Tooth extractions – the “pulling” of a tooth, root and all – are routine procedures for an oral surgeon. Still, modern dentistry does not take tooth extractions lightly: Today, we perform less extractions than ever. Tooth preservation is the number one goal of contemporary dental medicine. Although great progress has been made in the field of dental replacements and implants, your natural teeth are still the best chewing tools around. A root canal treated, devitalized tooth can fulfill its function for many years to come.
And even for a tooth with a decayed crown – or a crown that has been destroyed by an accident – a restorative solution, i.e., a dental crown or, if necessary, a post crown, will still be the preferred route in most cases. Why? The masticatory pressure that is transferred to the jaw bone via the tooth root plays a very important role in the preservation of bone substance. If that force transfer is interrupted (by removing the tooth), the bone will weaken and recede locally. Future implantation treatments will be complicated by the necessity of extensive bone augmentation measures.
Reasons for tooth extractions
Still, there may be valid reasons for a tooth extraction. The classical indications have been persistant pain and inflammations in the root area despite root canal treatments or root tip resections. Today, tooth preservation is possible in cases that would have been deemed hopeless before, thanks to the elaborate methods of modern endodontics. A lengthwise or crosswise root fracture, an injury that may be caused by accidents, is normally a clear indication for extraction of the injured tooth. Tooth extractions for orthodontic reasons are on the rise. Not every jaw offers enough room for all teeth to sit comfortably straight.
Faced with a lack of space during growth, developing teeth will become crowded, crooked or wedged into each other. Some children and teenagers present with teeth that overlap or are otherwise misaligned. For others, an emerged tooth might prevent the breakthrough of its neighbor (this situation is referred to as a retained or impacted tooth), or a growing tooth might actually erupt entirely out of line, behind the other teeth in the palate. Whether the extraction of a healthy tooth is an option in any of those cases must be decided on an individual basis, and also with regard to the patient’s age: as long as the jaw is still growing, there is a chance for the teeth to straighten themselves out (sometimes, extraction of a stubborn baby tooth may be needed to help them move in the right direction).
However, prior to installing a fixed brace to correct the alignment of teeth (this is usually done when the entire set of adult teeth has erupted), enough room must be created for teeth to take their proper places in the dental arch. This might mean removing the buds of the wisdom teeth (germectomy), or even sacrificing a few healthy adult teeth in the posterior region. For patients with out-of-control periodontitis and severe bone loss (50 percent loss of jaw bone are critical, 70 percent are the “death sentence” for a tooth), extraction of teeth may be a last resort measure (albeit a radical one) to stop the inflammation of the periodontium. Plaque in gingival pockets is the number one cause of periodontitis – and removing the tooth, of course, “removes” the gingival pockets, too. In every other case, talking about the vital role of teeth/tooth roots for the preservation of the jaw bone is entirely justified. With severe periodontitis, paradoxically, extracting the tooth might save what is left the jaw bone.
Since teeth are already loosened due to the advanced bone loss, their extraction doesn’t present much of a challenge. After the inflammation of the periodontium has healed completely, bone augmentation measures may rebuild the alveolar ridge and bring it in shape for the placement of implants. If the jaw already misses a couple of teeth, even a relatively healthy tooth might “fall victim” to dental replacement/prosthesis plans. The question whether to include the tooth into a bridge solution of dubious long term stability, or rather remove it, might be answered in favour of the extraction, particularly if the tooth is already somewhat weakened by periodontitis.
Conclusive overview of indications for a tooth extraction
- Severe inflammations of the root area/periodontium that can not be addressed with endodontic treatment
- Root fractures
- Orthodontic reasons – correction or prevention of dental misalignments
- Severe periodontitis
- Strategic planning of dental replacements
How is a dental extraction performed?
In principle, a simple tooth extraction performed today doesn’t differ much from an extraction performed a hundred years ago: Basically, the tooth is gripped and pulled out. However, it is the little details that matter and add up to an experience that, luckily, is quite different after all: A modern dentist will use an array of sterile instruments that are optimized for all sorts of tooth shapes and sizes.
And most importantly, highly efficient local anaesthetics have turned tooth extraction into a painless, “civil” procedure. In special cases, semiconscious sedation or general anaesthesia may be considered. The dentist will use a lifting, levering motion, combined with a rotation for single-rooted teeth, to widen the bony tooth socket (alveolus) and sever the periodontal ligaments that keep the tooth in place, until a little steady force is enough to remove the tooth. The resulting bleeding is stopped through pressure with a sterile swab. Stronger bleeding or the extraction of several teeth may necessitate some stitches to close the wound.
After the extraction
The clot of coagulated blood that forms in the empty tooth socket is extremely important for healing – it guides the regrowth of connective tissue and later new bone material. Loss of that blood clot will likely lead to painful and lasting inflammations of the wound. To stabilize the clot, you must not rinse your mouth for some time after the extraction.
On the day of the extraction, you even have official permission from your dentist to skip brushing… Expect some swelling and pain after a tooth extraction, and use cool gel pads and pain medication to ease these symptoms (important: no acetyl salicylic acid, as it inhibits blood clotting!). We will see your for a short appointment on the next day to check on the progress of wound healing. If surgical sutures have been placed, they will be removed after a week.
Surgical tooth extraction
If a tooth already misses its crown, if the tooth root is fractured cross-wise or even multiple times, or if a retained/impacted tooth needs to be removed, the extraction is a little more complicated, as the tooth cannot be gripped from the outside. Even for this small surgical procedure, a so-called osteotomy, local anaesthesia may be sufficient to control the pain. Of course, there is always the option of general anaesthesia, too.
First, the dentist will use a scalpel to create a gum tissue flap that will be folded back to reveal the jaw bone. Next, some bone material will be carefully removed until the root, the retained tooth or pieces of the tooth are exposed. After complete removal of the tooth, the gum flap will be closed again and secured with a suture. Usually, the suture material will be removed after a week. The bone under the gum flap will regrow and regenerate completely in the course of a few months.