Tooth Extraction

Updated: Apr 30, 2015
  • Author: Talib Najjar, DMD, MDS, PhD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Overview

Overview

Background

Tooth extraction is linked to dentists who perform oral surgery. Teeth that are embedded in bone (eg, impacted or wisdom teeth) must be removed by an oral and maxillofacial surgeon who is trained for 4-6 years after obtaining a dental or medical degree.

Compared with removal of an impacted tooth, tooth extraction appears to be a relatively simple technical procedure. However, both tooth extraction and removal of an impacted tooth must be performed in accordance with surgical principles that have evolved from both basic research and centuries of trial and error. Tooth extraction leaves a surgical wound, which has to heal. Accordingly, a basic understanding of wound healing is essential for performing this surgical procedure in the oral cavity.

Like any other minor surgical procedure, tooth extraction requires careful medical evaluation of the patient. Patients with diabetes, hypertension, renal disease, thyroid disease, adrenal disease, or other organ disease must be treated and their disease controlled before tooth extraction. Because the oral cavity is full of microorganisms, any surgical procedure in this area may give rise to postoperative infection, especially in immunocompromised patients.

Before, during, and after tooth extraction, pain management is an important issue. Medical, surgical, and legal considerations exist; for example, removing the wrong tooth is malpractice, as is breaking the jaw during extraction or causing paresthesia after extracting the mandibular third molar in close proximity to the inferior alveolar nerve without proper informed consent.

Indications

Teeth are important for aesthetic purposes and for maintaining masticatory function. Accordingly, all efforts to avoid tooth extraction must be exhausted before the decision is made to proceed with removal of a tooth. Nevertheless, there are circumstances in which it is clear that a tooth must be extracted, such as the following:

  • A tooth that cannot be restored, because of severe caries
  • A mobile tooth with severe periodontal disease, pulp necrosis, or periapical abscess, for which root canal treatment is required that the patient cannot afford (or for which endodontic treatment failed)
  • Overcrowding of teeth in the dental arch, resulting in orthodontic deformity [1]

Other conditions that may necessitate extraction include the following:

  • Malposed teeth causing soft tissue trauma to the cheek
  • Cracked teeth from trauma
  • Supernumerary teeth
  • Teeth adjacent to a pathologic lesion that must be excised
  • Planned radiation or intravenous (IV) bisphosphonate treatment, warranting prophylactic extraction
  • Teeth in the line of fracture
  • Aesthetic considerations (eg, teeth with endogenous staining)
  • Economic considerations (eg, teeth for which extensive restoration is required that the patient cannot afford [2] )

Contraindications

There are few contraindications for tooth extraction, and most of those that do exist can be modified by additional medical consultation and treatment. Some contraindications can be so severe that extraction should not be performed until the severity of the medical condition has been resolved.

Essentially, contraindications may be divided into local and systemic. Local contraindications are limited to the extraction sites. An example is an extraction site that was heavily exposed to radiation; if extraction is performed in the irradiated area, osteoradionecrosis results. Other local contraindication is proximity to a malignancy; extraction in the area of malignancy may increase the chances of dissemination of malignancy.

Extraction may be contraindicated in an area of infection that has not been adequately treated (eg, an impacted third molar associated with pericoronitis that is not treated with an antibiotic). Extraction may also be contraindicated when it is adjacent to the site of jaw fracture, because the teeth may be required for stabilization of the fractured bone. If the patient has very limited mouth-opening ability, extracting a tooth may be extremely difficult because of limited access to local anesthesia. [3]

A systemic contraindication systemic bisphosphonate therapy for malignancy. Extraction in patients receiving such therapy results in osteochemonecrosis, which is more severe than osteoradionecrosis and is more difficult to treat. Other systemic contraindications include brittle uncontrolled diabetes, end-stage renal and liver disease, uncontrolled leukemia, lymphoma, hypertension, cardiac dysrhythmias, and cerebrovascular accidents.

Pregnancy is a relative contraindication in the first or last trimester; extractions are deferred until after childbirth. Hemophiliac patients and those with severe platelet disorders or other bleeding diatheses should undergo extraction only after these coagulopathies have been corrected. Caution and extreme care are required before extraction in patients on long-term corticosteroids, immunosuppressants, or cancer chemotherapeutic agents. [4]

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Periprocedural Care

Equipment

Tooth extraction is performed either in a dental office by a dentist or in an oral surgery suite by an oral and maxillofacial surgeon. In either case, the suite is equipped with dental chair and a good source of operating light. The chair provides stability and support and affords the surgeon maximal control of the force being delivered to the patient through the dental forceps. The chair tilts to allow appropriate positioning for maxillary and mandibular tooth extractions. [5]

The oral surgery tray is equipped with surgical instruments for soft tissue, such as the following:

  • No. 15 scalpel
  • Dean scissors
  • Needle holder
  • Curved hemostat
  • Minnesota retractor
  • Right-angle Austin retractor
  • Weider tongue retractor
  • Seldin retractor
  • Molt periosteal elevator
  • Suction tip
  • Adson tissue forceps
  • Allis tissue forceps
  • Double-ended curette
  • Small half-circle needle
  • Suture materials

Other instruments included in the tray are for hard tissue, such as the following:

  • Blumenthal rongeur forceps
  • Bone file
  • Burs
  • Handpiece
  • Hall drill

In the past, a chisel and mallet were used to remove bone and teeth; currently, however, the use of these instruments is limited to removal of excess bone.

Additional instrument are also included, such as rubber bite blocks and a Molt mouth prop, which are designed to hold the mouth open during extraction.

The key instruments used for extraction are also included in the tray. These may include small and large straight dental elevators (see the image below), left and right triangle-shaped elevators, a Crane pick elevator, a root tip pick, or an apex elevator.

Use of straight elevator. Use of straight elevator.

Other important extraction instruments are the various dental forceps designed for extracting maxillary and mandibular teeth. Maxillary instruments include the No. 150 universal forceps, which is designed for extracting premolar and molar maxillary teeth (see the image below), the No. 53 right and left forceps, which are designed specifically for maxillary molars, and the No. 1 maxillary forceps, which is designed for extraction of maxillary incisors and canines.

No. 150 maxillary universal forceps in place. No. 150 maxillary universal forceps in place.

Instruments designed for extracting mandibular teeth include the No. 151 universal mandibular forceps, the Ash forceps, and the cowhorn forceps (see the images below).

Lower universal forceps No. 151. Lower universal forceps No. 151.
Cowhorn forceps No. 23. Cowhorn forceps No. 23.
Ash forceps. Ash forceps.

Patient Preparation

Patient preparation includes adequate anesthesia and appropriate positioning.

Anesthesia

Local anesthesia is required for tooth extraction. It achieves loss of sensation by blocking action potentials and nerve conduction. [6] Local anesthesia to the regional sensory nerves supplying the teeth eliminates pain, including that related to temperature and touch, but does not anesthetize the proprioceptive fibers of the involved teeth. For this reason (as well as out of anxiety), patients feel painful pressure during extraction. Consequently, many extractions are performed with local anesthesia along with intravenous (IV) sedation and inhaled nitrous oxide.

Local anesthetic agents commonly used in dentistry belong to either the ester group (eg, procaine) or the amide group (eg, lidocaine). Local anesthetics of the ester group are metabolized by plasma cholinesterase, whereas those of the amide group are metabolized in the liver by microsomal enzymes. Other local anesthetics included in the amide group are mepivacaine and long-acting bupivacaine.

Several local anesthesia techniques are used in the maxillary and mandibular regions. Maxillary techniques (see the images below) include the following:

  • Single tooth - Local infiltration or supraperiosteal injection is achieved for a single tooth by inserting the needle in the mucobuccal fold adjacent to that tooth
  • First, second, and third molars - Posterior superior alveolar nerve block anesthetizes the maxillary first, second, and third molars and the buccal mucosa surrounding the teeth; the needle is inserted above the second molar superiorly and medially at a 45º angle to the occlusal plane
  • Maxillary nerve block - This is performed via the high maxillary tuberosity approach or through the greater palatine foramen; it anesthetizes all maxillary teeth, the surrounding bone and mucosa, the lower eyelid and nose, and the upper lip ipsilaterally
    Insertion of local anesthesia needle into mucobucc Insertion of local anesthesia needle into mucobuccal fold.
    Supraperiosteal placement of local anesthesia need Supraperiosteal placement of local anesthesia needle.
    Direction of superior posterior nerve block (arrow Direction of superior posterior nerve block (arrow).
    Maxillary division nerve block. Maxillary division nerve block.
    Highlighted area is anesthetized by maxillary divi Highlighted area is anesthetized by maxillary division nerve block.

Mandibular techniques (see the images below) include the following:

  • Inferior alveolar nerve block - This anesthetizes all mandibular molars, premolars, canines, and incisors ipsilaterally, including lingual mucosa; the needle is inserted from the opposite side, parallel with the occlusal plane, into the pterygomandibular raphe at the medial side of the mandible toward the mandibular foramen, which is located midway between the external oblique ridge and the posterior ramus
  • Long buccal nerve block - This anesthetizes the buccal mucosa ipsilaterally, with the needle inserted into the retromolar region; it is usually given with the inferior alveolar nerve block
  • Mental nerve block - This anesthetizes the premolar, canine, and incisor teeth ipsilaterally; the needle is inserted in the mucobuccal fold toward the mental foramen, which is located between and inferior to the 2 premolars
    Highlighted area where injection of inferior alveo Highlighted area where injection of inferior alveolar nerve takes place.
    Direction of needle for inferior alveolar nerve bl Direction of needle for inferior alveolar nerve block.
    Site of needle insertion for long buccal nerve blo Site of needle insertion for long buccal nerve block.
    Insertion of needle in mucobuccal fold for infiltr Insertion of needle in mucobuccal fold for infiltration of incisor teeth.
    Highlighted area is anesthetized by local mandibul Highlighted area is anesthetized by local mandibular infiltration.

As indicated above, local anesthesia alone may not be adequate for an anxious patient who may require additional sedation with inhaled nitrous oxide and oxygen. In the extremely anxious patient, IV sedation with midazolam and opioid analgesia are used.

A study set out to evaluate hemodynamic changes of blood pressure and heart rate on hypertensive patients undergoing tooth extraction using various types of local anesthesia. The study concluded that there is no significant increase of blood pressure with Epinephrine and Felypressin. Therefore, it is safe to use 2 cartridges of Lidociane 2% with Epinephrine 1:80,000 or Prilocaine 3% with Felypressin 0.03 IU/ml for hypertensive patients whose blood pressure ≤ 159/99 provided negative aspiration is verified before injection. [7]

Positioning

The surgeon and the patient should be positioned in such a way that the patient is comfortable and the surgeon can stand or sit in front of the patient without undue strain. Ideally, the surgical instruments (especially the needle) should be placed out of the patient's sight (usually behind the patient but close to the surgeon).

For mandibular extraction, the positioning is as follows:

  • Chair axis - The chair is positioned so that the mandibular occlusal plane is parallel to the floor
  • Chair height - The chair is lowered to afford the surgeon the leverage and control needed for the extraction
  • Patient head - The patient is asked to turn the head toward the operator
  • Operator - The operator is at the 9 o'clock position relative to the patient
  • Second hand operator - The second operator is at the 3 o'clock position to help the operator in retracting the cheek, lip, and tongue and stabilizing the jaw
  • Assistant - The assistant places the suction tip in one hand and the soft tissue retractor in the other (and also helps with irrigation when needed)

For maxillary extraction, the positioning is as follows:

  • Chair axis - The chair is tipped backward so that the maxillary occlusal plane is at an angle of about 60º to the floor
  • Chair height - The chair is lowered to the height of the operator's elbow
  • Patient head - The patient is asked to lift the head and turn toward the operator for access and visualization
  • Operator - The operator is at the 9 o'clock position relative to the patient
  • Second hand operator - The second operator stands or sits at the 3 o'clock position and helps with retraction, suctioning, irrigation, and jaw stabilization
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Technique

Tooth Extraction

For proper extraction of a tooth, the operator must elevate the gingival soft tissue attachment, luxate the tooth with small and large straight elevators, and adapt the forceps to the crown of the tooth. Luxation requires apical pressure, buccal force, lingual pressure, rotational pressure, and tractional forces. The operator continues to luxate the tooth with the forceps in a buccolingual direction with slight rotation until the tooth is removed from the socket. [8]

Tooth extraction can be difficult in older patients with dense supporting bone, dilacerated roots, and broken crowns with extensive caries. Special attention should be paid to adjacent teeth and vital structures (eg, the maxillary sinus, the inferior alveolar nerve, and the lingual and mental nerves). To minimize the risk of pushing the tooth into the maxillary sinus or fracturing the mandible, extensive force should be avoided. [9] The best and easiest way of managing tooth extraction complications is to prevent them.

Tooth extraction often leads to root fracture. A small envelope flap can be reflected to expose fractured roots, and a small straight elevator can be used as a shoehorn to luxate broken roots. The buccal beak of the forceps can be used to grasp a portion of the bone at the same time it grasps the root.

The extraction forceps is seated with strong apical pressure to expand the crestal bone around the root and allow root removal. A small root tip can be addressed by placing an endodontic file in the root canal and twisting it with a needle holder. The root can be removed with a No. 4 round bur in a dental handpiece or a small elevator, which displaces the root from its apex.

Teeth that are liable to fracture during extraction are those with large carious lesions, those that have been treated by means of root canal procedures, and those surrounded by dense bone or with ankylosed and dilacerated roots.

Although every effort should be made to remove fractured roots during extraction, there are some circumstances in which these roots are best left in place, as when the root is suspected to be on the verge of entering an anatomic space or when further instrumentation would cause damage to a vital adjacent structure, would result in uncontrolled bleeding, or might necessitate an inordinate amount of bone excision.

Extreme care is required in extracting maxillary teeth close to the maxillary sinus to avoid sinus exposure and subsequent oroantral fistula. Attention is also needed in extracting mandibular teeth close to the inferior alveolar canal and mental foramen to avoid paresthesia.

Complications of Procedure

The most common intraoperative complications of tooth extraction are injuries to the soft tissue resulting from lack of attention to the delicate nature of the mucosa and the use of excessive and uncontrolled force during extraction; examples include lip abrasions or burns from a retractor or rotating handpiece.

The next most common complications are injuries to osseous structures, such as fractures of the alveolar plate in the buccal cortex of maxillary canines, molars, and mandibular incisors.

The maxillary tuberosity is often fractured during the extraction of a difficult molar (see the images below), especially a difficult maxillary third molar. [10] This complication can be prevented by performing a thorough clinical and radiographic examination and taking care not to apply an excessive amount of uncontrolled force. Fractured bone in the tuberosity can be carefully dissected from the tooth with a straight elevator; the bone and soft tissue can then be sutured in place and the extraction site closed primarily.

Radiograph taken before extraction of second maxil Radiograph taken before extraction of second maxillary molar.
Fracture of maxillary tuberosity occurred during e Fracture of maxillary tuberosity occurred during extraction of second maxillary molar.
Maxillary tuberosity was adherent to extracted too Maxillary tuberosity was adherent to extracted tooth.

Radiographically, the layers of the tooth are easily identifiable because they have different radiopacities. Enamel is the most mineralized of the calcified tissues of the body, and it is the most radiopaque of the 3 tooth layers. Dentin is less radiopaque than enamel and has a radiopacity similar to that of bone. The pulp tissue is not mineralized and appears radiolucent. [11] For more information about the relevant anatomy, see Tooth Anatomy.

Extracting a maxillary molar tooth close to the maxillary sinus may result in oroantral communication, which in turn may lead to maxillary sinusitis and the formation of a chronic oroantral fistula.

Intraoperatively, sinus communication can be detected by performing a nose-blowing test to check for passage of air or bubbling of blood in the extraction site. A small communication (< 2 mm) may close on its own with the formation of clot and, subsequently, granulation tissue.

A moderate-sized communication (2-6 mm) necessitates the placement of a figure-eight suture to stabilize the blood clot. Postoperatively, the patient should be instructed to avoid nose-blowing, violent sneezing, and sucking on straws. The patient should be placed on an antibiotic for 7 days, a nasal decongestant for 3 days, and an oral decongestant for 7 days. A larger communication (> 7 mm) necessitates a flap procedure to close the defect.

Even with meticulous surgical technique, tooth extraction may result in injury to adjacent vital structures. Lingual nerve paresthesia may result after injection if the needle passes through the nerve, the distal incision is positioned too far lingually, or the nerve is cut during lingual bone removal.

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