongue.[16] [17]

Surgical procedure

  1. Incisions are made full thickness through mucosa and periosteum to bone. In general, the flap is extended from one tooth behind the tooth concerned to one tooth in front, including the interdental papilla.
  2. An anterior relieving incision is made extending down into the sulcus. This flap design is called “two sided”. A “three sided” flap includes an additional relieving incision posteriorly.
  3. The flap is raised using periosteal elevator to expose the area of interest.
  4. The flap is held out of the way with an instrument such as a rake retractor.
  5. A small gutter of bone is drilled away around the tooth to make space into which an application point for instruments can be achieved. It is important that copious amount of saline is used to cool the bone during this process.
  6. The tooth concerned can be removed using a combination of luxators, elevators and extraction forceps.
  7. Any sharp bone is smoothed off and the wound is irrigated with saline.
  8. The flap is repositioned and sutured in place.

Pre-extraction consideration

Anticoagulant/Antiplatelet Use

Anticoagulants are drugs that interfere with the clotting cascade. Antiplatelets are drugs that interfere with platelet aggregation. These drugs are prescribed in certain medical conditions/situations to reduce the risk of a thromboembolic event. With this comes an increased risk of bleeding. Historically, the anticoagulant warfarin (belonging to the group of drugs called coumarins) and antiplatelets such as aspirin or clopidogrel, were prescribed commonly in these circumstances. However, whilst these drugs are still used, newer antiplatelet (e.g. ticagrelor) and anticoagulant (e.g. rivaroxaban, apixaban and dabigatran) drugs are being used more commonly. When considering dental treatment (including dental extractions) different guidance/precautions need to be followed depending on the drug prescribed and the individual patient circumstances. The Scottish Dental Clinical Effectiveness Programme (SDCEP) provides excellent guidance on this topic.[18]

Antibiotic Prescribing

Individual patient circumstances should be evaluated prior to the use of antibiotics to reduce the risks of certain post-extraction complications. There is evidence that use of antibiotics before and/or after impacted wisdom tooth extraction reduces the risk of infections by 66%, and lowers incidence of dry socket by one third. For every 19 people who are treated with an antibiotic following impacted wisdom tooth removal, one infection is prevented.[19] Use of antibiotics does not seem to have a direct effect on manifestation of fever, swelling, or trismus seven days post-extraction. In the 2021 Cochrane review, 23 randomized control double-blinded experiments were reviewed and, after considering the biased risk associated with these studies, it was concluded that there is moderate overall evidence supporting the routine use of antibiotics in practice in order to reduce risk of infection following a third molar extraction. There are still reasonable concerns remaining regarding the possible adverse effects of indiscriminate antibiotic use in patients. There are also concerns about development of antibiotic resistance which advises against the use of prophylactic antibiotics in practice.

Assessing risk of nerve damage

The inferior alveolar nerve (IAN), a branch of the trigeminal nerve (cranial nerve V), is a nerve that runs through the mandible (lower jaw) and supplies sensation to all the lower teeth, the lip and the chin. The lower teeth, and in particular the lower wisdom teeth, can therefore be in close proximity to this nerve. Damage to the inferior alveolar nerve is a risk of lower wisdom tooth removal (and other surgical procedures in the mandible). This means there is a risk of temporary or permanent numbness or altered sensation to the lip +/- chin on the side the surgery is taking place. Therefore, in order to assess this risk and inform the patient, the position of the inferior alveolar nerve in relation to a lower wisdom tooth needs to be assessed radiographically prior to extraction.[20]

The proximity of the root to the canal can be assessed radiographically and there are several factors which can indicate high risk of nerve damage:[21]

The lingual nerve can also be damaged (temporary or permanent) during surgical procedures in the mandible, in particular lower wisdom tooth removal. This would present as temporary or permanent numbness/altered sensation/altered taste to the side of tongue (side corresponding to side of surgery).[22]

Post-extraction healing

Immediate management

Immediately following the removal of a tooth, bleeding or oozing very commonly occurs. Pressure is applied by the patient biting on a gauze swab, and a thrombus (blood clot) forms in the socket (hemostatic response). Common hemostatic measures include local pressure application with gauze, and the use of oxidized cellulose (gelfoam) and fibrin sealant. Dental practitioners usually have absorbent gauze, hemostatic packing material (oxidized cellulose, collagen sponge), and suture kit available.[23] Sometimes 30 minutes of continuous pressure is required to fully arrest bleeding.

Complications

Talking, which moves the mandible and hence removes the pressure applied on the socket, instead of keeping constant pressure, is a very common reason that bleeding might not stop. This is likened to someone with a bleeding wound on their arm, when being instructed to apply pressure, instead holds the wound intermittently every few moments.

Coagulopathies (clotting disorders, e.g. hemophilia) are sometimes discovered for the first time if a person has had no other surgical procedure in their life, but this is rare. Sometimes the blood clot can be dislodged, triggering more bleeding and formation of a new blood clot, or leading to a dry socket (see complications). Some oral surgeons routinely scrape the walls of a socket to encourage bleeding in the belief that this will reduce the chance of dry socket, but there is no evidence that this practice works.

The most serious post extraction healing complication is that slow or halted healing caused by the adverse effects of use of bisphosphonates which can cause osteochemonecrosis of the bone.

Healing process

The chance of further bleeding reduces as healing progresses, and is unlikely after 24 hours. The blood clot is covered by epithelial cells which proliferate from the gingival mucosa of socket margins, taking about 10 days to fully cover the defect.[24] In the clot, neutrophils and macrophages are involved as an inflammatory response takes place. The proliferative and synthesizing phase next occurs, characterized by proliferation of osteogenic cells from the adjacent bone marrow in the alveolar bone. Bone formation starts after about 10 days from when the tooth was extracted. After 10–12 weeks, the outline of the socket is no longer apparent on an X-ray image. Bone remodeling as the alveolus adapts to the edentulous state occurs in the longer term as the alveolar process slowly resorbs. In maxillary posterior teeth, the degree of pneumatization of the maxillary sinus may also increase as the antral floor remodels.

Post-extraction management

Post-operative instructions

Post-operative instructions following tooth extractions can be provided to encourage healing of the socket and prevent post-operative complications from arising. The advice listed below is usually given verbally, and can be supplemented with instructions in the written form. The combination of both methods of delivery has been found to reduce the severity of pain experienced by patients post-extraction and results in higher levels of patient satisfaction compared to verbal post-operative instructions alone.[25]

General advice

The following can be recommended to encourage healing after a tooth extraction.

Pain management

Many drug therapies are available for pain management after third molar extractions including NSAIDS (non-steroidal anti-inflammatory), APAP (acetaminophen), and opioid formulations. Although each has its own pain-relieving efficacy, they also pose adverse effects. According to two doctors, Ibuprofen-APAP combinations have the greatest efficacy in pain relief and reducing inflammation along with the fewest adverse effects. Taking either of these agents alone or in combination may be contraindicated in those who have certain medical conditions. For example, taking ibuprofen or any NSAID in conjunction with warfarin (a blood thinner) may not be appropriate. Also, prolonged use of ibuprofen or APAP has gastrointestinal and cardiovascular risks.[30] There is high quality evidence that ibuprofen is superior to paracetamol in managing postoperative pain.[31]

Socket preservation

Socket preservation or alveolar ridge preservation (ARP)[32] is a procedure to reduce bone loss after tooth extraction to preserve the dental alveolus (tooth socket) in the alveolar bone. At the time of extraction a platelet rich fibrin (PRF)[33] membrane containing bone growth enhancing elements is placed in the wound or a graft material or scaffold is placed in the socket of the extracted tooth.[34] [35]

Post-extraction bleeding

Post-extraction bleeding is bleeding that occurs 8–12 hours after tooth extraction.[36] It is normal for bleeding to occur for up to 30 minutes following the extraction. It is not uncommon for the extraction site to discharge a small amount of blood or to see saliva blood-stained for up to 8 hours.[37]

Should post-extraction bleeding occur, UK guidance recommends biting onto a piece of damp gauze for at least 20 minutes whilst sitting in an upright position. It is important that the gauze is damp, but not soaking, to avoid disrupting clot formation and consequently inducing a rebound bleed. If the socket continues to bleed, it is recommended to repeat the process with a fresh piece of damp gauze for 20 minutes again. Should both attempts fail to stem the bleed, it is advised to seek professional advice.

Factors

Various factors contribute to post-extraction bleeding.[38] [39] [40]

Local factors

Systemic factors

Type of bleeding

1. Primary prolonged bleeding

This type of bleeding occurs during/immediately after extraction, because true haemostasis has not been achieved. It is usually controlled by conventional techniques, such as applying pressure packs or haemostatic agents onto the wound.

2. Reactionary bleeding

This type of bleeding starts 2 to 3 hours after tooth extraction, as a result of cessation of vasoconstriction. Systemic intervention might be required.

3. Secondary bleeding

This type of bleeding usually begins 7 to 10 days post extraction, and is most likely due to infection destroying the blood clot or ulcerating local vessels.

Interventions

There is no clear evidence from clinical trials comparing the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors.[41]

Complications

Atraumatic extraction

Atraumatic extraction is a novel technique for extracting teeth with minimal trauma to the bone and surrounding tissues. It is especially useful in patients who are highly susceptible to complications such as bleeding, necrosis, or jaw fracture. It can also preserve bone for subsequent implant placement.[56] Techniques involve minimal use of forceps, which damage socket walls, relying instead on luxators, elevators and syndesmotomy.[57]

Replacement options for missing teeth

Following dental extraction, a gap is left. The options to fill this gap are commonly recorded as Bind, and the choice is made by dentist and patient based on several factors.

Treatment option Advantages Disadvantages
BridgeFixed to adjacent teeth Drilling usually required on one or both sides of the gap if conventional bridge (average lifespan about 10 years). Conservative bridge (average lifespan about 5 years) preparation may cause minimal damage to adjacent teeth. Expensive and complex treatment, not suited to all situations, e.g., large gaps in the back of the mouth Alveolar bone will still resorb, and eventually a gap may show under bridge.
ImplantFixed to jawbone. Maintains alveolar bone, which would otherwise undergo resorption. Usually a long-term lifespan. Expensive and complex, requiring specialist. May involve other procedures such as bone grafting. Relatively contra-indicated in tobacco smokers.
DentureOften a simple, quick, and relatively cheap treatment compared to bridge and implant. Not usually any drilling of other teeth required. It is far easier to replace several teeth with a denture than place multiple bridges or implants. Denture is not fixed in mouth. Over time worsens periodontal disease unless there is good level of oral hygiene, and may damage soft tissues. Potential for slightly accelerated resorption of alveolar bone compared to no denture. Potential for poor tolerance in persons with over-sensitive gag reflex, xerostomia, etc.
Nothing (i.e., not replacing the missing tooth)Often the choice due to cost of other treatment or lack of motivation for other treatments. Part of a shortened dental arch plan, which revolves around the fact that not all teeth are required to eat comfortably, and only the incisors and premolars need be preserved for normal function. This is usually the choice taken if the reason of dental extraction is due to impacted wisdom teeth or orthodontics because of limited space. The alveolar bone will slowly resorb over time once the tooth is lost. Potential esthetic concern. Potential for drifting and rotation of adjacent teeth into the gap over time.

History

Historically, dental extractions have been used to treat a variety of illnesses. Before the discovery of antibiotics, chronic tooth infections were often linked to a variety of health problems, and therefore removal of a diseased tooth was a common treatment for various medical conditions. Instruments used for dental extractions date back several centuries. In the 14th century, Guy de Chauliac invented the dental pelican,[58] which was used through the late 18th century. The pelican was replaced by the dental key[59] which, in turn, was replaced by modern forceps in the 19th century.[60] As dental extractions can vary tremendously in difficulty, depending on the patient and the tooth, a wide variety of instruments exist to address specific situations. Rarely, tooth extraction was used as a method of torture, e.g., to obtain forced confessions.[61]

See also

Further reading

Notes and References

  1. Web site: Tooth extraction: MedlinePlus Medical Encyclopedia . MedlinePlus . 2024-02-03 . tooth extraction is a procedure to remove a tooth from the gum socket. It is usually done by a general dentist, an oral surgeon, or a periodontist..
  2. Book: Pedlar J, Frame JW . Oral and maxillofacial surgery : an objective-based textbook. 2001. Churchill Livingstone . 978-0-443-06017-5 . Edinburgh. 45708690.
  3. Bartlett G, Mansoor J . Articaine buccal infiltration vs lidocaine inferior dental block - a review of the literature . British Dental Journal . 220 . 3 . 117–120 . February 2016 . 26868800 . 10.1038/sj.bdj.2016.93 . 3343775 .
  4. Book: Wray D . Textbook of General and Oral Surgery. Churchill Livingston. 2003. 0443070830. Edinburgh. 208–211.
  5. McCormick NJ, Moore UJ, Meechan JG . Haemostasis. Part 1: The management of post-extraction haemorrhage . Dental Update . 41 . 4 . 290–2, 294–6 . May 2014 . 24930250 . 10.12968/denu.2014.41.4.290 .
  6. Book: Head and Neck Imaging Variants . 9780071808682 . Karagianis A . 2016-03-22. McGraw Hill Professional .
  7. Zadik Y, Sandler V, Bechor R, Salehrabi R . Analysis of factors related to extraction of endodontically treated teeth . Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics . 106 . 5 . e31–e35 . November 2008 . 18718782 . 10.1016/j.tripleo.2008.06.017 .
  8. Guidance on the Extraction of Wisdom Teeth . 27 March 2000 . National Institute of Clinical Excellence . 9781473131484 . none . 15 July 2019 . 7 April 2019 . https://web.archive.org/web/20190407130158/https://www.nice.org.uk/guidance/ta1/resources/guidance-on-the-extraction-of-wisdom-teeth-pdf-63732983749 . live .
  9. Web site: Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth) . Policy Statement Database . American Public Health Association . 2016-05-12 . 2016-05-12 . 2018-12-02 . https://web.archive.org/web/20181202075042/https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/14/29/opposition-to-prophylactic-removal-of-third-molars-wisdom-teeth . live .
  10. Book: Gadhia . Alisha . Pepper . Tom . StatPearls . Oral Surgery, Extraction of Teeth . StatPearls Publishing . Treasure Island (FL) . 2024 . 36943972 . A dental extraction would be indicated for a tooth with pulpal, or apical pathology that cannot be resolved with endodontic treatment or that would not be restorable following the endodontic treatment..
  11. Web site: Other Endodontic Treatment Options . American Association of Endodontists . 2022-06-25 . 2024-02-03 . Do everything possible to save your teeth before considering extraction – it should always be a last resort! If an endodontic procedure can’t save your tooth and it must be extracted, you should consider a dental implant that will enable you to bite and chew properly,....
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  15. Book: Brain injury and mental retardation: psychopharmacology and neuropsychiatry . C. Thomas Gualtieri . 9780781734738 . 2002 . Lippincott Williams & Wilkins .
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  17. Malden NJ, Maidment YG . Lingual nerve injury subsequent to wisdom teeth removal--a 5-year retrospective audit from a high street dental practice . British Dental Journal . 193 . 4 . 203–205 . August 2002 . 12222906 . 10.1038/sj.bdj.4801523 . free .
  18. Web site: Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs . Scottish Dental Clinical Effectiveness Programme . 2016-11-22 . 2017-03-28 . https://web.archive.org/web/20170328223906/http://www.sdcep.org.uk/wp-content/uploads/2015/09/SDCEP-Anticoagulants-Guidance.pdf . live .
  19. Lodi G, Azzi L, Varoni EM, Pentenero M, Del Fabbro M, Carrassi A, Sardella A, Manfredi M . 6 . Antibiotics to prevent complications following tooth extractions . The Cochrane Database of Systematic Reviews . 2021 . CD003811 . February 2021 . 2 . 33624847 . 8094158 . 10.1002/14651858.CD003811.pub3 .
  20. Juodzbalys G, Daugela P . Mandibular third molar impaction: review of literature and a proposal of a classification . Journal of Oral & Maxillofacial Research . 4 . 2 . e1 . July 2013 . 24422029 . 3886113 . 10.5037/jomr.2013.4201 .
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  37. Kumbargere Nagraj S, Prashanti E, Aggarwal H, Lingappa A, Muthu MS, Kiran Kumar Krishanappa S, Hassan H . Interventions for treating post-extraction bleeding . The Cochrane Database of Systematic Reviews . 3 . 5 . CD011930 . March 2018 . 29502332 . 6494262 . 10.1002/14651858.cd011930.pub3 .
  38. Ramos E, Santamaría J, Santamaría G, Barbier L, Arteagoitia I . Do systemic antibiotics prevent dry socket and infection after third molar extraction? A systematic review and meta-analysis . Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology . 122 . 4 . 403–425 . October 2016 . 27499028 . 10.1016/j.oooo.2016.04.016 .
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