Oral surgery - The tooth extraction procedure.

What takes place when you have a tooth pulled?

This page provides an overview of the process that a dentist uses when they extract a tooth for a patient.

Throughout, we explain the purpose of various instruments and steps. We also describe some of the routine sensations and sounds (both pain and non-pain related) that the patient has the potential to experience.

The more you know about the extraction process, the easier yours will be.

You're more likely to have a quick, uneventful extraction if you, the patient, contribute toward it. The contribution you need to offer is cooperation.

Patients who flinch, squirm, and moan at every routine, non-issue sound and sensation are simply making their procedure more difficult and prolonged.

Be intelligent. Take the time to learn what should be expected during a tooth extraction and what isn't (and therefore needs to be brought to the attention of your dentist). Doing so will help to insure that having your tooth pulled will go as quickly and smoothly as possible.

Having a tooth extracted - The procedure.

A syringe used to give dental injections.

A) Your dentist will numb your tooth.

Your dentist will need to anesthetize ("numb up") both your tooth and the bone and gum tissue that surround it.

At this point in time, there is still no way for a dentist to predictably administer a local anesthetic except as an injection (a "shot").

A tooth is held in its socket by a ligament.

We'll admit that this can hurt a bit. But we'll also emphatically state that it doesn't always.

Here's more information about this subject. It may help to put your mind at ease: Will my dental injection hurt?

B) The extraction process - What to expect.

1) Here's the overall game plan.

a) The root portion of a tooth is firmly encased in bone (its socket), and tightly held in place by a ligament.

b) During the extraction process, the dentist needs to both "expand the socket" (widen and enlarge it) and separate the tooth from its ligament, to the point where the tooth is loose and free to come out.

Rocking a tent stake back and forth enlarges its hole.
Rocking a tooth back and forth enlarges its socket.

What does it mean to "expand" a tooth's socket?

If you have ever tried to remove a tent stake that has been driven deeply into the ground, you know that you can't just pull the stake straight up. Instead, you first have to rock the stake back and forth so to widen (expand) the hole in which it is lodged.

Once the hole has been enlarged enough, the stake will come out easily.

Teeth are somewhat the same.

The bone inside the jaw is relatively spongy. That means, when a dentist applies firm pressure to a tooth (forcing it against the sides of its socket), the bone will compress.

After repeated application of pressure, from many different angles, the entire socket gradually becomes enlarged (expanded).

Finally, at some point, enough space will have been created (and the ligament separated from the tooth enough) that the tooth will come out.

Using a dental elevator to extract a tooth.

2) Here're the tools that your dentist will use.

Dentists have a variety of instruments that they use to manipulate and apply pressure to teeth. Some of them are specialized pliers called "extraction forceps." Others are levers (they look a bit like small screwdrivers) called "elevators."

a) Dental Elevators

During the extraction process, a dentist will usually use an elevator first.

These instruments are designed to be wedged in the ligament space between the tooth and its surrounding bone.

As the elevator is forced and twisted, the tooth is pressed and rocked against the bone. This helps to expand the socket. It also helps to separate the tooth from its ligament.

As this work is continued, the tooth will become more and more mobile. In some cases, the elevator may be able to shove the tooth on out. If not, the dentist will switch to the use of extraction forceps and remove the tooth with them.

Using extraction forceps to extract a tooth.

b) Extraction Forceps

A dentist will usually keep a number of different extraction forceps on hand. Each one will have a design that's been specially made to grasp a certain type of tooth.

When they're used, the dentist will grasp the tooth with the forceps and then firmly and deliberately rock it back and forth as much as it will. Because the bone that surrounds the tooth is compressible, the socket will expand.

In addition to a rocking motion, a dentist will also rotate the tooth back and forth. This twisting action helps to rip and tear the tooth from the ligament that binds it in place.

At some point, the socket will be enlarged enough, and the ligament torn enough, that the tooth can be easily removed.

C) What you'll feel during your extraction.

The anesthetics that dentists use to "numb up" teeth are very effective at inhibiting the function of nerve fibers that transmit pain. But they're not effective on those that transmit the sensation of pressure.

1) You'll feel pressure.

That means you should expect to feel pressure during your procedure, even a whole lot of pressure. But don't assume that doing so indicates that you will soon be feeling pain because it doesn't. Those fibers have been put out of commission by the anesthetic.

2) You shouldn't feel any pain.

There can be times when a patient's tooth hasn't been adequately anesthetized and more anesthetic is needed. So, if you do find that you feel pain during your procedure (discomfort that has a sharpness to it), you should let your dentist know so they can "numb you up" some more.

But be accurate in what you are reporting. More anesthetic will do nothing to take away the sensation of pressure. And, in fact, the needless administration of additional quantities of anesthetic may place you at greater risk for medical complications during your procedure.

D) Expect that you might hear some startling extraction noises.

As explained above, "pulling" teeth really is a very physical process. And in light of this, it should only be expected that some aspect of the procedure might create a minor snap or breaking noise.

The good news is the types of events that produce these sounds are often just routine and nothing to get excited about. (Not that doing so would help your extraction process go any easier anyway.) The two most common events, however infrequent, are bone fracture and root breakage.

a) Broken tooth roots.

Tooth roots can break during an extraction, and you might hear this noise. While it doesn't happen all of the time, it certainly does often enough that your dentist has probably dealt with many broken roots before.

The consequences root breakage can vary. The piece may prove to be uncooperative and retrieving it may add a fair amount of time to your procedure. In other cases, the part that's still in the socket is already somewhat loose and can be teased out relatively easily.

b) Bone fracture.

The bone tissue found in the center of the jawbone is relatively spongy. In comparison, a jaw's outer surface (the cortical plate) is relatively dense.

During an extraction, as pressure is applied to a tooth, the spongy bone that surrounds it will compress. The denser cortical plate, however, is more brittle and if it receives enough pressure it may snap.

In the vast majority of cases, this type of bone fracture is just a very minor, hairline event. After the extraction, the dentist will simply compress the empty tooth socket so the bone is squished back into place. The fracture can be expected to heal, uneventfully, in tandem with the extraction site as a whole.

E) "Closing" the extraction site.

Once your tooth has been removed, your dentist will begin the process of closing your extraction site. This may include:

  • Removing infected or pathologic tissue by curetting (scraping) the walls of the tooth socket.
  • Using finger pressure to re-compress the "expanded" socket.
  • Rounding off sharp bone edges.
  • Evaluating the tooth socket for sinus complications (upper back teeth).
  • Washing out ("irrigating") the socket, so to remove any loose bone or tooth fragments that remain.
  • Placing stitches (usually only after surgical extractions).
  • Placing folded gauze over your extraction site and then having you bite down on it so to create firm pressure.

Your dentist will then provide you with a list of postoperative instructions. These are extremely important and must be followed.

Not all extractions are "simple."

Simple extractions.

Two teeth, one of which will require a 'surgical' extraction, the other a 'simple' one.

The vast majority of tooth extractions are completed using the simple mechanics described on this page. In fact, there's a name (a classification) for these types of extractions. They're literally called "simple" extractions.

[The removal of the decayed tooth in our graphic (tooth #2) will likely be a simple extraction. It is erupted and has a normal positioning.]

Surgical tooth extractions.

There can be situations where some aspect of a tooth, such as its positioning, shape, brittleness or compromised state complicates its removal. In these cases, a "surgical" extraction will be required.

[The impacted tooth (#1) in our graphic will require surgical removal.]

For more information about this procedure, see our page: Surgical Tooth Extractions.

The interesting thing about these extractions is that their surgical steps are simply used so the tooth can then be removed using the same basic principles described above.

 All FYI's ► 

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