Dental extraction

Procedure

Assessment and special investigations

Obtaining consent from patient

Giving local anaesthetic

• infiltration - injection containing local anaesthetic is delivered into the gum near the root tip of the tooth to be extracted. This allows the local anaesthetic to penetrate through the bone, eventually reaching the nerve bundle of the tooth to be extracted.
• nerve block - injection containing local anaesthetic is delivered to an earlier branch of a nerve. For example, the inferior alveolar nerve block can be used to anaesthetise all the lower teeth.

Removal of tooth

Achieving haemostasis">Hemostasis">haemostasis

Providing post-operative instructions

• avoid rinsing mouth for 24 hours to prevent dislodging the blood clot
• avoid smoking for 24 hours to reduce risk of infection or development of a dry socket
• avoid carrying out strenuous exercises
• after 24 hours has passed use warm salty mouthwashes especially after meals to keep the wound clean
• if the socket starts to bleed bite down on gauze or clean handkerchief for about 20 minutes, if the bleeding continues seek professional help

Reasons

• Severe tooth decay or infection. Despite the reduction in worldwide prevalence of dental caries, it is still the most common reason for extraction of teeth, accounting for up to two thirds of extractions.
• Severe gum disease, which may affect the supporting tissues and bone structures of teeth.
• Treatment of symptomatic impacted wisdom teeth e.g. that are associated with pericoronitis, unrestorable caries or cysts.
• Prophylactic removal of asymptomatic impacted wisdom teeth. Historically, many asymptomatic impacted third molars were removed, however, both American and British Health Authorities  now provide guidance about the indication for third molar removal. The American Public Health Association, for example, adopted a policy, Opposition to Prophylactic Removal of Third Molars, because of the large number of injuries resulting from unnecessary extractions.
• Supernumerary teeth that are blocking other teeth from coming in.
• Supplementary or malformed teeth.
• Fractured teeth.
• Cosmetic: to remove teeth of poor appearance, unsuitable for restoration.
• Teeth in the fracture line of the jaw bone
• Teeth which cannot be restored endodontically.
• Prosthetics; teeth detrimental to the fit or appearance of dentures.
• Head and neck radiation therapy, to treat and/or manage tumors, may require extraction of teeth, either before or after radiation treatments.
• Lower cost, compared to other treatments.
• 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.

• In preparation for orthodontic treatment. Extractions are commonly required before the provision of orthodontic treatment, to create space for crowded teeth to me moved into. The premolar teeth are the most commonly extracted teeth for this purpose.

• Cosmetic: to remove teeth of poor appearance, unsuitable for restoration.

  Types

Surgical procedure:

Pre-extraction consideration

Anticoagulant/Antiplatelet Use

Antibiotic Prescribing

Assessing risk of nerve damage

• Darkening of the tooth root where it crosses the canal
• Deviation of the canal
• Narrowing of the roots
• Loss of the lamina dura of the canal
• Juxta apical area: a radiolucency associated with the root of the tooth which is not caused by periapical infection

Changes in face shape

• Extractions may be recommended to enhance a profile and appearance. If a teeth straightening procedure is performed in an overcrowded mouth without extractions, it may result in excessively protrusive teeth or lips which will be detrimental to the facial profile.
• However, If the removed tooth is an upper tooth, parts of the face may appear sunken in, resulting in asymmetry. If a lower tooth is removed, it may similarly result in asymmetry, and it also has the potential to exaggerate an underbite.

  Post-extraction healing

Immediate management

Complications

Healing process

Post-extraction bleeding

Factors

• Laceration of blood vessels
• Osseous bleeding from nutrients canal/ central vessels
• Inflammation
• Infection
• Traumatic extraction
• Failure of patient to follow post-extraction instructions

• Platelet problem
• Coagulation disorder/ excessive fibrinolysis
• Inherited/medication-induced problems

  Type of bleeding

Interventions

• Surgical area
• Location of bleeding
• Size of wound
• Extent of bleeding
• Accessibility of bleeding site
• Time of bleeding

• Involve suturing the bleeding site. Sutures aid socket closure and help bring the gingival tissues together. Interrupted or horizontal mattress are both recommended.
• If bleeding is secondary to trauma to a blood vessel, the patient may need to be sent to hospital as large vessel may require ligation and smaller vessels cauterized

• Involve the use of drugs, sealants, adhesives, absorbable agents, biologics, and combination of products

• A resorbable haemostatic pack, such as oxidised cellulose or collagen sponge, in addition to suturing are recommended if the source of bleeding is from the bone within the socket.
• Tablet tranexamic acid 500 mg may be crushed & mixed with water 20 to 25 ml and can be used as mouth rinse ,it is a temporary measure to stop control intra oral bleeds.

Complications

• Infection: The dentist may opt to prescribe antibiotics pre- and/or post-operatively if he or she determines the patient to be at risk of infection.
• Prolonged bleeding: The dentist has a variety of means at his disposal to address bleeding; however, small amounts of blood mixed in the saliva after extraction are normal, even up to 72 hours after extraction. Usually, however, bleeding will almost completely stop within eight hours of the surgery, with only minuscule amounts of blood mixed with saliva coming from the wound. A gauze compress will significantly reduce bleeding over a period of a few hours.
• Swelling: Often dictated by the amount of surgery performed, to extract a tooth. Generally, when a surgical flap must be elevated, minor to moderate swelling will occur. A poorly cut soft tissue flap, for instance, where the periosteum is torn off rather than cleanly elevated off the underlying bone, will often increase such swelling. Similarly, when bone must be removed using a drill, more swelling is likely to occur.
• Bruising: Bruising may occur as a complication after tooth extraction. Bruising is more common in older people or people on aspirin or steroid therapy. It may take weeks for bruising to disappear completely.
• Sinus exposure and oral-antral communication: This can occur when extracting upper molars. The maxillary sinus sits directly above the roots of maxillary molars and pre-molars. There is a bony floor of the sinus, dividing the tooth socket from the sinus itself. This bone can range from thick to thin, from tooth to tooth, from patient to patient. In some cases it is absent and the root is, in fact, in the sinus. At other times, this bone may be removed with the tooth, or may be perforated during surgical extraction. The doctor typically mentions this risk to patients, based on evaluation of radiographs showing the relationship of the tooth to the sinus. The sinus cavity is lined with a membrane called the Sniderian membrane, which may or may not be perforated. If this membrane is exposed after an extraction, but remains intact, a "sinus exposed" has occurred. If the membrane is perforated, however, it is a "sinus communication". These two conditions are treated differently. In the event of a sinus communication, the dentist may decide to let it heal on its own, or, may need to surgically obtain primary closure—depending on the size of the exposure and the likelihood of the patient to heal. In both cases, a resorbable material called "gelfoam" is typically placed in the extraction site to promote clotting and serve as a framework for granulation tissue to accumulate. Patients are typically provided with prescriptions for antibiotics that cover sinus bacterial flora, decongestants, and careful instructions to follow during the healing period.
• Nerve injury: This is primarily an issue with extraction of third molars, but can occur with the extraction of any tooth should the nerve be close to the surgical site. Two nerves are typically of concern, and are found in duplicate : 1. the inferior alveolar nerve, which enters the mandible at the mandibular foramen and exits the mandible at the sides of the chin from the mental foramen. This nerve supplies sensation to the lower teeth on the right or left half of the dental arch, as well as sense of touch to the right or left half of the chin and lower lip. 2. The lingual nerve, which branches off the mandibular branches of the trigeminal nerve and courses just inside the jaw bone, entering the tongue and supplying sense of touch and taste to the right and left half of the anterior 2/3 of the tongue as well as the lingual gingiva. Such injuries can occur while lifting teeth, but are most commonly caused by inadvertent damage with a surgical drill. Such injuries are rare and are usually temporary, but depending on the type of injury, can be prolonged or even permanent.
• Displacement of tooth or part of the tooth into the maxillary sinus. In such cases, the tooth or tooth fragment must almost always be retrieved. In some cases, the sinus cavity can be irrigated with saline and the tooth fragment may be brought back to the site of the opening through which it entered the sinus, and may be retrievable. At other times, a window must be made into the sinus in the Canine fossa—a procedure referred to as a "Caldwell-Luc".
• Dry-socket is a painful phenomenon that most commonly occurs a few days after the removal of mandibular wisdom teeth. It typically occurs when the blood clot within the healing tooth extraction site is disrupted. More likely, alveolar osteitis is a phenomenon of painful inflammation within the empty tooth socket because of the relatively poor blood supply to this area of the mandible. Inflamed alveolar bone, unprotected and exposed to the oral environment after tooth extraction, can become packed with food and debris. Dry-socket typically causes a sharp and sudden increase in pain commencing 2–5 days following the extraction of a mandibular molar, most commonly the third molar. This is often extremely unpleasant for the patient; the only symptom of dry-socket is pain, which often radiates up and down the head and neck. A dry-socket is not an infection, and is not directly associated with swelling because it occurs entirely within bone – it is a phenomenon of inflammation, within the bony lining, of an empty tooth socket. Because dry-socket is not an infection, the use of antibiotics has no effect on its rate of occurrence. There is some evidence that rinsing with chlorhexidine before or after extraction or placing chlorhexidine gel in the sockets of extracted teeth provides a benefit in preventing dry-socket, but potential adverse effects of chlorhexidine have to be considered. The risk factor for alveolar osteitis can dramatically increase with smoking after an extraction.
• Bone fragments: Particularly when extraction of molars is involved, it is not uncommon for the bones which formerly supported the tooth to shift and in some cases to erupt through the gums, presenting protruding sharp edges which can irritate the tongue and cause discomfort. This is distinguished from a similar phenomenon, where, broken fragments of bone or tooth left over from the extraction can also protrude through the gums. In the latter case, the fragments will usually work their way out on their own. In the former case, the protrusions can either be snipped off by the dentist, or eventually the exposed bone will erode away on its own.
• Trismus: Trismus, also known as lockjaw, affects functions of the oral cavity by restricting opening of the mouth. A double blind, clinical study was done to test the effect of two different medications on post-extraction trismus. The patients who received a corticosteroid by IV had a statistically significant lower level of trismus when compared to patients receiving an NSAID by IV or no medication.
• Loss of a tooth: If an extracted tooth slips out of the forceps, it may be swallowed or inhaled. The patient may be aware of swallowing it, or, they may cough, which suggests inhalation of the tooth. The patient must be referred for a chest X-ray in hospital if a tooth cannot be found. If it has been swallowed, no action is necessary as it usually passes through the alimentary canal without doing any harm. But if it has been inhaled, an urgent operation is necessary to recover it from the airway or lung before it causes serious complications such as pneumonia or a lung abscess.
• Luxation of the adjacent tooth: The application of force during the extraction procedure must strictly be limited to the tooth that requires the extraction. Most cases of surgical extraction procedures require that the forces are diverted from the tooth itself to areas such as bone surrounding the tooth to ensure adequate bone removal before proceeding any further in the extraction procedure. Either way, the forces applied by various instruments during both simple and complicated surgical procedure may loosen the teeth present both in front of or behind the tooth depending upon the impact direction and location of the force being applied and that happening only if the forces divert from the actual tooth that needs extraction. Such deleterious forces may weaken the anchorage of adjacent teeth from within their bony socket, and hence result in weakening of the adjacent teeth.
• Extraction of the wrong tooth: Misdiagnosis, altered tooth morphology, faulty clinical examination, poor patient history, undetected/unmentioned previous extractions that may predispose the operator to consider another tooth to be a replicate of the one previously extracted are a few causes of extraction of a wrong tooth.
• Osteonecrosis: Osteonecrosis of the jaw is the slow destruction of bone in an extraction site. A case control study of 191 cases and 573 controls were used to understand the relationship between osteonecrosis of the jaw and prior usage of bisphosphonate drugs, which are commonly prescribed to treat osteoporosis. All of the participants were over 40 years of age, mostly female, and had been taking bisphosphonates for six months or longer. The presence of osteonecrosis of the jaw was reported by dentists' previous diagnosis of the participating case and control patient's medical records. Reports showed that women using bisphosphonates for more than two years are ten times more likely to experience osteonecrosis of the jaw, while women who have taken bisphosphonates for less than two years are four times more likely to suffer from osteonecrosis of the jaw when compared to women who were not taking bisphosphonates. Therefore, it is extremely important to report all medications used to the dentist before an extraction, so that osteonecrosis can be avoided.

  Post-extraction management

Pain management

Socket preservation

Atraumatic extraction

Replacement options for missing teeth

History