Surgical tooth extractions.
Indications: Broken or cracked teeth, Impacted wisdom teeth, Curved roots, Root tip retrieval. / Techniques - 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 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.
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.
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.
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).
c) Thin, fragile roots - Comparatively longer, thinner roots will be more likely to break during a tooth's extraction process.
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.
b) Partial-bony impactions. - This classification involves teeth whose upper portion is both buried underneath the gums and partially encased by bone.
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.)
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.
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.
Surgical extractions - Procedure details.
There are 3 basic surgical techniques that might be utilized during a tooth's extraction. They are:
Creating a flap allows access to the jawbone and broken 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:
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.
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.
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 into 2 parts can make its removal easier.
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?
Less bone must be removed when a tooth is sectioned.
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.]
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.
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