Sometimes a tooth or molar can no longer be saved and must be pulled. Removing a dental element is called extracting. Extracting a tooth may be necessary for various reasons. Common reasons are:
- Advanced tooth decay (caries profunda);
- Inflammation of the nerve and around the root tip;
- Problems in the suspension system of the element, such as periodontitis;
- Root fracture;
Removing a tooth or molar can also be part of a treatment plan; for instance:
- During an orthodontic treatment with someone with a lack of space in his jaws;
- With a prosthetic treatment.
Finally, elements are also preventively removed, that is to say, as a precautionary measure:
- If someone has to undergo heart surgery or radiation.
A good diagnosis must be made prior to treatment by:
- Listen to the patient’s story;
- Do extraoral and intraoral research;
- Take X-rays.
It is also important to ask about the general health of the patient. An extraction is in fact a surgical operation. The wound has consequences not only in the mouth but also for the entire body of the patient.
The dentist consults with the patient if he wants to have his tooth or molar pulled. Or that, if possible, he opts for treatment to preserve the element, for example a nerve channel treatment. For someone who attaches great importance to maintaining his own teeth, a dentist will perform an extraction less quickly than for a patient who visits the dentist only when he is in pain.
Although extraction by using local anesthesia does not hurt, patients often find it an anxious experience. It is important that the patient is reassured.
The teeth are attached to the jawbone by the root membrane or the periodontal ligament. To extract a tooth, the fibers of the root membrane must be broken. This is usually done with siphons and extraction tongs.
An extraction pliers has a mouth, a hinge and a handle (see image below).
A pair of pliers must be chosen so that the mouth fits well to the neck, or the cervix, of the element in question. The better the mouth connects to the neck, the better the grip of the forceps and the less chance of the teeth breaking off. Because the elements are not anatomically identical, there are also different extraction tongs for the different elements.
The mouth of an extraction forceps consists of two hollow blades that are adapted to the curvature of the root surfaces. When the tongs are closed, the blades are a few millimeters apart (see figure below).
The shape and direction of the jaw depend on:
- How many roots does the element have: one, two or three;
- In which jaw the element is located: the upper or lower jaw;
- What kind of element it is: an incisive, cuspidate, premolar or molar.
If the element has multiple roots, the shape of the blades of the jaw is adjusted accordingly. For example, a bottom molar has two roots, or radices, and the blades then have not one cavity, but a cavity with two facets. The transition between the two facets forms a ledge that falls exactly in the root location.
The jaws of pliers for elements in the lower jaw are at an angle of 90 ° on the handle. It is possible to use the same forceps for the molars to the right and left in the lower jaw, because they both have a buccal and lingual furcation. They are anatomically similar at the neck (see image below).
With extracting pliers for elements in the upper jaw, the mouth and the handle are in line with each other. The pliers are completely straight for incisives and cuspidates, for premolars and molars the jaw has a small S-bend on the handle. The latter is necessary to be able to work well in the back of the mouth. The upper molars have two buccal roots and one palatal root. Because the molars at the top left are a mirror image of the molars at the top right, two different extraction pliers are needed (see image below).
With root tongs, the blades of the jaws are narrower and come together when the tongs are closed. This is easier if a small root residue has to be removed.
A siphon is used as an aid for extractions. The elements can be carefully loosened with the help of levers, after which the extraction with a pair of pliers is easier.
Furthermore, siphons are used when an extraction tong has no hold, for example with elements that have an abnormal position, with broken roots or with very carious elements.
A lever consists of a handle, a shaft and a blade.
The most common levers are:
- Straight or hollow lever: The blade is hollow. The straight lever is mainly used to pry loose molars in relation to the molar (wedge action) and for removing root remains from the upper jaw.
- Triangle or winter lever: The blade is triangular and slightly concave. There is a left and a right version. The triangle lever is mainly used for removing root remains in the lower jaw.
- Curved or heather-colored lever: The blade is small, pointed and slightly concave and stands at an angle on the handle. There is a left and a right version. The bent lever is mainly used to remove small root tips in the lower jaw (see image below).
To extract the element, the extraction forceps are placed just above the gingiva on the neck of the element and then pushed as deep as possible under the gingiva. The direction of the jaw is in line with the axis of the element.
The root membrane is then released by turning the element, a rotational movement, or by moving the element back and forth in buccolingual direction, a luxation movement. Extracting is therefore not so much the ‘pulling’ of an element as the rotation or luxation of an element. Luxing or rotating is done until the fibers of the periodontal ligament are broken and the element can be taken from the alveole, the tooth greenhouse.
With a rotational movement, the jaw bone is less damaged than with a luxation movement. Rotation is only possible with round, straight roots such as the premolars in the lower jaw.
When an extraction is done in the upper jaw, the bladder and muzzle test must always be done. With these tests it is checked whether there is no connection between the oral cavity and the oral cavity. We call this open connection an antrum perforation. This is discussed later in this chapter for the complication? Sinus or antrum perforation.
Remove wisdom teeth
The wisdom teeth can break through at the age of 18. But there is no other element that has so much variation in breakthrough time. The location and morphology can also vary enormously. It often happens that wisdom teeth are not applied. We call that agenesis.
Often there is little room for the wisdom teeth to break through. This is mainly the case with wisdom teeth in the lower jaw. Due to a lack of space, the element cannot break through completely and a little gum remains on the occlusal surface distally. We call this piece of gums an operculum. This includes easy food residues and bacteria that cause inflammation. We call this pericoronitis (see image below).
To remedy the acute symptoms of pericoronitis, the space under the operculum is flushed out with a syringe with hydrogen peroxide (H2O2) 1.5-3%. If it is likely that the symptoms will recur, the operculum can be surgically removed. Usually it is better to remove the wisdom tooth.
Due to lack of space, the patient bites his cheek faster. The regular occurrence of a bite trauma is a reason to remove a wisdom tooth.
It is a myth that the wisdom teeth make the front teeth crooked when there is a lack of space. Skew of the front teeth is a phenomenon that gets worse with age. It also happens to patients who have no wisdom teeth and is a natural process.
A wisdom tooth can best be removed at a young age. Preferably before the age of 25. The jaw bone is even more elastic and heals easily. Fewer complications and back issues arise. The overall health of young people is also better than that of the elderly.
An X-ray helps to estimate whether the wisdom tooth can be removed by the dentist or whether it is better to remove it surgically by the dental surgeon. Factors that determine the difficulty are:
- Impaction. The farther a tooth is broken, the easier it will be to remove it.
- Tilt. A wisdom tooth that is tilted all the way forward or inclined to the distal end must be removed in parts. Bone is often removed to make room.
- Shape of the roots. The number of roots and their shape can make extraction difficult.
- Canalis mandibularis. If the roots are around the canalis mandibularis, the alveolaris inferior nerve can be damaged during extraction. The patient then loses the feeling in (a part of) his lower lip (see image below).
- Sinus maxillaris. If the root tips are in contact with the bottom of the maxillary sinus, an anti-perforation can occur during extraction.
The patient receives a local anesthetic for the surgical removal of a wisdom tooth. An incision, or a cut, is then made with a scalpel. After this the gums are folded up: the mucoperiost is pushed off the bone with a raspatorium. With a bone cutter, bone is removed to give the molars room. A groove is milled in the bone to be able to use the lever.
Sometimes it is necessary to sharpen the element into parts, or to split it (see image below). The wisdom tooth is pried loose with a lever and pushed out of the tooth box. When the molar is removed, sharp bone edges are smoothed with a cutter. With the help of the surgical piston, the assistant keeps the work site free of blood, saliva and bone sharps. To prevent the heat from becoming too great when grinding the bone, a physiological saline solution is used for cooling. Heating the bone can cause it to die.
With very difficult extractions, a tampon with iodoform vaseline is sometimes introduced into the extraction wound. This is intended to prevent inflammation of the dental greenhouse, or alveolitis.
Finally, the mucoperiostal patch is put back and sutured with a soluble suture, such as Vicryl®.
By wound toilet we mean the care of a wound, in this case an extraction wound. Usually no special treatment is needed for extraction wounds. After an extraction in which only the periodontal ligament is torn and the bone and gums are not damaged, the wound heals quickly. Optionally, the wound can be pinched to push the gum edges closer together. Then have the patient close tightly on a gauze to stop the bleeding. If the patient closes for about fifteen minutes, a blood clot, a coagulum, can form in the dental greenhouse. After fifteen minutes the patient may spit out the gauze. It is wise to only let a patient go home when the wound is no longer bleeding.
Sometimes an extensive wound toilet is needed. This is discussed in the healing of the extraction wound later in this chapter.
Before the patient leaves the practice, he is given information to prevent complications and he is advised to have aftercare treated.
Instruction after extraction of dental elements
After an extraction, the patient receives instructions about the consequences of the treatment and about possible complications. The following topics must in any case be discussed during this information session.
A blood clot should form in the alveole so that the wound can heal properly. That is why the patient has to close for about fifteen minutes on a gauze pad. He must then avoid actions that damage or loosen the blood clot. The advice is:
- Do not rinse or gently rinse (with lukewarm water);
- Not to suck on the wound;
- Avoid hot and cold food;
- No or little alcohol use;
- Not to do heavy labor;
- Do not take a hot shower or bath;
- Gently brush your teeth.
If the wound starts to bleed again or continues to bleed, the patient must close for fifteen minutes on a gauze pad or a clean napkin. If that does not help, the patient should contact the practice or the dental emergency room (evening or weekend).
Sometimes the patient gets pain after the anesthetic has worked out. He must know that the pain can last for about two days.
In pain, the patient can use pain killers based on paracetamol or ibuprofen, but definitely no pain killers based on acetylsalicylic acid (such as Aspirin®). Acetylsalicylic acid has a blood-thinning effect and therefore increases the chance of bleeding. The patient may also receive a prescription for the right pain killers. The patient should be advised that he does not exceed the stated dose for the painkiller.
If the pain is not clearly reduced after two to three days, the patient can contact the practice or the dental emergency room.
If the pain only occurs after two to three days, the patient should contact the practice or the dental emergency room as an inflammation may have occurred.
Sometimes a thickening, swelling occurs, around the wound and in the face. This happens especially if the extraction was difficult. If the swelling is not clearly less after about a week, the patient can contact the practice.
If the extraction wound is sutured, the patient will receive information about the type of suture:
- A bond of silk or plastic must be removed by the dentist (after about a week). An appointment is made for this.
- A Vicryl® suture dissolves itself after two weeks. The patient does not have to come back to have the suture removed.
Other possible points for attention in the information after extraction (s)
- The patient must be careful with food if the anesthetic has not worked out. He can then bite his cheek or lip and damage himself. Hot foods can also be avoided better.
- It is not wise for the patient to drive himself if an extraction has been performed with him. Advise arranging a driver when making the appointment.
This information and answering questions from the patient are very important. Because the patient is often strained by the treatment, he often does not remember all the instructions. It is therefore wise to provide the information in writing, for example in the form of a brochure.
Complications with extractions
Unfortunately it happens that an extraction does not proceed as intended. Complications can occur: the dental element, especially the root, can break off, an anterior perforation can occur in the upper jaw and after extraction an after bleeding or alveolitis is possible. These four complications are discussed here.
Break off an element
It is possible that an element is so carious that the crown with a part of the root breaks off when it is removed. The remaining part of the root must therefore be removed. If it is not possible to grab the remaining piece with a carrot tong, an attempt must first be made to pry off the carrot residue with a siphon or excavator. If the carrot residue is loose, it can be removed with a carrot tong.
If all this fails, then the gums must be folded up. The mucoperiost is pushed from the bone of the alveolar processus. This is usually done on the buccal side. With a cutter or round drill, bone is then removed around the root point. If the root remains free, it can be pushed up with a siphon or excavator. The mucoperiostal patch is then replaced and sutured with a soluble suture, for example Vicryl® (see image below).
Sinus or antrum perforation
After extracting a premolar or molar in the upper jaw, the bladder and muzzle test must always be done. In this way the dentist checks whether a hole has been created in the bottom of the maxillary sinus, also known as the antrum. Because the jaw cavity is in open connection with the nose, a connection between the mouth and the nasal cavity is created through such a hole.
The muzzle test involves the following: the dentist pinches the patient’s nose and asks if he wants to blow his nose. If sinus perforation has occurred, air bubbles will bubble into the extraction wound. The compressed air from the nose then escapes this way. If there are no bubbles, the bladder test must still be done.
The bladder test involves the following: the dentist asks the patient if he wants to blow through his mouth while he keeps his mouth shut. For example, by blowing on the mouse of his hand. If there is an opening in the sinus floor, the air in the mouth will escape through the jaw cavity to the nose. You will hear air coming out of the nostrils. If you don’t hear anything, then everything is fine.
An anti-perforation must always be closed. If this does not happen, a sinusitis can occur, a jaw infection. The patient can then have trouble drinking, because the liquid can literally come out of his nose. Patients playing a wind instrument are no longer able to properly compress the air in the oral cavity: the air escapes through the jaw cavity to the nose.
The perforation must therefore be closed. This must be done as quickly as possible: within 24 hours. Depending on the size of the perforation, the dentist can decide whether to do this himself or to refer the patient to a surgeon.
When the perforation is small, the wound can simply be sutured. The blood clot in the alveole ensures that the hole is sealed. If the perforation is large, the wound must be sutured so that no air can get through. A gum patch is detached from the bone buccally of the extraction wound and sutured over the wound. To make this easier, it is sometimes necessary to lower the buccal bone margin. Suture is used that does not dissolve by itself, for example silk. The patient receives an appointment to have the suture removed (see image below).
In all cases, a patient must receive instructions after closing an anterior perforation. He must avoid (air) pressure differences between the nose and mouth. This means that he may not suppress coughing and sneezing during the first five days after the operation. He is also not allowed to blow his nose or play a wind instrument. Lifting heavy things and stooping is not recommended. If the stitches are removed, it can be checked whether the perforation is properly closed.
Precautions may be taken to reduce the risk of sinus perforation. An X-ray can provide information about the size and location of the maxillary sinus. Especially with solitary (single) elements in the premolar-molar region above, there is a greater chance of sinus perforation. With multi-rooted elements, such as the upper molars, the chance of a perforation can be reduced by removing the roots of those molars separately. The molar for this is split into parts.
To split a tooth, the crown is first ground off the element. A groove is then cut through the molar in a mesiodistal direction. The buccal and palatal parts are detached from each other with a siphon. In this way, the buccal and palatal roots can be removed separately. Optionally, a groove can also be made between the two buccal roots, so that these too can be removed separately. However, the latter is not often necessary (see images below).
By splitting an element, a perforation can usually be prevented. This method is also useful with elements that are very stuck in the jaw, for example because the roots are spread out.
If an anti-perforation is not detected and is therefore not closed in time, a sinusitis can occur. This can cause considerable problems for the patient. The patient then has a painful and oppressive feeling at the top of the face and around the eyes. When bending over, the feeling of pressure can increase. Sometimes there is also a headache. The surgeon then cleans the jaw cavity and closes the perforation.
Healing of extraction wounds
In general, we know two ways in which wounds can heal:
- Per primam, if the wound edges are directly against each other;
- Per granulationem, if the wound edges do not lie against each other.
The extraction wound is healed because the empty alveole fills with blood. When the blood is clotted, the coagulum serves as a kind of dressing. The clot seals the wound and prevents infection and escape of body fluids.
Over the extraction wound, epithelial cells grow from the wound edges over the blood clot. The closer the wound edges are to each other, the faster this happens. Blood vessels also grow into the coagulum. The recovery takes place from here. Bone-forming cells, the osteoblasts, enter the alveole through the blood vessels in the coagulum and do their work there. After about two weeks, small bone bars arise from the bone edge. After a month, young spongy bone fills almost the entire extraction wound. This young bone is still very soft and is not clearly visible on an X-ray.
After about three months, the bone in the alveole has a normal structure and hardness. Hardly anything can be seen on the X-ray on the alveole.
Healing of a wound is faster when the wound is well cared for; in other words, when a wound toilet is performed. Wounds with a tight, smooth wound edge heal faster than wounds with a ragged edge. After extractions, sharp bone edges are often felt under the gingiva. These edges can be smoothed with a sharp spoon or nibbling tongs. A ragged gingival border can be trimmed.
If the wound edges are then pinched or stitched together, the wound can heal faster. The wound heals fastest when he is sutured. Bonding also prevents an after bleeding. If soluble suture material is used for suturing, the patient does not need to return to have the suture removed: for example, Vicryl® dissolves in about two weeks. If a suture has been used that does not dissolve, for example silk, the patient should have the suture removed after about a week.
Complications for wound healing
An after bleeding is a bleeding of the extraction wound that only occurs after a while. This sometimes happens when the vasoconstrictor has been worked out in the anesthetic. It may also be because the patient did not follow the instructions and the blood clot came out of the wound. Usually the bleeding stops again if the patient spends a while on a gauze or clean napkin.
If this does not help, the patient must come to the practice as soon as possible to be treated. He must first be put at ease there. After bleeding is an intense experience. The patient is also often nauseated by the blood he has swallowed.
Once the patient is in the chair, the mouth (and possibly also the face) must be cleaned. It is not wise to let the patient flush himself: then he sees again the blood that makes him so sick. If the cause of the bleeding is found, the gums must be numbed. Sometimes the vasoconstrictor in the anesthetic fluid already stops the bleeding. After the anesthetic, the wound is carefully sutured: an astringent can possibly be enclosed in the alveole. The bleeding then decreases quickly, but the healing of the wound is slower, because the body now also has to break down the used agent.
Alveolitis is an acute inflammation of the alveole wall. The inflammation only occurs two to four days after the extraction. The patient has severe pain, which often pulls to the ear. This pain can usually only be made bearable with painkillers.
An alveolitis is also called “dry socket” or “dry tooth“. Almost no symptoms can be seen in the mouth. There is hardly any swelling or redness. What is striking is that the extraction wound is not filled with a blood clot but has a gray color and smells terribly.
If nothing is done about an alveolitis, the alveole will heal automatically after about three weeks. Because the pain with alveolitis is very severe, the dentist must prescribe good pain killers. The inflammatory wound can also be flushed out with hydrogen peroxide (H2O2) 1.5-3%. The cause of an alveolitis is often an infection with anaerobic microorganisms, which are killed by the oxygen in the hydrogen peroxide.
After this, the patient can rinse the wound himself several times daily using a jaw rinsing syringe (Monoject®). He must continue this until the pain is over (see image below).
With very difficult extractions, a tampon with iodoform vaseline is sometimes introduced into the extraction wound. This is to prevent an alveolitis. Such a tampon slows healing, but at least counteracts an alveolitis.