Extraction of teeth

A dental extraction (also referred to as exodontia) is the removal of a tooth from the mouth.

Extraction is performed for positional, structural, or economic reasons. Teeth are often removed because they are impacted. Teeth become impacted when they are prevented from growing into their normal position in the mouth by gum tissue, bone, or other teeth. Impaction is a common reason for the extraction of wisdom teeth. Extraction is the only known method that will prevent further problems with impaction.

Teeth may also be extracted to make more room in the mouth prior to straightening the remaining teeth (orthodontic treatment), or because they are so badly positioned that straightening is impossible. Extraction may be used to remove teeth that are so badly decayed or broken that they cannot be restored. In addition, some patients choose extraction as a less expensive alternative to filling or placing a crown on a severely decayed tooth.

Reasons

The most common reason for extraction is tooth damage due to breakage or decay. There are additional reasons for tooth extraction:

  • Severe tooth decay or infection (acute or chronic alveolar abscess). Despite the reduction in worldwide prevalence of dental caries, still it is the most common reason for extraction of (non-third molar) teeth with up to two thirds of extractions.
  • Extra teeth which are blocking other teeth from coming in.
  • Severe gum disease which may affect the supporting tissues and bone structures of teeth.
  • In preparation for orthodontic treatment (braces)
  • Teeth in the fracture line
  • Teeth which cannot be restored endodontically
  • Fractured teeth
  • Supenumerary, supplementary or malformed teeth
  • Prosthetics; teeth detrimental to the fit or appearance of dentures
  • Cosmetic; teeth of poor appearance, unsuitable for restoration
  • Receiving radiation to the head and neck may require extraction of teeth in the field of radiation.
  • It was once a common practice to remove the front teeth of institutionalized psychiatric patients who had a history of biting.
  • Reduced cost compared to other treatments

Types

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

  • Simple extractions are performed on teeth that are visible in the mouth, usually 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, rocked back and forth until the periodontal ligament has been sufficiently broken and the supporting alveolar bone has been adequately widened to make the tooth loose enough to remove. 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, either because they have broken under the gum line or because they have not erupted fully. Surgical extractions almost always require an incision. In a surgical extraction the doctor may elevate the soft tissues covering the tooth and bone and may also remove some of the overlying and/or surrounding jawbone tissue with a drill or osteotome. Frequently, the tooth may be split into multiple pieces to facilitate its removal.

Diagnosis/Preparation

In some situations, tooth extractions may be temporarily postponed. These situations include:

  • Infection that has progressed from the tooth into the bone. Infections may complicate administering anesthesia. They can be treated with antibiotics before the tooth is extracted.
  • Use of drugs that thin the blood (anticoagulants). These medications include warfarin (Coumadin) and aspirin . The patient should stop using these medications for three days prior to extraction.
  • People who have had any of the following procedures in the previous six months: heart valve replacement, open heart surgery, prosthetic joint replacement, or placement of a medical shunt. These patients may be given antibiotics to reduce the risk of bacterial infection spreading from the mouth to other parts of the body.

Before extracting a tooth, the dentist will take the patient's medical history, noting allergies and other prescription medications that the patient is taking. A dental history is also recorded. Particular attention is given to previous extractions and reactions to anesthetics. The dentist may then prescribe antibiotics or recommend stopping certain medications prior to the extraction. The tooth is x rayed to determine its full shape and position, especially if it is impacted.

Diagramatic Representation of Extraction Process

 
 

Aftercare

A dental surgeon uses special forceps to pull out a tooth (A). In its place, a blood clot forms (B), which becomes new bone with gum tissue over the top (C). If the blood clot does not form or falls out, a dry socket occurs (D). No new bone forms, and the nerves are exposed, causing pain.

An important aspect of aftercare is encouraging a clot to form at the extraction site :-

  • The patient should put pressure on the area by biting gently on a roll or wad of gauze for several hours after surgery. Once the clot is formed, it should not be disturbed.
  • The patient should not rinse, spit, and drink with a straw, or smoke for at least 24 hours after the extraction and preferably longer.
  • He or she should also avoid vigorous exercise for the first three to five days after the extraction.
  • For the first two days after the procedure, the patient should drink liquids without using a straw and eat soft foods.
  • Any chewing must be done on the side away from the extraction site.
  • Hard or sticky foods should be avoided.
  • The mouth may be gently cleaned with a toothbrush, but the extraction area should not be scrubbed.
  • Wrapped ice packs can be applied to reduce facial swelling. Swelling is a normal part of the healing process; it is most noticeable in the first 48–72 hours after surgery. As the swelling subsides, the patient's jaw muscles may feel stiff. Moist heat and gentle exercise will restore normal jaw movement. The dentist or oral surgeon may prescribe medications to relieve postoperative pain.

Post-extraction healing

Following extraction of a tooth, a blood clot forms in the socket, usually within an hour. Bleeding is common in this first hour, but its likelihood decreases quickly as time passes, and bleeding has usually stopped after 24 hours. The raw open wound overlying the dental socket takes about one week to heal. Thereafter, the socket will gradually fill in with soft gum tissue over a period of about one to two months. Final closure of the socket with bony remodelling can take six months or more.

Risks

Potential complications of tooth extraction include postoperative infection, temporary numbness from nerve irritation, jaw fracture, and jaw joint pain. An additional complication is called dry socket. When a blood clot does not properly form in the empty tooth socket, the bone beneath the socket is exposed to air and contamination by food particles; as a result, the extraction site heals more slowly than is normal or desirable.

Morbidity and mortality rates

Mortality from tooth extraction is very rare. Complications include a brief period of pain and swelling; post-extraction infections; and migration of adjacent teeth into the empty space created by an extraction. Most people experience some pain and swelling after having a tooth extracted. With the exception of removing wisdom teeth, migration into the empty space is common. Braces or orthodontic appliances usually control this problem.

Alternatives

Alternatives to tooth extraction depend on the reason for the extraction. Postponing or canceling an extraction to correct tooth crowding will cause malocclusion and an undesirable appearance. Not removing an impacted wisdom tooth may cause eventual misalignment, although it may have no impact. Not removing a decayed or abscessed tooth may lead to septicemia and other complications.