Surgical tooth extractions.

Indications for them: Broken or cracked teeth, Impacted wisdom teeth, Curved roots, Retained root tip removal. | Techniques used: Tooth sectioning, Bone removal.

Your dentist may determine that the addition of certain surgical steps to your tooth's extraction process will help to make its removal go more smoothly, quickly and/or predictably.

Or, in some cases (like removing impacted wisdom teeth, teeth that have broken under the gum line or retrieving root tips) a surgical approach may be the only way the procedure can be accomplished.

The added procedures might include:

When one or more of these techniques are used, the procedure is formally categorized as a "surgical" extraction. (Tooth extractions where these steps are not performed are referred to as "simple" extractions.)


Indications / Applications for surgical extractions.

There can be a number of situations where surgical technique might be used (either as a planned, anticipated or even impromptu procedure). They include:

 

This page discusses the difficulties associated with each of these situations and explains what surgical steps can be used to overcome them.

Problem situations and their surgical solutions -

1) Broken teeth.

  • A tooth may be slated for extraction because a large portion of its crown has fractured away. (The "crown" of a tooth is that part that's visible above the gum line.)
  • Or, sometimes during its extraction process, a tooth's crown may break off.

The problem - If breakage has occurred, the shape of the tooth structure that remains may be such that it's difficult for the dentist to manipulate it with their extraction instruments. Since it takes using them to apply pressure to the tooth so it will loosen up enough to come out, this can present a challenge.

As a worst (most difficult) case scenario, the entire crown may have broken off right at, or possibly below, the gum line.

 
Solutions for this situation.

One remedy is for the dentist to remove bone from around the broken tooth so more of it is exposed. Once it has been, it can then be worked with conventional extraction instruments, like being grasped with forceps.

  • In this case, the procedure used to remove the bone may be as simple as the dentist using their drill to create a trough around the tooth, thus exposing more of it.

    If so, the whole process may be completed in just a minute or two, with little extra attention required after the tooth has been pulled.

  • With other cases, the dentist may find that they need a greater portion of the tooth exposed, or better access. If so, a gum tissue flap will be raised, then the bone underneath trimmed.

    This is a more involved process. Stitches will need to be placed afterward.

(See below to learn more about both of these procedures.)

2) Fragile or cracked teeth.

Another concern with broken teeth is that they may be fragile.

The problem - The same force that originally broke the tooth may have cracked it as well. Or, the portion of the tooth's crown that remains may be fragile and thus prone to breaking once force from an extraction instrument is applied.

Solutions for this situation.

With these types of cases, the dentist may want to take steps that will help to lessen the chances that the tooth will break further during the extraction process. There are two ways they can do this:

  • Just like above, the dentist may remove some of the bone that encases the tooth's root(s). This way the tooth can be loosened up and removed using less force.
  • The dentist may decide to section the tooth. "Sectioning" means cutting a tooth into pieces and taking them out individually.

    As an example, a two-rooted molar might be cut in half. That way each piece, each attached to one of the roots, can be removed separately.

(See below for more details about these procedures.)

3) Teeth with long or curved roots.

An extraction's level of difficulty is often tied to the configuration of its roots. (This is one reason why dentists typically recommend that wisdom teeth should be removed at a stage of only 2/3rds root development.)

Here are some situations that may exist:

a) Curved roots - Multi-rooted teeth (like molars) that have especially curved, hooked or crooked roots can be stubborn extractions. Beyond just being difficult, the act of pulling these teeth may require the use of excessive forces that may result in bone or tooth breakage.

Solutions for this situation.

Molars are frequently sectioned when pulled. Cutting the tooth into parts, each having its own individual root, means that each piece will take less force to remove than if the tooth were whole.

The dentist will also have the luxury of removing especially curved roots each on their own, instead of locked together as an unmanageable unit.

(See below for more details about sectioning teeth.)

b) Long, large roots - Teeth (like eyeteeth) that have relatively larger, longer roots will take more force to extract than those with comparatively shorter, smaller ones (like lower incisors).

Solutions for this situation.

A dentist doesn't want to be placed in the position where they must apply excessive forces during the extraction process. Doing so places both the tooth, surrounding bone and even the jawbone at risk of fracture.

By removing some of the bone that encases the roots of stubborn teeth, or sectioning them if multi-rooted, the dentist can lower the level of force they must use, thus lowering the risk of procedure complications.

(See below for more details about these procedures.)

c) Thin, fragile roots - Comparatively longer, thinner roots will be more likely to break during a tooth's extraction process.

Solutions for this situation.

In cases where a dentist fully expects that a tooth's root(s) will break, a surgical extraction (bone removal, sectioning) may be indicated. That's because at the time of surgery, broken root tip retrieval can be routine but isn't always.

For example, the layer of bone encasing the tips of the roots of upper molars can be paper thin. In the case where a root does break, an attempt to retrieve the broken piece may result in it being pushed through this fragile bone and into the nasal sinus. This is a major complication.

(See below for more details about these procedures.)

4) Impacted teeth.

"Impacted" teeth involve the situation where a tooth has not been able to come into its normal positioning. The most likely type of tooth to be impacted is 3rd molars (wisdom teeth).

With this situation, some type of additional surgical steps will be required. It's simply a question of which ones.

[Use this link for a graphic illustrating the different impaction types discussed below.]

a) Soft tissue impactions. - This is the case where the tooth is only buried by a layer of gum tissue.

Solutions for this situation.

The dentist will need to make an incision in the overlying gum tissue and then reflect it back as a flap.

Now that the tooth has been exposed, it can be removed (possibly just using routine extraction methods). The flap is then closed and tacked in place using stitches.

(See below for more information about tissue flaps.)

b) Partial-bony impactions. - This classification involves teeth whose upper portion is both buried underneath the gums and partially encased by bone.

Solutions for this situation.

Just as above, the gum tissue must be flapped back so the tooth is exposed. Whatever bone stands in the way of removing the tooth is trimmed. The tooth is then removed and the tissue flap repositioned and stitched into place.

(See below for more information about how these procedures are performed.)

c) Full-bony impactions. - With this situation the impacted tooth if fully encased in the jawbone. (The most difficult types of wisdom teeth to remove are full-bony impactions.)

Solutions for this situation.

The same general steps taken with partial-bony impactions are taken here also, although much more bone tissue is trimmed away. And while any of the cases discussed above may, this one frequently involves the use of tooth sectioning technique to cut the tooth into smaller pieces that can then be removed individually.

(See below for more information about tooth sectioning.)

5) Dense, inelastic bone.

The problem - Conditions may exist that have affected the bone that encases a tooth. This can include increased bone density and age-related bone inelasticity.

Solutions for this situation.

With these cases, the use of bone removal or tooth sectioning techniques can help to reduce the level of force that's needed for the extraction.

(See below for more information about these procedures.)

X-ray showing a situation where a surgical extraction may be needed to remove a broken root tip.

Some bone removal may be needed to retrieve this root tip.

6) Root tip removal.

The problem - The outcome of an extraction may be such that a fractured root tip has been either inadvertently or purposely left behind. (Doing so is never a dentist's first choice.)

The broken piece may remain in it's original location or possibly migrate toward the surface.

 
Solutions for this situation.

If a decision is made to remove the tip, the surgical steps needed will simply depend upon the location of the piece.

If it has been ejected from the bone, a simple incision through its overlying gum tissue may create all of the access that's needed to flick it out.

If the broken tip still remains at the base of the tooth's socket, a tissue flap and bone removal will be required.

 

Surgical extractions - Procedure details.

There are 3 basic surgical techniques that might be utilized during a tooth's extraction. They are:

 
Animation illustrating creating a gum tissue flap so a broken tooth can be extracted.

Creating a flap allows access to the jawbone surrounding the tooth.

a) Tissue flaps.

A gum tissue flap is created and raised (peeled back) when the tooth or bone lying underneath needs to be accessed during the extraction procedure.

Then, once the tooth has been removed, it's positioned back into place and stitches are used to hold it there during the initial phases of its healing process.

Use this page "Gum tissue flaps" for information about how they're designed and made, as well as information about types of, placing and removing stitches.

b) Trimming bone.

Trimming bone tissue from around a tooth can serve two, often overlapping, purposes:

  • Changing the nature of the extraction - By removing some of the bone that encases a tooth's root, the dentist can reduce the level of force that's need to loosen and remove it.

    This is a positive thing because it helps to make the extraction process more predictable. When excessive forces must be used, tooth or bone fracture or jaw joint aggravation may occur.

  • Access -In the case of impacted teeth (like wisdom teeth), the primary purpose of removing bone may simply be to create an opening through which the tooth can be accessed and ultimately removed.

Whatever the purpose, as the dentist makes their plans one of their prime considerations will be how they can keep the amount of bone removed as conservative as possible.

Trimming away bone - The process.

The method a dentist uses to trim bone tissue will depend on their access to it.

a) Bone within and immediately around the tooth's socket.

In cases where the dentist can see directly into aspects of the tooth's socket, they generally have the access to the bone that they need to remove it.

This would be the type of situation that exists when a broken tooth is being pulled, or a tooth has broken or has been sectioned (see below) during its extraction process.

What the dentist will do.

A dentist will often just use their dental drill to remove bone. They'll trim along side and around the tooth creating a trough. This method can be a quick and simple way of establishing better access for their instruments (forceps or elevators), and reducing the amount of force they'll need to use with them.

Deeper within the socket, drilling might be used to remove bone from in between individual tooth roots. Or simply create the space needed for better instrument access or easier root dislodgement.

Issues

One advantage of this method is that no secondary wound is created (like when a gum tissue flap is reflected, see below). The trimming is primarily accomplished within the wound that would have generally existed anyway. This is favorable for the healing process.

What you'll experience.

If your dentist does need to perform this step, it shouldn't present much of a concern to you. You'll hear the noise, and feel the vibrations, of the drill as it's being used. Other than that, it should be a non issue.

Trimming bone in this manner may take very little time. And as opposed to a separate step, it's often just incorporated into the flow of the procedure.

Since they don't want to remove more bone than is necessary, a dentist will frequently drill an initial amount, then try to remove the tooth. If it doesn't come out as expected, and after evaluating why, they'll make adjustments in their plan and trim some more.

b) Bone external to the tooth's socket.

In situations where the bone that needs to be removed lies in an area covered by gum tissue, a flap will need to be raised.

This type of scenario would apply to cases such as removing impacted wisdom teeth (where a layer of bone lies over the tooth) or removing the bone along side of a tooth (so to expose a portion of its roots, so it's easier to remove).

What the dentist will do.

  • The dentist will first need to design and create the gum tissue flap (see above), and then reflect it back.
  • The exposed bone can then be removed (either via the use of a drill or hand instruments).
  • Once the extraction has been completed, the flap is closed and tacked back into place with stitches.
Issues

The fact that a gum tissue flap is made, and likely a significant amount of bone removed, typically makes this a somewhat involved procedure.

A higher level of surgical trauma is created with this procedure than with a routine tooth extraction. And this fact will be reflected in the overall time frame needed for its healing process.

In cases where performing this step is even remotely optional, what the dentist is trying to accomplish by choosing it is to create trauma "surgically" (quickly, neatly, in a controlled manner) as opposed to via the blunt force typically created during a blundered extraction (i.e. torn or bruised tissues, broken, bruised or otherwise traumatized bone and broken teeth.)

What you'll experience.

You'll feel pressure as the outline of the flap is scored with a scalpel and then peeled back.

You'll also hear the sounds, and feel the vibrations and pressure, created by the tools used to remove the bone (probably a drill, possibly hand chisels). But other than that, this whole process should be a non-event.

The addition of this step will mean that your extraction may take a little longer. With simple cases, just an extra 15 minutes or so. With impacted wisdom teeth, this step may be a major component of the extraction process.

After your procedure has been completed, it's important for you to understand if you need to return to have your stitches removed or not.

Minimizing trauma to the bone.

Whichever of the above methods is used, first on your dentist's mind will be making sure that the drill they use doesn't overheat the bone tissue during their work. They'll do this by flushing the site with water (or salt water) continuously throughout the trimming process.

This constant irrigation will also wash away spicules of loose bone that are created (they could interfere during healing). It also helps to keep the bone moist during the extraction process.

All of this care is important because bone is a living tissue. The more precautions that are taken, the fewer complications you'll have with postoperative pain, swelling and bleeding. At the extreme, if it's severely traumatized portions of it may die, thus delaying the healing process.

c) Sectioning teeth.

Tooth sectioning, or "controlled tooth division," can help to lower an extraction's level of difficulty. By splitting (sectioning) a tooth into parts, an otherwise difficult extraction can be transformed into a simpler one because now each part can be removed individually.

Sectioning a molar.

Animation illustrating how a multi-rooted teeth might be sectioned into parts.

Each piece is easier to remove than the tooth as a whole.

What sectioning accomplishes.

Tooth sectioning has various purposes. They include:

  • Reducing the level of force needed to remove the tooth. - By splitting a multi-rooted tooth into parts, each piece can be removed using less force than if the tooth were whole.

    This lessens the likelihood that tooth or root fracture will occur, or the jaw joint irritated.

  • Simplifying a tooth's configuration. - Multi-rooted teeth that have especially curved, hooked or crooked roots are frequently sectioned. That way each root's path of withdrawal out of the socket can be managed individually.

    Without sectioning, these types of extractions are often difficult and result in root breakage.

  • Allowing smaller access. - In the case where bone tissue must be removed to gain access to impacted teeth (like wisdom teeth), sectioning the tooth into smaller portions allows it to be removed through a smaller opening (see picture below).

    A smaller wound is favorable for the healing process and results in a smaller post-surgery defect ("dent") in the jawbone.

How are teeth divided up?

Sectioning an impacted molar.

Animation illustrating the sectioning of an Impacted wisdom tooth.

By sectioning the tooth into parts, less bone removal is needed.

The dentist's goal when sectioning a tooth is to divide it up into smaller parts. But each one must still remain large enough to be easily manipulated by their extraction instruments.

  • In the case of a two-rooted lower molar, a logical place to cut the tooth is in half, right between its roots (see picture above).
  • With some impacted wisdom teeth, the tooth's crown portion may need to be cut off and removed first. Then the root portion can be sectioned and removed.

How does a dentist section a tooth?

Nowadays, teeth are usually sectioned using a dental handpiece (drill). [In the past, teeth were broken into parts using a mallet and chisel.]

  • During this process, the dentist will continuously flush the working area with water.

    This removes any chips or fragments that are created. It also helps to keep the amount of bone-traumatizing heat that's generated during the process to a minimum.

  • After the tooth has been sectioned, the individual pieces are teased out using conventional extraction instruments (forceps and elevators).
  • The pieces may be interlocking, so sometimes it takes getting a first one out before the others follow more easily.
What you'll experience.

Sectioning a tooth into pieces typically does involve cutting into its pulp chamber and nerve tissue. The good news is that since your tooth has already been numbed for its extraction, you won't feel it as it does.

  • You will hear the sound of the drill and feel the vibrations it creates as it works.
  • In some cases, your dentist may cut your tooth most of the way through but not all. They'll then split the two halves apart by wedging a tool in between them.

    If so, you'll feel a little bit of pressure and hear the snap as they separate.

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Other details about surgical extractions.

Yours may be planned or unplanned.

As beneficial as the surgical steps we discuss on this page can be, no dentist will choose to include them in their patient's extraction process unless they feel sure they are needed. As examples:

  • During your pre-treatment examination, your dentist may discover reasons why they feel a surgical extraction should be planned right from the start. Examples of these reasons are given at the top of this page.
  • Your dentist might observe clues that hint that surgical steps will be needed but they choose to hold off on them until they have further proof.

    For example, the x-ray of your tooth may suggest that the bone encasing its roots is quite dense. Finding the tooth very difficult to loosen during the initial stages of your extraction process would confirm this fact for your dentist. If so, they might immediately switch to the use of a surgical approach.

  • As a last scenario, the nature of the routine extraction that your dentist expects might suddenly change. For example, the crown of your tooth might snap off at the gum line. If so, a switch to a surgical approach would be likely.

Don't be frightened of the idea of having a surgical extraction.

As a patient, the last thing you want is for the unexpected to occur during your tooth extraction, or for it to be a more difficult process than it needs to be (including healing).

Implementing surgical steps with your procedure generally means that it will go quicker, more predictably and result in less surgical trauma than if (probably likely) undesired events did occur.

Try to think of having a surgical extraction as a form of insurance that helps to guarantee that your entire experience will be as pleasant and uneventful as it can be.

Details about: "Simple" (routine, "non-surgical") tooth extractions. ▶

 

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