Dental Extraction

May 2019
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Dental extraction

Dental extraction

A dental extraction 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 wisdom teeth are impacted (stuck and unable to grow normally into the mouth) and may cause recurrent infections of the gum (pericoronitis). In orthodontics if the teeth are crowded, sound teeth may be extracted (often bicuspids) to create space so the rest of the teeth can be straightened.

Tooth extraction is usually relatively straightforward, and the vast majority can be usually performed quickly while the individual is awake by using local anesthetic injections to eliminate painful sensations. Local anesthetic blocks pain, but mechanical forces are still vaguely felt. Some teeth are more difficult to remove for several reasons, especially related to the tooth’s position, the shape of the tooth roots and the integrity of the tooth. Dental phobia is an issue for some individuals, and tooth extraction tends to be feared more than other dental treatments like fillings. If a tooth is buried in the bone, a surgical or trans alveolar approach may be required, which involves cutting the gum away and removal of the bone which is holding the tooth in with a surgical drill. After the tooth is removed, stitches are used to replace the gum into the normal position.

Immediately after the tooth is removed, a bite pack is used to apply pressure to the tooth socket and stop the bleeding. After a tooth extraction, dentists usually give advice which revolves around not disturbing the blood clot in the socket by not touching the area with a finger or the tongue, by avoiding vigorous rinsing of the mouth and avoiding strenuous activity. Sucking, such as through a straw, is to be avoided. If the blood clot is dislodged, bleeding can restart, or alveolar osteitis (“dry socket”) can develop, which can be very painful and lead to delayed healing of the socket. Smoking is avoided for at least 24 hours as it impairs wound healing and makes dry socket significantly more likely. Most advise hot salt water mouth baths which start 24 hours after the extraction.

The branch of dentistry that deals primarily with extractions is oral surgery , although general dentists and periodontists often carry out tooth extraction routinely since it is a core skill taught in dental schools. Periodontists are performing more and more extractions, since they often follow up and place a dental implant.

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, it is still the most common reason for extraction of (non-third molar) teeth with up to two thirds of extractions.
  • Supernumerary 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
  • Supernumerary, supplementary or malformed teeth
  • Prosthetics; teeth detrimental to the fit or appearance of dentures
  • Treatment of symptomatic impacted wisdom teeth, whose impaction is causing pathosis that will lead to yet more (infection, inflammation, bone resorption)
  • Preventive/prophylactic removal of asymptomatic impacted wisdom teeth. Although many dentists remove asymptomatic impacted third molars, both American and British Health Authorities recommend against this routine procedure, unless there is evidence for disease in the impacted tooth or the near environment. The American Public Health Association, for example, adopted a policy, Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth), because of the large number of injuries resulting from unnecessary extractions.
  • Cosmetic – to remove teeth of poor appearance, unsuitable for restoration
  • Head and neck radiation therapy, to treat and/or manage tumors, may require extraction of teeth, either before or after radiation treatments
  • Deliberate, medically unnecessary, extraction as a form of physical torture.
  • 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. Surgical extractions are usually performed under a general anaesthetic.