Overview of Oral Surgery, Extraction of Teeth

Dental extractions, or getting a tooth pulled, are common procedures done by different types of dental practitioners in many places. Even though modern dental care aims to keep your teeth for as long as possible, there are still times when a tooth needs to be pulled. It’s important that every dentist knows how to do tooth extractions well and safely.

This information is about non-surgical tooth extractions, or simple extractions, so that we can talk about the basic steps involved. A tooth is removed non-surgically by gradually widening the tiny bone compartment, or ‘socket,’ where the tooth fits. This makes the tooth shake and finally be removed from your jaw bone. However, dental extractions are not without risks, and all the medical and patient aspects that can influence this risk need to be considered and discussed with the patient before the procedure.

Having a clear understanding of related anatomy, extraction methods, and factors around the operation is crucial for giving effective dental care.

Anatomy and Physiology of Oral Surgery, Extraction of Teeth

The anatomy related to tooth extraction varies depending on the position of the tooth in the mouth. Knowledge of this anatomy helps your dentist decide on the best way to numb your mouth and to understand potential risks of the procedure.

Your upper jaw, known as the maxilla, houses your upper teeth. Its structure separates your mouth from your nose and the hollow spaces in your cheeks called sinuses. In comparison to the lower jaw, the upper jaw’s bone is softer, less dense, and has thinner protective coverings. This makes injecting local anesthesia and pulling out a tooth generally easier. The upper jaw has a rich blood supply which can speed up healing after a tooth extraction.

The lower jaw is called the mandible. It’s shaped like a horseshoe and holds the lower teeth. The mandible bone is denser and has thicker coverings than the maxilla, which makes tooth extractions a bit more challenging and the healing process slower. There’s a small bumpy area in your mouth called the lingula that helps your dentist know where to administer an injection to numb the lower jaw.

Nerves play a crucial role in tooth extraction as they provide sensation to the face, teeth, and mouth area. The fifth cranial nerve, also known as the trigeminal nerve, branches out to supply sensation to different areas of your face. Its various branches cater to the upper teeth and their surrounding structures, like the gums and hard palate. When numbing the area for pulling out an upper tooth, your dentist may use injections in multiple places.

The third branch of the trigeminal nerve, known as the mandibular nerve, provides sensation to the lower face, lower teeth and mouth, front part of the tongue, chin and lower lip. Before pulling a tooth in the lower jaw, your dentist needs to ensure that this nerve is properly numbed. It enters the mandible bone and then comes out again as the mental nerve.

The maxillary sinuses are air-filled spaces in your cheeks which connect to your nasal cavity. The roots of upper back teeth can sometimes extend into these sinuses. An extraction of these teeth carries a risk of creating an opening between your mouth and the sinus, a condition known as oro-antral communication. If the opening is not treated properly, it can develop into an oro-antral fistula, a long-term abnormal connection.

The structure of the tooth, including the shape, length, and number of its roots, needs to be considered when planning for a tooth extraction. A thorough examination checks for relevant factors such as cavities that might influence the method of extraction. The condition of the bone around the tooth is also taken into account because signs of bone loss can make extraction more complicated.

Why do People Need Oral Surgery, Extraction of Teeth

There are various reasons why your dentist might suggest that you have a tooth taken out, a process called a dental extraction. While dentists usually aim to keep as many of your natural teeth intact as possible, sometimes it’s just not possible, or in your best interests, to keep a tooth.

Dental Caries

One reason you might need a tooth extraction is due to dental caries, or tooth decay. If the decay has progressed too far, there may not be enough healthy tooth left to save with a filling or other restoration. In this case, extraction becomes the only option to treat the decay. In fact, tooth decay is the most common reason why teeth are removed.

Pulpal/Apical Pathology

Dental caries can lead to another issue called pulpal or apical pathology. This is a disease in the pulp or root of the tooth. If this condition cannot be fixed with a procedure known as endodontic treatment (also known as a root canal) or if the tooth cannot be restored after the treatment, then the tooth may need to be removed. A dentist might also recommend a tooth extraction if you opt not to have a root canal but still want the tooth in question to be treated.

Severe Periodontal Disease

Severe gum disease can cause the bone in the upper or lower jaw to be destroyed. This leads to a loose tooth that can be bothersome. Since there are limited ways to regenerate bone, the best course of action may be to extract the tooth.

Fractured Teeth

If a tooth breaks and cannot be restored or saved, it might need to be extracted.

Retained Dental Roots

Sometimes, only the crown of the tooth, the part you can see, breaks off and the root is left behind. This can happen due to decay and trauma or after a tooth extraction that didn’t remove the entire tooth. While there are certain circumstances where the root can be left in place, often it’s best to remove it to prevent future infection and discomfort.

Impacted Teeth

A tooth that cannot grow in properly due to a physical barrier is considered impacted. These teeth are often removed to prevent complications. Leaving an impacted tooth untreated can potentially lead to the formation of cysts. These situations are common with certain teeth, like lower wisdom teeth, upper canines, and lower premolars. The decision to remove or observe the impacted tooth should be made with your dentist.

Supernumerary Teeth

A supernumerary tooth is an extra tooth beyond your typical set. These teeth most commonly appear in the roof of the mouth. They can cause a variety of dental issues which include preventing permanent teeth from coming in, overcrowding, and other dental problems. If it causes trouble, your dentist may suggest removal.

Orthodontic Extractions

Sometimes, extractions are necessary before orthodontic treatment, such as braces. This is often to create space for the alignment of other teeth.

Pre-prosthetic Extractions

Extraction of a tooth may be necessary to create the ideal fit for dental prosthetics, like dentures. Additionally, if a tooth is likely to negatively affect the fit of a prosthesis in the future, it may be removed ahead of time.

Tooth In a Fracture Line

If a fracture of the lower jaw includes a tooth, which could potentially cause an infection or slow down the healing of the fracture, or if the tooth is broken, your dentist or oral surgeon may suggest removing that tooth during the fracture repair surgery.

Teeth with Associated Pathology

If a tooth is associated with certain diseases, such as jaw cysts or cancer, it might need to be removed.

Prior to Radiotherapy

Before starting radiation therapy for cancers located in the head and neck area, a dental assessment is typically performed. This allows the dentist to spot any teeth that may cause problems or infections in the future, as extracting a tooth after radiation treatment poses a risk for a serious condition known as osteoradionecrosis of the jaw, which should be avoided if possible.

When a Person Should Avoid Oral Surgery, Extraction of Teeth

In simple terms, while urgent dental extractions may be necessary, it is crucial to understand the patient’s overall health before any procedure. This means analyzing the possible risks and benefits of the extraction concerning their overall situation. Any health conditions which could impact the procedure should be brought under control.

In cases where the patient has a noticeable medical condition that isn’t under control, the dentist ought to coordinate with the patient’s doctor to manage it. For instance:

  • Patients with uncontrolled epilepsy are at a higher risk during procedures due to possible seizures.
  • Patients with a history of high blood pressure or stroke are susceptible to another stroke during surgery.
  • People with breathing problems, like Chronic Obstructive Pulmonary Disease (COPD), might be uncomfortable lying flat and may have issues with sedation for dental procedures due to medication reactions.
  • Heart disease patients, specifically those with infective endocarditis, a type of heart infection, need to have their blood pressure monitored throughout an extraction.
  • People with severe kidney disease are at a higher risk of infection and bleeding during operations.
  • Poorly controlled diabetes can affect healing and infection rates after surgery.
  • Patients with weakened immune systems, possibly from chemotherapy or certain medicines, face a risk of infection due to dental procedures.

In addition to these conditions, medications can impact the ability of a tooth extraction to proceed.

  • Certain bone medications like bisphosphonates, which are used to treat bone loss conditions, can slow down the healing process after an extraction.
  • Steroids can affect the healing process after an extraction.
  • Medications like anticoagulants and blood thinners can affect dental procedures because they can increase the risk of bleeding.

In any case, each patient’s situation is unique and must be evaluated individually. The dentist will work closely with the patient’s doctor to ensure a safer procedure. The patient’s understanding and consent for treatment, as well as attentive scheduling of necessary follow-ups, should always be a priority.

Equipment used for Oral Surgery, Extraction of Teeth

It’s crucial that your dentist uses the right tools when extracting a tooth, to ensure the procedure is as swift, safe, and pain-free as possible. There’s a variety of equipment that dentists have at their disposal and they need to know which one fits the situation best. Below are some commonly used tools in this process.

Dental Anesthesia Equipment

A tooth extraction typically involves local anesthesia, which is administered with a syringe, a needle, and a plunger. The syringe and plunger might be either disposable or reusable. The needle is double-ended; one end goes into the anesthetic cartridge while the other punctures your gum. Dental needles come in three lengths: extra-short, short, and long, with a short needle being about 21 mm and a long needle about 32mm. The diameter of a dental needle is known as the gauge, with higher gauge numbers indicating smaller diameters. Studies have shown that patients typically don’t experience different pain levels for different gauges. Dental local anesthesia is available in various drug formulations and concentrations. Including adrenaline in local anesthesia can help prolong its effectiveness.

Elevators

Elevators are tools used to loosen the tooth from the ligaments holding it in place, and to lift the tooth out of its socket. They should be placed in a way that the inside is in contact with the tooth and the outer part is touching the jaw bone, not the neighbouring tooth.

Coupland Elevators and Warwick James Elevators

Coupland elevators (which come in three widths) and straight Warwick James elevators are used for slowly expanding the tooth socket, while the curved Warwick James elevators are used with a “scooping” motion to displace a tooth.

Cryers

Cryers are similar to Warwick James elevators, but feature a sharp, triangular tip. This design makes them effective for lifting the root tips at the base of a tooth socket when the adjacent root has been removed.

Luxators

While similar in appearance to elevators, luxators have a different purpose. They’re used for cutting the ligaments that hold a tooth in place and widening the tooth socket, which makes the extraction process gentler and preserves bone for possible future dental implant.

Forceps

Dental extraction forceps have three parts: the handle, the hinge, and the beaks. The beaks, which are designed to grip the tooth, angle differently depending on whether they are meant to remove a tooth in the upper or lower jaw. Forceps are used to apply pressure to a tooth using either a turning motion, a side to side motion, or both.

Scalpel

The most common scalpel used in dentistry has a 15-blade, which is also often used in skin procedures. It is ideal for use in the mouth due to its fine, thin tip.

Surgical Handpiece and Burs

In certain cases, a surgical handpiece, which works with burs, may be used to remove bone during the extraction process.

Who is needed to perform Oral Surgery, Extraction of Teeth?

Before teeth are removed, a dentist checks the patient’s health. Ideally, the dentist who examines you should also be the one who takes your tooth out. But sometimes, different dentists will do these tasks, especially in a hospital setting.

The tooth removal procedure, also known as extraction, is always done by a specially trained dentist called a dental surgeon. A dental assistant, who is like the surgeon’s helper during the procedure, makes sure that the all the necessary tools are ready when needed.

The dental assistant also plays a vital role during the tooth removal. They help the surgeon get a clear look at the tooth by using a suction tool to keep your mouth dry and by moving your gums gently out of the way if needed. If the dental assistant knows how, they can also give you advice on what to do after your tooth is removed to help you recover quickly.

After the tooth is removed, the surgeon must safely get rid of any tools with sharp ends. The dental assistant or a specialist cleaning team will then clean or dispose of the rest of the equipment so that everything remains hygienic.

Preparing for Oral Surgery, Extraction of Teeth

Before having a tooth pulled out, it’s important for you, the patient, to talk with your dentist. Generally, it’s best for this discussion and the actual operation to happen on different days. This offers you time to process the information and decide if you’re okay with the procedure.

During your talk with your dentist, he or she will ask about your medical history. This includes any current illnesses or conditions and any medicines you’re taking, whether prescribed or not. The dentist will also inquire about any allergies. This information helps your dentist consider any special limitations for your treatment. Other factors, like how much you weigh, can affect how much local anesthesia (numbing medicine) you can safely receive.

Before deciding to remove your tooth, your dentist must diagnose the problem accurately. Through an examination and conversation with you about your symptoms, your dentist will identify the tooth that’s causing issues. Proper diagnosis prevents removing a healthy tooth accidentally. Once the problem is found, your dentist will share with you all the possible treatment plans.

If you agree to go ahead with tooth extraction, you and your dentist will have a detailed discussion about your consent. Your dentist should explain all the usual risks that come with a tooth extraction like pain, bleeding, swelling, or infection, as well as less common ones. They might talk about potential damage to nearby teeth; this sometimes happens during the procedure, particularly if those teeth have undergone a lot of treatment already.

The conversation will also cover potential risks unique to your situation, such as an IDN injury—an injury that could alter sensation in your lip, cheek, tongue, and teeth, change your sense of taste, or create an OAC (a hole in the bone where the tooth used to be). While such events are less common, your dentist will consider your particular risk for these problems after a thorough examination. It is important to have your agreement in writing and to reaffirm your consent on the day of the operation.

Your dentist might need to conduct more in-depth examinations. For instance, X-rays of the problematic tooth should be taken before the extraction. Depending on what the X-ray reveals, you might have to agree to additional investigations.

There might be some medical conditions or medications that need to be addressed before the operation. For example, if you need to discuss your treatment with your doctor, this should be done before the procedure. This avoids any potential conflicts with pre or post-operation instructions. If you need to stop taking a certain medication or change the dosage, your dentist will let you know well in advance to let you prepare.

Before the surgery begins, your dentist will confirm your consent. They will have already studied the necessary information and X-rays to prepare for the procedure. The dentist and the assistant will prepare the tools needed for the treatment based on your specific case. This approach helps your dentist to carry out the operation smoothly and safely.

How is Oral Surgery, Extraction of Teeth performed

This section breaks down the steps in removing a tooth, referring to a dental extraction. All these steps come right after the ones mentioned in our previous discussion on the topic.

Anesthesia

Different teeth require different types of anesthesia. For teeth on your upper jaw, injecting anesthesia into the inner and outer side of your mouth usually works. Usually, a small needle lets out a liquid that numbs your tooth. This liquid is typically lidocaine or articaine. On the other hand, for lower jaw teeth, a nerve block injection on the side of your lower jaw plus the anesthesia on the outer side of your mouth is typically used, and it’s administered with a longer needle. There’s also an option of another type of injection where a short needle delivers the numbing agent directly beside the tooth.

Usually, lidocaine is the preferred anesthetic because there are some concerns about the potential of articaine to harm nerves, although no solid evidence supports these concerns.

After the initial dose, the doctor waits for the numbing agent to kick in. This might need up to five minutes. Then they check if the anesthesia is working by pressing a dental probe into your tooth to see whether you feel pain. They’ll let you know that pressure is normal but sharp pain is not. If you still feel sharp pain, they’ll give you more anesthesia. You might need more doses during the procedure.

Luxation/Elevation

The dentist might have to loosen or lift each tooth before it can be pulled out. They do this with a tool called a luxator. To lift or loosen the tooth, they slide the luxator deep into your mouth alongside the tooth. Sometimes, this loosens the tooth enough to pull it out. Or, they might have to follow up with something called forceps. If the crown of the tooth (the visible part of the tooth) breaks during this process, they can also use the luxator to remove the root, which remains in your gums.

Forceps

Forceps are like pliers used to remove the tooth. The dentist will choose a forceps according to the tooth being removed and will try to apply it as close as possible to the base of the tooth to prevent breaking the visible part of the tooth. Once the forceps are in place, they use a combination of twisting and rocking movements to gently disentangle the tooth from its socket.

Achieving Hemostasis

After the tooth is removed, the dentist will ask you to bite down on a roll of gauze or a bite pack placed over the empty socket. This helps stop the bleeding. You might need to bite down for at least five minutes, and they’ll check to make sure any bleeding has stopped before you’re allowed to get up from the chair. If the bleeding continues, they might need to use special clotting agents.

All these steps are typically followed to remove the tooth. But if these steps don’t work, a surgical approach might be necessary.

Possible Complications of Oral Surgery, Extraction of Teeth

Just like any surgery, taking out a tooth carries certain risks. That’s why it’s important that your dentist talks to you about these risks before they do the procedure. Some common issues that might come up after tooth removal include:
– Pain
– Bleeding
– Bruising
– Swelling
– Infection

It’s also possible that nearby structures, like other teeth, might be affected, especially if those teeth have fillings or crowns.

Pain is common after dental extraction, and usually, over-the-counter painkillers, such as paracetamol and ibuprofen, can help. If those don’t work, you may feel the need to visit your dentist again due to the pain. Your dentist will reassure you that the pain should decrease within 3 to 7 days and may prescribe stronger painkillers.

One condition that can cause pain is alveolar osteitis, also known as dry socket. This happens if the blood clot that normally forms after an extraction breaks down before the wound has healed. It typically gets worse 1 to 3 days after the extraction and you might taste something bad in your mouth or have bad breath. Treatment includes cleaning the socket and putting a medicated dressing in it.

Bleeding is also common after tooth extraction. If it doesn’t stop after pressure is applied for a long period of time, your dentist might use medicines to stop the bleeding. If you experience continuous bleeding at home, you should seek urgent help from a dentist or doctor.

You may experience some bruising and swelling after tooth extraction, but these should disappear in a few days. Speaking of swelling, this might also be a sign of an infection, so your dentist will be looking out for signs of fever or difficulty breathing. Be reassured that a little swelling is normal, but if you suspect an infection, get checked by a healthcare professional.

While infections after tooth removals are rare, they can be serious. For this reason, you need to be aware of the risk, even though you won’t need antibiotics unless you get an infection. Other risks that your dentist will inform you about include damage to nearby teeth and nerve injury, which could lead to a changed feeling in the lip, cheek, tongue, and teeth.

Your dentist should also inform you about the risk of oroantral communication (OAC), which is more common when the tooth near your upper jaw is removed. This happens when an opening forms between your mouth and sinuses during extraction. If the opening is small enough, it will close on its own. However, if it’s larger than 2mm, it could turn into an oroantral fistula (OAF), which can lead to sinus issues. Usually, a surgeon will need to close these openings within 24 hours.

Lastly, remember that mistakenly removing the wrong tooth is a rare but unfortunate complication. It’s crucial that you and your dentist communicate clearly to avoid any potential mixups.

These are just a few of the common issues people might have after tooth extraction. You should discuss them with your dentist to get all the information you need.

What Else Should I Know About Oral Surgery, Extraction of Teeth?

It’s essential to understand certain basic principles if routine dental surgeries are to be carried out effectively. Regular tooth removals are fundamental procedures that all professional dentists should be able to do. So, knowing when tooth extraction is needed (indications), when it should be avoided (contraindications), and taking into account any relevant health factors is absolutely crucial.

Furthermore, being able to properly plan for a tooth extraction, choosing the right tools, and knowing how to use these tools effectively can greatly increase the chance of a successful treatment. The theoretical knowledge discussed here is meant to be used in conjunction with ongoing hands-on experience.

Frequently asked questions

1. What is the reason for extracting my tooth? 2. What are the risks and potential complications associated with the extraction? 3. How will the extraction be performed and what tools will be used? 4. What type of anesthesia will be used and what are the potential side effects? 5. What is the expected recovery process and are there any specific post-operative instructions I should follow?

Oral surgery, specifically the extraction of teeth, can affect you in various ways. The anatomy of your upper and lower jaw plays a role in the procedure, with the upper jaw generally being easier to extract teeth from due to its softer bone and richer blood supply. Nerves also play a crucial role, with the trigeminal nerve providing sensation to different areas of your face and the mandibular nerve needing to be properly numbed before extracting a tooth in the lower jaw. Additionally, the structure of the tooth and the condition of the surrounding bone need to be considered when planning for a tooth extraction.

There are several reasons why someone may need oral surgery, specifically extraction of teeth. Some of these reasons include: 1. Severe tooth decay: If a tooth is extensively decayed and cannot be restored with a filling or crown, extraction may be necessary to prevent further damage and infection. 2. Impacted wisdom teeth: Wisdom teeth, also known as third molars, often do not have enough space to fully emerge or develop properly. This can cause pain, infection, and damage to surrounding teeth, requiring extraction. 3. Crowded teeth: In some cases, teeth may be overcrowded, causing misalignment and bite problems. Extracting one or more teeth can create space and improve the alignment of the remaining teeth. 4. Gum disease: Advanced gum disease can lead to the loosening of teeth. In some cases, extraction may be necessary to remove severely affected teeth and prevent the spread of infection. 5. Trauma or injury: If a tooth is severely damaged or fractured due to trauma or injury, extraction may be the best option to prevent further complications and restore oral health. 6. Orthodontic treatment: In certain orthodontic cases, extraction of one or more teeth may be necessary to create space and achieve proper alignment of the teeth. It is important to note that each patient's situation is unique, and the need for oral surgery and tooth extraction should be evaluated on an individual basis by a dentist or oral surgeon.

One should not get oral surgery, extraction of teeth if they have certain medical conditions that are not under control, such as uncontrolled epilepsy, high blood pressure, breathing problems, heart disease, severe kidney disease, poorly controlled diabetes, weakened immune systems, or if they are taking certain medications that can impact the healing process or increase the risk of bleeding. It is important to evaluate each patient's unique situation and work closely with their doctor to ensure a safer procedure.

The recovery time for oral surgery, specifically the extraction of teeth, can vary depending on the individual and the complexity of the extraction. In general, it takes about 7-10 days for the initial healing process to occur, during which time you may experience some discomfort, swelling, and bleeding. However, complete healing and full recovery can take several weeks to a few months.

To prepare for oral surgery and the extraction of teeth, it is important to have a clear understanding of the procedure and any potential risks involved. This includes discussing your medical history, current medications, and any allergies with your dentist. Your dentist will also diagnose the problem accurately and discuss the treatment plan with you, including the risks and potential complications. Finally, you will need to give your informed consent for the procedure and discuss any specific concerns or questions you may have with your dentist.

The complications of oral surgery, extraction of teeth include pain, bleeding, bruising, swelling, infection, damage to nearby teeth, nerve injury, alveolar osteitis (dry socket), oroantral communication (OAC), and mistakenly removing the wrong tooth.

Symptoms that require oral surgery and extraction of teeth include dental caries or tooth decay that has progressed too far, pulpal or apical pathology in the root or pulp of the tooth, severe periodontal disease causing bone destruction, fractured teeth that cannot be restored, retained dental roots causing infection or discomfort, impacted teeth that cannot grow in properly, supernumerary teeth causing dental issues, the need for extractions before orthodontic treatment or dental prosthetics, teeth in fracture lines that could cause infection or hinder healing, teeth associated with certain diseases, and the need for extractions prior to radiation therapy to prevent complications.

The safety of oral surgery, specifically the extraction of teeth, during pregnancy depends on several factors. It is generally recommended to avoid elective dental procedures during the first trimester and the second half of the third trimester. However, if the extraction is necessary due to infection, pain, or other urgent reasons, it can be performed at any stage of pregnancy with proper precautions. Before proceeding with the extraction, it is important for the dentist to consult with the patient's obstetrician to ensure that the procedure is safe for both the mother and the baby. The dentist will also consider the patient's overall health, the complexity of the extraction, and any potential risks or complications. Local anesthesia is commonly used during tooth extractions, and it is generally considered safe during pregnancy. However, the dentist may choose to use alternative anesthesia techniques or adjust the dosage to minimize any potential risks to the fetus. It is important to inform the dentist about the pregnancy and any medications or supplements being taken. In summary, while dental extractions during pregnancy should be avoided if possible, they can be performed if necessary with proper precautions and consultation with the obstetrician. The dentist will assess the individual situation and take steps to ensure the safety of both the mother and the baby.

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