Surgical tooth extractions.

Indications for this procedure - Broken or cracked teeth, Impacted wisdom teeth, Curved roots, Root tip removal. | Techniques used: Tooth sectioning, Bone removal.

What is a surgical extraction?

A surgical tooth extraction is a procedure that's used to remove a tooth that includes additional surgical steps that aren't performed with routine extractions. These added steps may be:

  • Creating a gum tissue flap. - With this procedure, an outline incision is made in your gum tissue so that section can be reflected (peeled) back, thus providing your dentist with access to the bone tissue and/or tooth that lies underneath.
  • Removing bone (ostectomy) - Trimming away bone tissue may be needed to give your dentist better access to, or a better view of, your tooth. Or it may be required to create an opening through which your tooth is taken out.
  • Tooth sectioning - This is a process where your tooth is cut into pieces ("sectioned"), so it can be removed more easily.
Which procedures classify as a surgical extraction?

When one or more of the above techniques are used, the procedure is formally categorized as a "surgical" extraction. Procedures that don't require any of these steps are termed "simple" extractions.

When are surgical extractions needed?

Indications / Applications

There can be a number of situations where the inclusion of one or more of the above surgical techniques might be needed to remove a tooth, either as a planned, anticipated or even impromptu addition. These situations include:

 

Our next section discusses the difficulties and challenges that the above situations can pose for a dentist, and then explains what surgical steps (gum tissue flap, bone removal, tooth sectioning) are used to overcome them. (Jump to a specific section using the links above.)

If instead you'd rather learn more about the process itself, use this link: Surgical tooth extraction procedure details.


Problem situations and their surgical solutions -

1) Broken teeth.

Many teeth are slated for extraction because much of their crown (the portion of a tooth that lies above the gum line) has been lost (fractured) or severely damaged (decayed), and now the tooth is beyond repair.

Or it's possible that during its extraction procedure a tooth has broken, possibly leaving little of it if any, visible or accessible to the dentist.

The problem - In cases where significant portions of a tooth are missing, the shape of the piece(s) that remains may be difficult for the dentist to grasp or manipulate with their extraction instruments.

And since these are the tools the dentist will use to remove the tooth, the dentist now has a dilemma.

 
Solutions for this situation.

One remedy is for the dentist to remove bone from around the pieces of the broken tooth that remain, so they're more accessible and visible. Then, once this process has been completed, the tooth can be worked and removed using conventional extraction instruments.

How it's done.
  • In some cases, the procedure that's 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 for the wound because this technique has been used.

  • With other cases, the dentist may find that they need more of the tooth exposed, or a greater extent of bone removed to reach where the broken bit lies. If so, a gum tissue flap will be raised, then the bone underneath trimmed away.

    This scenario is a more involved surgical process than the first one. And afterward, stitches will be needed to hold the flap in place as it heals.

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

2) Fragile or cracked teeth.

Beyond just having missing parts, what remains of a broken tooth may be fragile. And traumatized teeth that may still appear substantially intact, may have cracks that suggest to the dentist that they'll fracture during the extraction process.

The problem - Teeth are extracted by way of applying forces to them. And obviously these same forces might cause a fragile tooth to break apart. If so, the portion that remains in the tooth's socket may be difficult to access and manipulate, thus adding greatly to the degree of difficulty of the procedure.

(A study by Ahel determined that the level of force that results in tooth fracture is often only slightly greater than that required for the extraction process. This suggests that the potential for fracture of structurally compromised teeth is very real.)

Solutions for this situation.

With these types of situations, the dentist may decide that approaching the tooth's procedure as a surgical one right from the start makes the best plan because it minimizes the chances of complications associated with the unpredictability of the tooth fracturing.

Here's how performing a surgical extraction can help.

  • Removing some of the bone that encases the tooth's root(s) can make it so it can be loosened up and removed with less force, thus reducing its chances for fracture.
  • 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 having one of the roots attached, 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 often hinges on 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 root-related challenges that a tooth may pose that a dentist can manage by performing its extraction surgically:

a) Curved roots - Removing multi-rooted teeth (like molars) that have especially curved, hooked or crooked roots can prove to be stubborn extractions. Beyond just being difficult procedures, the act of pulling these teeth may require the use of excessive forces that may cause 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, canines) that have relatively larger, longer roots will take more force to extract than those that have comparatively shorter, smaller ones (such as lower incisors).

And when having to extract a tooth with a longer root, the dentist doesn't want to be placed in the position where they must apply excessive forces. Doing so puts the tooth, surrounding bone and even the jawbone at risk of fracture.

Solutions for this situation.

By removing some of the bone that encases the roots of stubborn teeth, or sectioning them into parts 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. And this concern doesn't just exist with small teeth. Some of the roots of multi-rooted teeth (molars, premolars) can be small, fragile and easily broken too.

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 that encases the tips of the roots of upper molars can be paper thin. So in the case where a root does break, an attempt to retrieve the piece that remains may result in it being pushed through this fragile bone and into the nasal sinus. If this occurs, this is a major complication.

(See below for more details about these procedures.)

4) Impacted teeth.

"Impaction" involves the situation where a tooth has not been able to come into its normal position in the mouth. And as a result, still lies buried under gum tissue and possibly bone tissue too. The type of teeth most likely to be impacted are 3rd molars (wisdom teeth).

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

With impacted teeth, a surgical extraction will be required. It's only a question of which added surgical steps will be needed.

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 techniques. The flap is then positioned back and and tacked into 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 is 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 performed 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 the roots of a tooth. This can include increased bone density (often a result of excessive tooth clenching and grinding) and age-related bone inelasticity.

Other patients may have added deposits of bone on their jaws (termed exostoses) whose presence complicates the extraction process.

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, thus making it a more controlled and predictable process.

(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 a tooth's extraction process may be such that the fractured tip of one of its roots has either been inadvertently, or possibly purposely, left behind.

Over time, the broken piece may remain in it's original location, or possibly migrate toward the jaw's surface. But either way, if at some point a decision is made to retrieve the root tip, a surgical extraction will likely be needed.

 
Solutions for this situation.

The type of procedure needed will simply depend on the tip's current position.

  • If it now lies close to the surface of the gums, a minor incision through the overlying tissue may create enough access to flick it out.
  • If the broken tip still remains encased in bone, a tissue flap and bone removal will be required to retrieve it.

 

Surgical extractions - Procedure details.

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

 

 Reference: 

Resources for our outline of the surgical tooth extraction process -

Fragiskos FD. Oral Surgery (Chapter: Surgical Tooth Extraction)

Koerner KR. Manual of Minor Oral Surgery for the General Dentist. (Chapter: Surgical Extractions)

Wray D, et al. Textbook of General and Oral Surgery.

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 change (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 controlled and predictable. When excessive forces must be used, tooth or bone fracture or jaw joint aggravation may occur.

  • Access -When extracting broken teeth, surrounding bone is often removed so more of the tooth is exposed. This makes it easier for the dentist to grasp and manipulate what's left of the tooth, thus making the extraction process more like a conventional one.

    In the case of impacted teeth (like wisdom teeth), the purpose of removing bone may be as fundamental as being what's needed to even access the tooth.

Whatever the purpose, as the dentist makes their plans one of their prime considerations will be how to keep the amount of bone they remove as limited as possible.

Trimming away bone - The process.

The method a dentist uses to trim bone tissue from around a tooth will depend on the access they have to it.

a) Removing bone immediately adjacent to and within the tooth's socket.

In cases where much of the tooth is missing and what is left is its root portion in its socket, the dentist may already have the direct access they need to remove bone.

This type of situation might exist when pulling teeth that have already fractured, or those that during their extraction procedure have broken or been sectioned into pieces (see below).

What the dentist will do.

Since they already have the access they need, a dentist will often just go ahead and trim away bone tissue from around the tooth using their dental drill. Doing so can be a quick and simple way of exposing more of the tooth without making a big production out of the process.

Deeper within the socket, this same method might be used as a way of removing bone from in between individual roots, or simply creating whatever additional space is needed for better instrument access.

Issues

One advantage of this method is that no secondary wound is created (like when a gum tissue flap is raised, 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 things this way, it won't be much of an issue for 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) Removing 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 plan and then make the incision(s) needed to create the gum tissue flap (see above). They'll then reflect (peel) it back.
  • Once exposed, the 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 along with bone removal a gum tissue flap is raised too makes this a more involved procedure than that described above.

And because a flap is created, a higher level of surgical trauma is experienced than with routine extractions, and this will affect the healing timeline of the resulting wound.

In cases where choosing to perform this step is even remotely optional, what the dentist is trying to accomplish by doing so is to create trauma "surgically" (quickly, neatly, in a controlled manner) as opposed to via the blunt force typically created during a messy, 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 10 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 preferably 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 bone tissue is 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 split 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 as it's applied, and then a snap as the two parts 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 something unexpected to happen during your tooth extraction. Or for the process to be more difficult than it needs to be (including the healing process).

Implementing surgical steps with your procedure generally means that it will go more quickly and predictably, and likely result in less overall surgical trauma, than if the potential undesired events did occur.

Try to think of having a surgical extraction as a form of insurance, in the sense that it places your dentist in a position where they have more control. Thus helping to guarantee that your entire experience will be as pleasant and uneventful as it can be.

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

 

Last revision/review: 10/22/2018 - Revision, content added.

 
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Comments

Surgical broken tooth extraction.

I have a broken tooth that needs to come out. The tooth doesn't hurt but the dentist says that what's left is so decayed that a crown can't be placed. My dentist says that a surgical extraction is needed and that I need to take sedation medication for it. I'm scared, this seems like a big process.

Kelly

Your situation seems to be one where tooth extraction seems to be the only option. If so, you should look at your dentist's pre-treatment planing of your extraction as a surgical one a very positive thing.

A dentist with less clinical expertise might first attempt your extraction as a conventional (simple) one, only to fail.

Instead of that (which involves you sitting through the failed attempt, creating additional tissue trauma, extending the length of your procedure, etc...), your dentist has identified that surgical steps are needed. By doing that right off the bat, your procedure will be quicker and less eventful, both during your procedure and the healing process that follows. Those are all very positive things.

As far as the use of the medication for your procedure goes, it's not uncommon that some type of sedation method is used with surgical extractions. And in your case you clearly state you are scared about the procedure, so that seems a reasonable thing to do. In general terms, using it helps you to be more relaxed, and gives your dentist a more compliant/cooperative patient. Once again, these things are all positive. Good luck.

Tooth extraction

My wisdom tooth was extracted a week a go and lots of pain I have had for the last two days. It was a very stuff extraction process due to its location and I heard him complain of one root that was still in place after the extraction but later on lost its whereabouts. Am back to the hospital and AwAiting an x Ray to be done to rule out any remnant roots. Am worried about her competence.

Joseph

Since we obvious know nothing about the circumstances involving your situation, it's not possible for us to state anything specific. In our response, we're making the assumption that the treatment was provided by a general dentist.

Any dentist will tell you that what it takes to actually complete a procedure (level of skill or expertise) may be different that what they initially thought would be required. With the question then becoming, was their level of expertise one where they should have suspected that the procedure would be difficult (like noticing telltale signs on an x-ray).

For anyone else reading in preparation of an extraction, about all you can do is ask the dentist bluntly: Is this a type of extraction you routinely perform? Is this the type of extraction that general dentists routinely refer to an oral surgeon? Is there anything about the tooth or situation that might indicate that referral would make a good choice?

Make it clear to them that the process and outcome of the procedure are as important to you as factors such as cost or convenience, and that you are open to the idea of being referred if that makes the more predictable procedural choice.

Joseph, we hope you have a quick recovery. While you don't mention, we assume that your having a dry socket has been ruled out as the problem.


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