Tooth and bone fragments (following a tooth extraction). -

Why do they appear? | What do they look like? (pictures) | Removal - By your dentist. / How to remove them yourself. | What causes bone sequestra (fragments, spurs) to form?

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 and are now sticking out of your gums.

The scenario.

  • Following your surgery, the healing of your wound has been progressing normally and uneventfully.
  • After some days or weeks, your tongue suddenly discovers a tiny hard object sticking out of your gums.
  • What you feel may be a small rounded lump or a sharp-edged splinter.

This scenario is more likely to take place after relatively more difficult tooth extractions, especially surgical ones (which includes the type of procedure used to remove impacted wisdom teeth).

What you need to know.

This page explains why these hard bits and shards (tooth fragments / bone sequestra) form, and gives pictures of what they look like.

It also outlines how they are usually removed, either by your dentist or, in the case of the smallest splinters or spurs, 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. These bits can include:

Post-extraction
Complications

  • Tooth pieces / Root tips. - It's not terribly uncommon for a tooth to break or splinter during its extraction process. For 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 strategically decide to cut it up into parts (referred to as "sectioning" the tooth). Doing so can make it easier to get out.

    But either way, if any fragments are created, 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, spurs, bony flakes. - Two different scenarios may be involved when these types of objects form.

    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 traumatized enough during the extraction process aspects of it may die (see below). These types of fragments are called "sequestrum" (singular) or "sequestra" (plural).

The potential for your experiencing any of the above will be affected by 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.

What do the fragments look like?

In many cases you'll be able to visualize the spur of bone or shard of tooth sticking through your gums. But if you can't, don't be too surprised.

  • The location of the protruding bit may be such that it's essentially impossible to view it without aid (such as the good light source and small oral hand mirror that your dentist has to use).
  • Sharpness or irritation that your tongue feels may be produced by objects that are astoundingly minute in size, and therefore difficult to visualize.
How the lesion looks in your mouth.

As a response to the presence of the offending hard object, the soft tissue surrounding the fragment will characteristically show signs of redness (erythema), and possibly some minor level of swelling (oedema). It may be tender to touch.

Some degree of ulceration may form, especially when bigger bone fragments are involved. Larger lesions may display a whitish surface membrane surrounding a hard center section of exposed bone.

Any exposed or protruding bone is usually non-responsive to touch (its dead or dying) but the surrounding tissue may be extremely sensitive. (Farah 2003) Likewise, tooth fragments themselves will be non-sensitive to touch but their surrounding tissue may be.

Post-extraction bone sequestrum and tooth fragment.

Close up picture of a post-extraction bone sequestrum and tooth fragment.
Inspecting the fragment.

No doubt the piece that has surfaced or has come out will be a curiosity to you.

  • Bone bits (sequestra) - These items are usually very irregular in shape, with rounded or sharp edges. Their color is usually light tan to white. Their surface will look smooth but lobulated (not perfectly flat but bumpy).
  • Tooth fragments - These bits can be very shard-like (pointed, sharp edged, etc..., just like you'd expect a piece of broken tooth to be). However, if the aspect you're looking at is the tooth's original outer surface, that side will have contours that are smooth and rounded.

    Those portions covered with dental enamel will be white and have a shiny appearance when dry. Aspects involving the inner portions of the tooth or its roots (both composed of dental dentin) will have a more yellowish tint, and a dull appearance when dry.

The size of the fragment can be quite variable. What you see sticking through your gums in no way correlates with the full extent of what lies underneath (be it large or small).

Why do these bits and slivers come to the surface?

You might find that discovering pieces of tooth or bone coming from your extraction site to be somewhat disturbing. But experiencing this phenomenon is actually a fairly common occurrence, and it's easy enough to understand why it needs to take place.

Why it occurs.

  1. From your body's perspective, these pieces of tooth and lumps of dead bone (sequestra) are foreign objects.

    (They aren't healthy, live tissue that can once again be a part of your body. To the opposite, their presence complicates and delays your wound's healing process.)

  2. Since these objects have no beneficial value, and in fact are instead a complication, your body's goal is to eject them.

What takes place.

Fragment migration.

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 of your jawbone, they begin to penetrate into the gum tissue that lies over it, until they ultimately wind up poking through and sticking out of its surface.

Shard discovery.

In cases where the object is somewhat rounded and relatively smooth, and especially if there's a substantial portion of it still not sticking through yet, these pieces may feel like a small (possibly movable) lump in your gum tissue.

If instead the fragment has any degree of roughness or sharpness, it won't take long for your tongue to find it. And probably be quite annoyed by its presence.

Exfoliation or removal.

If given enough time, most fragments would probably work their way on through the gum tissue and ultimately fall out (exfoliate) on their own.

For most of us however, the presence of the spur is too much of a novelty or irritation to our tongue, or the process simply too drawn out, and a quicker remedy (see below) is wanted.


X-ray showing root tip fragment left after an extraction.

If this root fragment is not removed at the time of surgery it may eventually come to the surface on its own.

When can you expect fragments to appear?

Routine bone sequestra and tooth fragments can come to the surface of an extraction site at any point during its healing process timeline.

But you're most likely to start to notice these bits sticking out of your gums 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 later, if at all) following your surgery.

 

Risk factors / Prevention.

The likelihood of experiencing tooth and/or bone chips after an extraction is most likely to occur after those where the surgery involved has been relatively difficult or traumatic in nature. The paragraphs below explain why.

[And no, despite their best efforts no dentist can prevent this complication from happening 100% of the time.]

a) Bone fragments (sequestra).

Bone is a living tissue and if it has been traumatized enough during the extraction process portions of it may die. (When a sequestrum comes out, the piece you are looking at is literally a chunk of dead bone.)

What your dentist can do.

To minimize the level of trauma that's created, your dentist will take great care whenever they work directly with bone tissue. (Like during those times when the gums lying over it have been flapped back so the dentist has direct access to it.)

This includes completing your procedure as quickly as possible, keeping the exposed bone moist, and when trimming it, constantly flushing it with water so it doesn't become overheated by the drilling process.

b) Broken bone.

The bone that makes up a tooth's socket is fragile and aspects of it can be broken during the extraction process.

An x-ray a tooth socket after having its tooth pulled.

Your dentist will thoroughly flush out your tooth's socket to remove any loose debris.

Complete breaks.
  • Any pieces that have broken free entirely and are noticed by the dentist can be picked out or washed away when the tooth's empty socket is "irrigated" (flushed out with water or saline solution).
  • Some bits may go unnoticed but will get flushed away anyway during the socket's post-extraction irrigation.

Any fragments that have broken free that aren't removed from the socket will ultimately be ejected as bone sequestra during the healing process and following.

Attached bone fragments.

Those broken pieces of bone that are still attached to tissue (still have a relationship with surrounding bone and/or gum tissue) and still maintain an adequate blood supply (the broken bit's source of nourishment), may ultimately heal and therefore may be left in place by your dentist (this is a judgment call on their part).

If they don't survive, they will become bone sequestra.

c) Tooth pieces.

Routine fragments.

Anytime a tooth does splinter or break, a dentist will make sure to thoroughly irrigate (wash out) the tooth's socket with water or saline solution in an attempt to flush away any and all remaining loose bits.

X-ray showing root tip fragment left after an extraction.

A broken root tip remaining in the tooth's socket.

Root tips.

While never a first choice, a dentist may decide that leaving a broken root tip leaves the patient at less risk for harm than the damage that might be caused by trying to retrieve it.

As general rules:

  • If a tooth remnant 3mm or less (which is just slightly less than 1/8th inch) lies in close proximity to a vital structure (e.g. nerve bundle, sinus floor, etc...), the risk vs. reward (see below) of removing it as compared to just leaving it alone should be carefully evaluated.
  • Unless grossly infected, leaving behind a small fragment is usually of no consequence.
  • Any pieces of broken tooth root that do remain should be periodically monitored via x-ray examination.
  • Over time, the broken 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 a fragment, a dentist may inadvertently use more force than what the sometimes very fragile surrounding bone can bear. If so, the root tip may be pushed beyond the tooth's socket and into an adjacent anatomical space (like the patient's sinus area).

While this type of event isn't necessarily common, it can occur. And in situations where the potential for a complication occurring seems relatively possible (in this case the displaced piece will need to be retrieved), leaving the broken fragment alone in the first place 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. (In more straightforward terms, make it so your dentist is able to focus more so on the process of performing your extraction, instead of managing you.)


Removing bone fragments and tooth pieces.

a) Treatment performed by 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 aid.

What your dentist needs to do.

In short, your dentist simply needs to remove the shard. With the small types of fragments that are the focus of this page, the procedure is usually quite easy. However, and as explained below, larger bits may offer your dentist more of a challenge and require a more involved procedure.

How they'll do it.

  • With most cases, removing the offending 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.

Anesthetic options.

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 patient's gums around the protruding fragment.

    Generally speaking a topical anesthetic is only able to numb up the surface of the gum tissue. But since that's where the bulk of the fragment likely (hopefully) resides, its effects are usually sufficient.

  • Local anesthetic (i.e. "novocain") - This type of anesthetic is given via injection (a dental "shot").

    This method of anesthesia provides a deeper, more profound level of numbing. The trade-off is that you're likely to feel the pinch of the shot as it's given.

You'll simply have to rely on your dentist's judgment as to which method is needed for your procedure. They'll base their decision on their interpretation of how small the object is and how quickly they expect it to flick out. Your concerns can be an important part of this calculation too, so let them be known.

Situations involving larger fragments.

With the most involved cases, your dentist may feel that 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.

As far as the removal process itself goes, the hope is that once your dentist has adequate access to the fragment that they can then tease it out easily. But even your dentist won't know how much effort is required until the procedure has been completed.

Once removed, if just a small incision was made stitches may not be required. If instead your dentist had to create a tissue flap (the situation where your gums are peeled back so to give better access), 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 radiograph.

  • Since live and dying bone (sequestra) will both have a similar level of mineral content, it may be difficult, if not impossible, for your dentist to distinguish one from the other because objects are apparent on x-rays because they have different densities. So when bone fragments are involved, an x-ray may not provide as much information as desired.
  • Because tooth shards, root tips and pieces of filling material each do have different densities than bone, they are much more likely to be visible on a radiograph.

Proactive treatment.

For small, routine shards, a dentist will usually just provide treatment for their patient on an as-needed basis (as each bit surfaces and is discovered sticking out of the gum tissue).

Less common is the scenario where the dentist goes after the pieces surgically before they surface. Here are some reasons why:

  • As we've just explained, some types of fragments can be hard to identify on dental x-rays. And even if seen, routine x-ray imaging only provides a two dimensional representation, which means that it can still be difficult to know exactly where the offending shard(s) lies.
  • Visibility in an extraction site can be limited. Bleeding can further complicate this issue. Overall, especially when smaller, multiple fragments are involved, locating all of the offending bits may not be simple or entirely successful.
  • Probably the biggest question is simply, why create a whole new surgical wound just to remedy a situation that your body will most likely handle relatively uneventfully on its own?

Having stated the above, when the fragments are relatively fewer and larger, or it's your dentist's interpretation that a piece will not shed so easily or uneventfully, the case for surgical intervention can make a lot of sense.

Using our referral links for purchases supports this website at no additional cost to you. It's sincerely appreciated if you do.
Shop either ▶ Amazon related products below on this page, or else for any items on ▶ Amazon.com or ▶ Walmart.com.

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 to a point where its loose enough to come free.
  • When it comes out, you'll probably get a bit of bleeding but it should be very minor. (Bleeding is best controlled by biting firmly on gauze.)

Anesthetic.

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 that are often used with children to control teething pain.

Best practices for at-home treatment.

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 any fragments show up. (It's your dentist's obligation to provide you with the post-extraction follow-up care you require.)

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 significant complications with bone tissue healing.

Healing following fragment removal.

Since the wound that's left after removing a small fragment will primarily be soft tissue borne (lies entirely within the thickness of the gum tissue), once the offending tooth shard or bone spur has been removed you can expect a substantial amount of healing and pain reduction to take place within the first few days, with complete healing occurring within 7 to 10 days.

The actual time frame you experience will of course be influence by the initial size (diameter) and depth of the wound that was left behind.


Bone fragments not associated with a tooth extraction.

The contents of this page address the subject of small, routine bone spurs and tooth fragments that rise to the surface of a patient's gum tissue following a tooth extraction. Similar in experience to this situation is the condition referred to as "uncomplicated spontaneous sequestrum."

Just as above, the word "sequestrum" as used here (the plural form is sequestra) refers to dead, ejected bits of jawbone. However, with this condition the cause of the sequestra is unrelated to the removal of a tooth. And in fact, the precise cause of the bone tissue's devitalization (death) frequently remains unexplained.

A common location for the formation of these bone bits is the tongue side of the lower jaw in the area of the molars.

Why they form.

The usual explanation given for the formation of these sequestra is local tissue trauma.

  • The idea is that the gum tissue in the affected region has been traumatized to the point where there is a disruption to its blood supply. This might take the form of continuous low-grade trauma, or a more substantial event.
  • Due to the blood supply loss, the soft tissues that lie over the bone are less capable of protecting it, and as a result it necroses (dies), ultimately resulting in the formation of a sequestrum (the body's ejection of dead bone tissue).

Some suggested causes of continuous, low-grade trauma include abrasion associated with eating foods (in cases where there's a less than ideal teeth-jawbone relationship or jaw shape, or an area of missing teeth) or trauma caused by repeated activities such as tooth brushing.

Treatment and concerns.

After evaluation, with very minor cases a dentist might conclude that the event has been a self-limiting condition that lies within the normal limits of what a person may experience.

With these minor cases, once the sequestrum has been lost (either spontaneously or assisted) the patient's pain relief and healing will progress rapidly, with complete healing occurring within 7 to 10 days.

With more involved cases, the potential for contributory systemic health factors may need to be considered and evaluated. Additionally, the size of the affected area/lesion may be large enough that your dentist feels that surgical intervention is required.

(Farah 2003)

Back to our post-extraction complications page. ▶

 

search

Topic Menu ▶  Tooth Extractions

 
 
search

Comments

Bone Fragments

A bit of advice here for people wearing dentures maybe? It seems that using the dentures exacerbates the problem greatly, causes much pain and is ill-advised while you have fragments of bone still working through.

Nice calmly worded article! Helped me to find this after ripping a nice large shard of bone out of my mouth!

Uppers all out

Last 5 pulled, uppers jan25--- lots of seemingly large debris extremely sensitive to touch made last 40 days have been miserable, lost 18 lbs....only good thing. Going this aft for Dr to do something, hopefully get the daggone pieces out so I can get new uppers

Somewhat related to this post

Somewhat related to this post and the one above is the issue of ridge shape augmentation in preparation for denture placement.

While no dentist can know what exactly will transpire in regard to bone fragments appearing after an extraction. And we can only assume that both posters here have/had active plans with their dentist about denture placement ...

... if in your mind you have future plans about dentures and you have not yet shared those thoughts with your dentist when you are having extractions done, make sure they know.

Knowing that dentures are definitely in your future might influence them as the degree of alveoloplasty (use link above) they preform. (The assumption here being that any additional bone they feel should be smoothed off, removed, etc... because of denture placement might be at least some of the same fragile/disrupted bone that has greater potential to become a sequestrum.)

Nasty bone shards

I agree with Isaac about how nicely the article is worded. I didn’t see any reference to how excruciating these pesky shards are. I’ve had several, not due to an extraction, and they are no fun! They also don’t mention that your gun will not heal until the shard is removed.

An FYI for removal of a shard yourself: a very tiny (1/16” wide) metal crochet hook works great, if you can stand the pain. Make sure to clean it and swab it with alcohol before you start digging. Good luck!

Bone fragments

I had a tooth extracted mid January. Over the past several weeks the site has been sore due to what I believe are teeth or bone fragments working their way up through the gum. So far I’ve managed to extract only 2 teeny tiny pieces (which still blows me away because my tongue was telling me these were huge pieces of tooth or bone). My mouth is so sore all the time now. Should I wait until these fragments work their way out or go to my dentist to have them removed? I don’t want to go back to the oral surgeon who pulled my tooth. Can my regular dentist do it? Thanks for advice in advance.

Dj

If you're uncomfortable all of the time, it makes sense to check in with a dentist so they can pass judgment on what you are experiencing. Small, routine fragments are expected to be a non-issue until that point in time when they come through the surface of your gums and your tongue finally discovers them.

In regard to a proactive solution, fragments can be difficult to identify and locate, and for that reason a dentist may be hesitant to perform a surgical procedure to (hopefully) remedy what your body would have taken care of on its own. (For example, with multiple small bits it would be easy for some to be overlooked or not found and therefore left behind.) It just all depends on what they determine when they evaluate you.

The obvious choice of practitioners for your evaluation would be the oral surgeon since they performed your work, know your case, might consider this follow-up treatment as opposed to a separate procedure, and should generally have more experience with this complication than a general dentist.

But yes, a general dentist is perfectly capable of making an evaluation (and making a referral if needed) and/or removing extraction fragments, especially smaller ones already near the gum's surface.

Hope this experience is over for you soon.

Thank you!

Thank you!

Bone fragment

Had my last 9 teeth extracted 5 weeks ago, and waiting to heal and be fitted for dentures. Everything went well, except for the 2 mollars side by side .(on the bottom right). I was told by a previous dentist, he wouldn't pull the 2 Millard, that from the x-rays it showed they were really deep, and he suggested an oral surgeon. I went for months, until I finally HAD to get them pulled, and got in to see a dentist I use to go to years prior. He said no problem, and pulled them. Litterly took him max, 15 minutes to pull ALL 9 teeth! I thought it a little odd because he did it so quickly, and thought about the dentist who wouldn't pull them because they were so deep...this guy pulled and tugged pretty hard, fragments went flying everywhere! I was gagging on broken chunks of teeth floating down my throat! Stitched me up, and sent me on my way...The first week and the stitches started dissolving, one to the particular molar come loose, and the opening gapped open! Its been real slow healing in that one only, and I believe it's the same molar that this razor sharp piece of bone is protruding through the gum, on the inside next to my tougne! Each movement from my tougne, feels like it is being sawed on! Hurts like all heck! I have been back in to see this dentist 2 more times. They x-rayed it, and her said it is bone, and that in time it will work its way out. He said to leave it alone and don't touch or mess with it. I went for another week, the pain was miserable! This time he decided to shave some of it off, it was very little, but it seemed to help for the time. It started to feel a bit better in a week, but now, it's like it grew back or something! This is really getting to me, and most miserable!!! I don't want to have to call him again, because he's giving me the idea he has done all that he can for me. HELP PLEASE! I can't live with this like this!

Lona

We've taken some of the lines out of what you report and have added our comments, some for your benefit, and then others for the benefit of others reading about your experience.

You state the first dentist recommended having the teeth removed by an oral surgeon ("... and he suggested an oral surgeon ..."). You don't state whether the dentist that actually did the work was an oral surgeon or not ("... a dentist I use to go to years prior ...").

Both general dentists and oral surgeons can be expert at removing teeth. However, and as this page explains, the formation of bone sequestra is frequently related to the level of trauma created during the extraction process (... pulled and tugged pretty hard, fragments went flying everywhere! ...").

Either type of provider may encounter the exact same procedural difficulties and same outcome. But especially with difficult cases, the expectation would be that the added experience and advanced skills that an oral surgeon typically has would result in the creation of less trauma during the extraction process.

--
"... I have been back in to see this dentist 2 more times ..." "... They x-rayed it, and her said it is bone, and that in time it will work its way out. He said to leave it alone and don't touch or mess with it...".

As we describe above, identifying the full scope of a bone sequestrum can be difficult. Over time the object can be expected to ultimately work it's way out. That doesn't mean however that at some point in time a dentist might not feel that conditions are right to speed things along by surgically removing the bit. Your dentist won't be able to decide if this is an option unless you allow them to continue to monitor your situation.

"... but now, it's like it grew back or something ...". This could be evidence that the bony bit continues to migrate up and out, which is what is supposed to be happening.

"... I don't want to have to call him again, because he's giving me the idea he has done all that he can for me ...". It is your dentist's obligation to provide you with the post-operative care that you require.

All dentists understand that some cases will be simple and others won't be. And while it may be that your solution only can be solved by allowing time and the bone fragment to pass, as mentioned, there may be a point where their assistance might provide a quicker outcome. And for that reason, they should encourage you to allow them to continue to monitor your situation.

You mention that you plan to have dentures made. If a different dentist will be providing that service, you might go ahead and appoint with them for evaluation. They can double check that everything you are experiencing seems within normal limits, and that all of the proper ground work about your jawbone (general shape, contours, etc...) are appropriate for future denture construction.

Good luck with this. We hope your situation resolves soon.

Add new comment

Plain text

  • No HTML tags allowed.
  • Lines and paragraphs break automatically.
Please answer the question so we know you're a human.
Feedback