Tooth Removal (Tooth Extraction)

In dentistry, a tooth extraction (Latin ex-trahere “to pull out”) is the removal of a tooth without further surgical measures. To mobilize the tooth, instruments are used to rotate (turn) or luxate (push) the tooth rather than “pull it out” in the true sense. Tooth extraction is the most common surgical procedure in dentistry. If more extensive surgical measures are required to mobilize a tooth, such as the formation of a mucosa-periosteum flap (mucosa-bone flap) and the removal of bone, one enters the realm of surgical tooth removal, known as osteotomy or flaring. A surgical procedure is usually required for displaced, retained (retained refers to a tooth that has not yet appeared in the oral cavity at its normal eruption time) or partially retained teeth, or for the removal of root debris, among others. However, even in the case of teeth that should be removable by a supposedly simple extraction, the need for flaring may arise during the course of the procedure. Therefore, planning the procedure based on clinical assessment and radiographs is mandatory. In case of doubt, the decision is made in favor of osteotomy.

Indications (areas of application)

  • Periodontal reasons such as severe loosening (grade III) without prospect of regeneration of the periodontium (periodontium) by appropriate measures.
  • Tooth fractures – longitudinally fractured teeth (longitudinal root fracture); transversely fractured teeth (transverse root fracture) with an unfavorable course of the fracture line for tooth preservation.
  • Apical periodontitis (inflammation of the periodontium (periodontium) just below the tooth root; apical = “tooth rootward”), which is not endodontic (by a root canal treatment) or by a root tip resection (WSR; surgical ablation of the root tip) to treat.
  • Teeth that cause progressive infections such as lodge abscesses (accumulations of pus that take place in compartments formed by muscles, so-called lodges)
  • Wisdom teeth with dentitio difficilis (difficult tooth eruption), whose setting in the dental arch due to lack of space is not possible
  • Partially retained teeth with signs of inflammation
  • Retained teeth with symptoms
  • Teeth with diseased pulp (tooth pulp), which are not accessible to root canal treatment.
  • Teeth after endodontics (root canal treatment) with persistent pathological (pathological) findings and complaints without the possibility of a revision (review) of the root filling or root tip resection.
  • Teeth with pronounced root resorptions (melting at the roots of the teeth), e.g. after trauma (dental accident).
  • Dentition rehabilitation with removal of all teeth that can not be safely preserved before a radiotherapy (radiation treatment) in the oral and maxillofacial region or before chemotherapy.
  • Before organ transplants in the case of immunosuppression (suppression of defense reactions).
  • Teeth in the fracture gap of a jaw fracture.
  • Systematic extraction therapy – as part of orthodontic treatment to eliminate tooth crowding resulting from a mismatch between tooth and jaw size, or as a compensatory extraction to restore symmetry and prevent midline shift, e.g., when only one premolar (anterior molar) is not in place
  • Obstacles to eruption – removal of supernumerary teeth or deciduous teeth that hinder the eruption of permanent teeth.
  • Deep degree of destruction – teeth destroyed by caries, which can not be permanently preserved by measures such as fillings or crowns.
  • Functionless root remnants

Contraindications

  • Untreated coagulation disorders
  • Known coagulation disorder without prior determination and, if necessary, adjustment of the current coagulation status by the treating general practitioner or internist.
  • Severe cardiovascular insufficiency
  • Acute myocardial infarction (heart attack)
  • Rehabiliationsphase of a myocardial infarction.
  • Acute leukemias (blood cancers) and agranulocytoses (severe reduction of granulocytes, a subset of white blood cells (leukocytes)).
  • Immunosuppression (suppression of defense responses).
  • Radiatio (radiotherapy)
  • Chemotherapy
  • Acute pericoronitis of the lower wisdom tooth (pocket inflammation around the crown of the erupting wisdom tooth).

In the presence of a contraindication, pain must be eliminated, for example, by trepanation (opening) of the affected tooth and drainage (drainage or the suction of pathological or increased body fluids) of an inflammatory process, before the extraction can take place in a stabilized general condition after targeted pre-treatment by the specialist.

Before surgery

  • Radiographs to provide an overview of the pathologic (disease) process and to plan the procedure
  • Informing the patient about the nature and necessity of tooth extraction, typical risks associated with it, and alternatives and consequences of not performing the procedure
  • Informing the patient about rules of conduct after the procedure
  • Information about the limited ability to react after the extraction: during the period of action of local anesthesia (local anesthesia) is to be expected with a limited ability to react, so that the patient should not actively participate in road traffic and also not operate machines.
  • Before removal of several teeth, if necessary, a dressing plate is made in the dental laboratory.
  • Coordinate treatment with the family doctor or internist in the presence of a coagulation disorder.
  • If necessary, initiation of an antibiotic adjunctive therapy, e.g., at risk of endocarditis (risk of inflammation of the inner lining of the heart (endocardium)), condition after radiotherapy (radiotherapy) or bisphosphonate therapy (used in osteoporosis and cancer therapy) or otherwise increased local risk of infection

The surgical procedure

1. local anesthesia (local anesthesia).

  • In the maxilla, infiltration anesthesia is usually used, in which a depot of the anesthetic (numbing agent) is placed close to the bone in the envelope crease on the tooth to be extracted. A second depot anesthetizes the palatal mucosa in the area of the tooth. For the anterior teeth (13 to 23), the second anesthetic is placed next to the papilla incisiva (incisor papilla).
  • In the mandible, infiltration anesthesia is not performed because it cannot sufficiently penetrate the stable mandibular bone. Here, a conduction anesthesia of the inferior alveolar nerve (a branch of the mandibular nerve) is performed, which supplies the dental compartments of one half of the mandible at a time. The depot is placed at the point where the nerve enters the mandible. The lingual nerve (tongue nerve), which supplies the anterior two-thirds of the tongue with sensation, runs in the immediate vicinity, so this is also anesthetized. Another depot is placed in the area of the tooth in the vestibulum (in the envelope fold) to capture the buccal nerve (cheek nerve) and thus the mucosa and gingiva (mucosa and gums) located to the cheek.
  • Both procedures can be combined with intraligamentary anesthesia (ILA, IA, synonym: intradesmodontal injection). For intraligamentary anesthesia, the anesthetic is injected into the desmodontal crevice (desmodont is the technical term for root membrane or periodontium) with a special syringe that has a particularly thin cannula and can build up high pressure, from where it is distributed through the cancellous bone to the apex (root tip). The defined dosage per stroke is 0.06 ml for Citoject, for example. An anesthetic quantity of 0.15 to 0.2 ml is required per root, with the depots being distributed over two puncture sites. With restrictions affecting the mandibular posterior teeth, ILA can also be used as a sole anesthetic technique. Anesthesia is limited to the tooth in question. Since much less anesthetic is required, the procedure is suitable for patients with cardiovascular disease, for example.

2. severance of the supra-alveolar connective tissue.

The gingival margin is supra-alveolar (above the bony tooth socket) connective tissue connected to the neck of the tooth by a tight, functionally aligned fibrous mesh. This tightly fixed connective tissue is first released from the neck of the tooth using a lever, e.g. the Bein lever. 3. luxation, rotation and tooth removal

Most teeth cannot be removed by “pulling” alone. Rather, to mobilize (move) a tooth out of its alveolus (tooth socket), the Sharpey’s fibers connecting the tooth to the alveolus (bony tooth socket) must be torn and the alveolar socket widened.Depending on the tooth and jaw, a wide variety of forceps and levers are available as instruments. They are used to sensitively perform rotation and/or luxation movements (rotation, lever and tilting movements) and to feel in which direction the tooth gradually gives way. At the same time, the fingers of the free hand are used to support the surrounding bone walls, and in the mandible also the jaw itself, in order to protect the temporomandibular joints. After sufficient loosening, extrusion (extraction) is usually performed with forceps, which are placed with the mouth of the forceps against the enamel-cement interface of the tooth and guided in the direction in which extrusion appears to be most easily possible. 4. exclusion of an oral-antral connection

The root tips of the upper posterior teeth may extend below the mucosa of the maxillary sinuses. To exclude an opening between the oral and maxillary sinuses, a so-called nasal blow test is performed after the removal of upper posterior teeth, and the alveolus (bony tooth compartment) is carefully palpated with a button probe. A connection must be tightly closed with a vestibular (in the oral vestibule) pedicled expansion flap using a plastic cover. 5. curettage and wound care

After extraction, soft tissue with inflammatory changes is carefully curetted (scraped out with so-called sharp spoons) and, if necessary, sent for pathohistological (fine tissue) examination. Since extraction injures the blood vessels of the gingiva, the periodontium and the bone, bleeding is an inevitable side effect. This can usually be staunched by a pressure dressing in the form of a sterile swab for about ten minutes, which the patient bites on during this period. In the alveolar compartment, a blood coagulum (blood clot) forms as an ideal wound dressing, which is crucial for primary wound healing. In cases of coagulation disorders, collagen, fibrin glue, or other inserts may be required to promote blood coagulation in the extraction wound. Tranexamic acid, applied as a gel or lozenge, inhibits fibrinolysis (the body’s own enzymatic dissolution of a clot) in the course of wound healing, helping to stabilize the wound plug. When extracting multiple teeth, an interlaced papilla suture can be placed to reduce the wound surface, bringing the papillae (gums in the interdental spaces) alternately closer together. A dressing plate previously made of plastic can also be inserted to protect the wound surface. If tooth extraction is unavoidable after radiation therapy or bisphosphonate therapy (bisphosphonates are used to treat metabolic bone diseases, bone metastases, osteoporosis, etc.), even with a strict indication, plastic covering of the wound is necessary even in the case of a simple tooth extraction in order to prevent infection (inflammation) of exposed bone areas. 6. postoperative pain therapy

An analgesic (painkiller) may be prescribed after the procedure. Since acetylsalicylic acid inhibits platelet aggregation (clumping of platelets) and thus negatively affects blood clotting and coagulation, preference should be given to ibuprofen, acetaminophen, or the like.

After surgery

After the procedure, the patient is best given the behavioral instructions in writing to properly handle the extraction wound:

  • Do not operate vehicles and machines until the anesthesia wears off.
  • Cool for 24 hours with cool packs or wet, cold washcloths to reduce blood flow
  • Abstaining from food until the anesthesia wears off.
  • For a few days soft food – avoid grainy foods.
  • Do not rinse the wound, otherwise it will prevent the formation of a wound plug
  • Dental care nevertheless continue to operate
  • No mouthwash in the wound area!
  • Avoid dairy products, as lactic acid bacteria can lead to the dissolution of the wound plug, which is important for the primary wound healing.
  • Avoid caffeine, nicotine and alcohol even on the following day, as these increase the bleeding tendency and thus the risk of secondary bleeding
  • Sports and heavy physical work also on the following day still refrain, as these promote the bleeding tendency
  • In case of light post bleeding bite on a rolled up clean cloth handkerchief until the bleeding stands
  • In case of heavier post-bleeding always contact the dentist
  • If severe pain occurs three days after the procedure, alveolitis sicca is suspected: consult a dentistNote: Alveolitis sicca causes severe pain (= dolor post extractionem) in the wound area approximately two to four days after a tooth extraction. The coagulum has decayed or been lost, which may be accompanied by unpleasant odors (foetor ex ore). The bone is exposed. The wound is sometimes reddened at the wound edges and the tooth compartment appears empty or contains the dissolved, malodorous coagulum

Follow-up inspection of the wound usually takes place the following day. If a wound plug has formed, the wound heals primarily within a few weeks. If sutures were placed, they are removed after about a week. Sutures to close an opened maxillary sinus remain for at least ten days.

Possible complications

  • Abnormal root conditions such as hypercementosis (thickening of the root), splayed or severely curved roots can act as an obstacle to extraction, leading to root fracture (root breakage) and thwarting extraction without further surgical intervention
  • Crown fracture – Deeply destroyed teeth can fracture when accessed with forceps in the crown area.
  • Tuber fracture (tuber fracture) in dislocation attempts of the upper wisdom teeth (tuber maxillae: protrusion on the posterior surface of the maxillary bone).
  • Mouth-antrum junction (MAV) – opening of the maxillary sinus during the removal of upper posterior teeth; as a result, the MAV must be surgically closed (plastic coverage).
  • Ossification of Sharpey’s fibers in devitalized teeth – moving the tooth in the alveolar compartment is impossible, so an osteotomy is inevitable.
  • Luxation (dislocation) of a temporomandibular joint during extraction of a mandibular tooth.
  • Edema (swelling)
  • Post-bleeding
  • Hematoma (bruise), especially in blood clotting disorders.
  • Increased bleeding tendency in blood clotting disorders.
  • Alveolitis sicca – dry alveolus: the wound plug has dissolved, leaving the bone of the tooth socket exposed and painfully inflamed. The wound must be curetted (scraped) and tamponade at several follow-up appointments (secondary wound healing).
  • Swallowing teeth or broken parts of teeth.
  • Soft tissue inflammation
  • Aspiration (inhalation) of teeth or broken parts of teeth: Further treatment by a specialist
  • Luxation of a tooth or tooth fragment into the maxillary sinus or soft tissues.
  • Soft tissue injury
  • Vascular injury
  • Injury to adjacent teeth
  • Injury to nerves, especially the lingual nerve and the inferior alveolar nerve
  • Mandibular fracture (fracture)
  • Alveolar process fracture (fracture of the tooth-bearing portion of a jaw).