Tooth and bone fragments (after tooth extraction). -
One common complication associated with having a tooth pulled is finding that one or more small hard fragments (splinters, shards, spurs, chips) of tooth or bone have worked their way to the surface of your extraction site.
- The healing of the wound from your surgery has been progressing normally and uneventfully.
- After some days or weeks, your tongue discovers a tiny hard object sticking out of your gums.
- It may be a small rounded lump or sharp-edged splinter.
This scenario is more likely to occur following relatively more difficult tooth extractions, especially "surgical" ones (the type of procedure used to remove impacted wisdom teeth).
What you need to know.
This page explains why these fragments (such as bone sequestra, see below) form. It also outlines how they are removed, either by your dentist or, in the case of the smallest splinters or shards, own your own as self-treatment.
What types of fragments might you find?
Any slivers or pieces you discover sticking out of your extraction site have come from within it. They can include:
- Tooth pieces / Root tips. - It's not terribly uncommon for a tooth to break or splinter during the extraction process. As an example, root fracture is the most common intraoperative complication and estimated to occur in 9 to 20% of cases. (Ahel 2015) [page references]
Or, before a tooth does break, a dentist may cut it into parts. Doing so often makes it easier to get out. Either way, if fragments exist some may get left behind.
- Remnants of the tooth's dental restoration. - The forces used to remove a tooth may dislodge or break its filling. If so, they may find their way into the empty socket and get left behind.
- Bone fragments / Bony flakes. - Two different scenarios may cause these.
1) Broken bone - Bits of a tooth's bony socket may break off during the extraction process.
2) Damaged bone - Bone is a living tissue, and if it's severely traumatized during the extraction process portions of it may die (see below). These types of fragments are called "sequestrum" (singular) or "sequestra" (plural).
The potential for experiencing any of the above will be related to a multitude of factors including: skill of the dentist, extraction technique and instruments used, as well as the patient’s age and quality of bone.
Why do these slivers come to the surface?
Having pieces of tooth or bone coming out of your extraction site might seem mildly disturbing. But this is actually a somewhat common occurrence and it's easy to understand why it needs to take place.
Why it occurs.
- To your body, these pieces of tooth and lumps of dead bone (sequestra) are foreign objects.
- They can't be integrated into the healing tissues and, in fact, their presence complicates and delays the healing process.
- Since these objects have no beneficial value, your body's goal is to eject them.
What takes place.
The path of least resistance for these pieces is through the newly forming tissues of the healing socket. Then, once they've migrated to the surface, they begin to penetrate into the gum tissue where they wind up sticking out.
In cases where they're somewhat rounded, or there's a substantial portion of the shard that's still not sticking through yet, these pieces may feel like a small (possibly movable) lump underneath your gums.
If given enough time, most fragments would probably work their way on through the gum tissue and ultimately fall out. For most of us, however, their presence is too much of an irritation or novelty (like too our tongue) and a quicker remedy is found (see below).
If this root fragment is not removed at the time of surgery, it may eventually come to the surface.
When can you expect fragments to appear?
Routine bone sequestra and tooth fragments can come to the surface of an extraction site at any time during its healing process. But you're most likely to notice these pieces sticking out during the first few weeks after your tooth was removed.
Some may take longer.
Some tooth fragments, especially root tips, may prove to be an exception to the above general rule. These shards may not surface for months (or even years, if at all) following your surgery.
Risk factors / Prevention.
The likelihood of experiencing tooth and bone chips is most likely to occur after extractions where the surgery has been relatively involved, difficult or traumatic.
The paragraphs below explain why. And no, despite their best efforts no dentist can always prevent this (typically minor) complication.
a) Bone fragments (sequestra).
Bone is a living tissue and it can be traumatized enough during the extraction process that portions of it will die. (When a sequestrum comes out, you are literally looking at dead bone.)
To minimize trauma, your dentist will take great care when they work directly with bone (like when its overlying gum tissue has been peeled back).
This includes completing your procedure as quickly as possible. Keeping the bone moist. And when trimming it, constantly flushing it with water so it's not overheated by the drill.
b) Broken bone.
The bone making up the tooth's socket is fragile and portions of it can break during the extraction process. Pieces that have broken free can be washed or picked out of the socket.
Those that are still attached (and still have a blood supply) may heal and are usually left in place. If they don't survive, they become bone sequestra.
Your dentist will thoroughly flush out the socket to remove debris.
c) Tooth pieces.
If a tooth does splinter or break, a dentist will make sure they thoroughly wash the tooth's socket in an attempt to flush out any and all remaining loose bits.
While never a first choice, a dentist may decide that leaving a broken root tip leaves the patient at less risk than the damage that might be caused trying to retrieve it. As general rules:
- If a tooth remnant 3mm or less (less than approximately 1/8th inch) lies in close proximity to a vital structure (e.g. nerve bundle, sinus floor, etc...), the risk vs. reward of removing it should be carefully evaluated.
- Unless grossly infected, leaving behind a small fragment is usually of no consequence.
- Any pieces of broken tooth that do remain should be periodically monitored via x-ray examination.
- Over time, the fragment may migrate to the surface of the bone where it can be removed, possibly quite easily.
Possible complications with removing root tips.
As you might imagine, the tips of some broken roots can be hard to visualize and access. And if so, they can be a challenge to remove.
In their zeal to remove the fragment, a dentist may inadvertently use a level of force that exceeds what the sometimes very fragile surrounding bone can bear. If so, the root tip may be pushed beyond the tooth's socket and into some other anatomical space (like the patient's sinus).
While this type of event isn't necessarily common, it does sometimes occur. And in situations where the potential for this type of complication seems relatively likely, leaving the broken fragment alone may make the most prudent choice.
d) Your part.
There's really not much you, the patient, can do to prevent extraction fragments, other than giving your dentist your full cooperation so they can complete your procedure under as ideal circumstances as possible.
Removing bone fragments and tooth pieces.
a) Treatment from your dentist.
It's your dentist's obligation to provide the assistance you require during your extraction site's healing process. So, if you've found anything hard or sharp sticking out of your gums, you should never be hesitant to ask for their attention and help.
What your dentist needs to do.
In short, your dentist simply needs to remove the shard. With the small types of fragments we discuss on this page, the procedure is usually quite easy.
How they'll do it.
- With most cases, removing the piece usually just takes a quick flick or tug using a dental instrument, with no anesthetic required.
- In some cases, the spur or sliver might be large enough and/or still buried under your gums enough that a longer, harder tug or push is required. If so, the use of some type of anesthetic might be in order.
A dentist has two types of numbing agents that might be used:
- Topical anesthetic (i.e. benzocaine) - This type of product is usually a gel that's smeared on the gums around the protruding fragment.
- Local anesthetic (i.e. "novocain") - This type of anesthetic is given via injection (a dental "shot").
Of the two, local anesthetic provides a more profound numbing effect. But you have to put up with the pinch of the shot when it's given.
Application of topical anesthetic is painless. But generally these products can't numb up more than just the surface of your gums. You'll simply have to rely on your dentist's judgment as to which makes the reasonable choice for your procedure.
With the most involved cases, your dentist may feel they need to make an incision in your gums to be able to access and remove the shard.
If so, local anesthetic will definitely be needed. If just a short incision alone is made, stitches may not be required. If your dentist needs to create a tissue flap (peel back the gums), they will be.
Taking an x-ray.
Your dentist may feel it's necessary to evaluate your tooth's socket by way of taking an x-ray.
- Since live and dying bone (sequestra) will both have a similar level of mineral content (the same density), an x-ray is unlikely to provide much information about the current situation (one can't be distinguished from the other).
- Because tooth shards, root tips and pieces of filling material do have a different density than bone, they will be visible on the film.
b) Do-it-yourself treatment.
You may be able to remove very small tooth and bone splinters on your own.
- These bits can usually be flicked out using your finger nail or pushing them out with your tongue.
- It may take working with both methods, repeatedly and over the course of a day or two, to finally wrestle the piece free.
- When it comes out, you will probably get a bit of bleeding but it should be very minor. (Bleeding is best controlled by biting firmly on gauze.)
If you're squeamish about the way it feels to wrestle one of these fragments out, you might consider using an over-the-counter gum-numbing product.
Look for products (liquids, gels) that contain the anesthetic benzocaine (ask your pharmacist). These are the same types of products used with children to control teething pain.
Do-it-yourself treatment is fine for emergencies and when the bit comes out easily. But overall it just makes good sense to touch base with your dentist when fragments present themselves.
If you're a generally healthy person and the area where the fragment appears was involved with a challenging extraction, then what's explained on this page likely applies to your situation.
But for others and other situations, what you're experiencing may be an indication of more serious complications. As examples, people having a history of taking bisphosphonate drugs (such as Fossmax®) or people who have undergone head and neck radiation treatments are at risk for complications with bone tissue healing.
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