The tooth extraction procedure. -

How dentists pull teeth (the steps and tools used). / What it's like to have a tooth removed (what you'll hear and feel). / What the term "simple" extraction means.

This page provides an outline of the process that a dentist uses when they extract a tooth for a patient.

  • It explains the purpose of each of the steps of the procedure and how the dentist uses their instruments when performing them.
  • It also describes some of the routine sensations and sounds (both pain and non-pain related) that you'll have the potential to experience.

The more you know about the extraction process, the easier yours will be.

Pulling your tooth is more likely to go quickly and uneventfully if you, the patient, contribute toward it. The contribution you have to offer is cooperation.

Patients who moan, flinch and squirm at every routine, non-issue sound or sensation are simply making their procedure more difficult and drawn out.

Be intelligent. Take the time to learn what can be expected during a tooth extraction and what shouldn't (and therefore needs to be brought to the attention of your dentist if it occurs).

Doing so will help to insure that having your tooth pulled will go as easily and smoothly as possible.


Extracting teeth - The procedure.

A) Numbing your tooth.

As a first step, your dentist will need to anesthetize ("numb up") both your tooth and the bone and gum tissue that surround it.

A dentist giving a dental injection.

At this point in time, there is still no way for a dentist to predictably administer a local anesthetic except as an injection (a "shot").

We'll admit that receiving one may hurt a bit. But we'll also emphatically state that it doesn't always.

Here's more information about this subject. It may help to put your mind at ease: Will my dental injection hurt?


A tooth is held in its socket by a ligament.

B) The extraction process - What to expect.

1) The overall game plan.

When a tooth is pulled, here's the situation that a dentist faces.

  1. The root portion of the tooth is firmly encased in bone (its socket), and tightly held in place by its ligament (the fibrous tissue between the tooth and bone that binds the two together, see picture).
  2. To remove the tooth, the dentist must both "expand its socket" (widen and enlarge it, see next section) and separate it from its ligament.
  3. After working towards this goal, a point is finally reached where the tooth is finally loose and free to come out.
 
Rocking a tent stake back and forth enlarges its hole.

Rocking a stake back and forth "expands" its hole.

What does "expanding" the tooth's socket mean?

If you've ever tried to remove a tent stake that's been driven deeply into the ground, you know that you can't just pull the stake straight up and out.

Instead, you first have to rock it back and forth, repeatedly, so to widen (expand) the hole in which it's lodged. (See animation.)

Then, once the hole has been enlarged enough, the stake can be easily withdrawn.

Rocking a tooth back and forth enlarges its socket.

Rocking a tooth back and forth expands its socket.

Teeth are somewhat the same.

The bone that encases a tooth's root is relatively spongy.

And due to this characteristic, when a dentist firmly rocks it back and forth against the walls of its socket, the bone compresses.

After repeated cycles of side-to-side pressure, the entire socket gradually increases in size (expands). (See animation.)

Finally, a point is reached where enough space has been created (and simultaneously the root's ligament torn away enough) that the tooth can be removed easily.

2) Your dentist will use these tools.

Dentists have a variety of tools they use to grasp and apply pressure to teeth. Some of them are pliers-like instruments called "extraction forceps." Others are specialized levers called "elevators."

Using a dental elevator to extract a tooth.

Using an elevator to extract a tooth.

a) Dental Elevators

To look at one of these instruments you might mistake it for a narrow screwdriver. That's because just like one an elevator has a handle and then a specially designed "blade" or tip portion.

How they're used.

The tip of an elevator is designed to be wedged into the ligament space between a tooth and its surrounding bone (as shown in our animation).

As the elevator is forced into and twisted around in this space, the tooth is rocked around and pressed against the walls of its socket. This helps to both expand the shape of the socket and separate the tooth from its ligament.

As this work is continued, the tooth gradually becomes more and more mobile.

In some cases, the dentist may be able to completely remove the tooth just using their elevator. If not, they will choose a point where they feel they have accomplished as much as they can with it and will then switch to using extraction forceps (see below) to complete the job.

Using extraction forceps to extract a tooth.

Extracting a tooth with forceps.

b) Extraction Forceps

Dental forceps are pliers-like instruments that are used to grasp teeth. A dentist will usually have a number of different ones on hand, each having a design that's tailored to:

  • The specific shape of the tooth it's intended to remove (such as incisors vs. molars having two roots vs. molars having three roots).
  • The location of the tooth in the mouth (such as front vs. back, or left lower molar vs. right upper molar.)
How they're used.

A dentist will grasp a tooth with their forceps and then firmly and deliberately rock it back and forth as much as it will.

Because the bone that surrounds the tooth is compressible, the socket will gradually start to expand. As it does, the range of the dentist's side-to-side motions will increase.

In addition to this rocking motion, the dentist will also rotate the tooth back and forth. This twisting action helps to rip and tear the tooth away from the ligament that binds it in place.

At some point, the socket will be enlarged enough, and the ligament torn away enough, that the tooth can be easily removed.

C) What you'll feel during your extraction.

The anesthetics dentists use to "numb up" teeth are very effective at inhibiting (conking out) those nerve fibers that transmit pain. But they're not effective on those that transmit the sensation of pressure.

1) You'll feel pressure.

That means you should expect to feel pressure during your extraction procedure, possibly even a whole lot of it. But don't assume that doing so indicates that you'll soon be feeling pain too because it doesn't.

That sensation is transmitted by entirely different nerve fibers. And they have been put out of commission by the anesthetic.

2) You shouldn't feel any pain.

There can be times when a patient's tooth hasn't been adequately anesthetized and more anesthetic is needed.

So, if you do find that you do feel pain during your procedure (discomfort that has a sharpness to it), you should let your dentist know so they can "numb you up" some more.

But be accurate in what you are reporting. More anesthetic will do nothing to take away the sensation of pressure. And, in fact, the needless administration of additional quantities of anesthetic may place you at greater risk for medical complications during your procedure.

D) Expect that you might hear some startling noises.

As explained above, pulling teeth is a fairly physical process.

And in light of this fact, it should be no surprise to learn that you may hear a minor snap or breaking noise during your procedure. After all, hard tissues (teeth and bone) are involved.

The good news is that most of these events are just routine and nothing to get excited about. The two most common ones are bone fracture and root breakage.

A broken tooth root tip still in its socket.

a) Broken tooth roots.

You may hear your tooth's root break during the extraction process. In fact this isn't necessarily an infrequent occurrence.

A study by Ahel (2015) determined that the level of force that has resulted in tooth fracture may only be slightly greater than that required for routine tooth removal.

Root fracture is the most common intraoperative (during procedure) complication, occurring in 9 to 20% of cases (Ahel 2015). Making it a difficulty that your dentist has no doubt dealt with many times before.

[page references]

The consequences of having a root break can vary.

  • The piece may prove to be uncooperative and retrieving it may add a fair amount of time to your procedure.
  • In other cases, the part that's left has already loosened up somewhat and can be teased out relatively easily. (Remember our elevator Takeaway above?)

b) Bone fracture.

The type of bone tissue found in the center of the jawbone is relatively spongy. In comparison, its outer surface (the cortical plate) is relatively dense.

During an extraction, as pressure is applied to the tooth the spongy bone that surrounds its root will compress. The denser cortical plate, however, is more brittle and if it receives enough of this pressure it may snap. In the vast majority of cases, this type of breakage is just a minor event (a "hairline" fracture).

After the tooth has been removed, the dentist will simply compress the empty socket so the bone is squished back into place. The fracture can be expected to heal, uneventfully, in tandem with the extraction site as a whole.

Tooth socket, immediately after extraction.

Tooth sockets immediately after the extraction process.

E) "Closing" the extraction site.

Once your tooth has been removed, your dentist will begin the process of closing up your surgical site. This process frequently includes:

  • Gently curetting (scraping) the walls of the empty socket so to remove any residual infected or pathological tissue. This process is referred to as curettage and performing it can help to prevent subsequent cyst formation.
  • Irrigating (washing out) the socket with saline solution, so to remove any loose bone or tooth fragments that remain.
  • Inspecting for the presence of sharp bone edges. Any that are found will be trimmed off or filed down.
  • When upper back teeth have been removed, evaluation of the socket for sinus cavity involvement (communication between the two).
  • Using finger pressure to compress the sides of the "expanded" socket. Doing so restores the shape of the jawbone and aids in controlling bleeding.
  • If your dentist is concerned about the possibility of prolonged bleeding, placing materials in the socket that assist with blood clot formation.
  • Placing stitches. This is most likely after a "surgical" extraction (see below) or when several teeth in a row have been removed.
  • Placing folded gauze over your extraction site and then having you bite down on it so to create firm pressure.

What becomes of your tooth and its dental restoration?

F) Dismissing you at the end of your appointment.

Once your extraction procedure has been completed, there are still a few steps your dentist must do.

Controlling bleeding.

Your dentist will place one or more pieces of gauze over your wound and then ask you to bite down. The steady pressure you apply over the next hour will play an important role in helping to control the bleeding from it. (More details.)

Minimizing swelling.

If your dentist anticipates that much post-operative swelling will occur, they may give you an ice pack to apply to your face. That's because generally speaking, the sooner this is begun after the completion of your extraction the more effective this preventive will be. (More details.)

Postoperative instructions.

With both of the above, your dentist will need to provide you with instructions (see "details" links above). They'll also need to give you a separate, more comprehensive list of postoperative directions. These are extremely important in helping you to avoid complications and must be closely followed. They'll include a whole list of things to do and not to do, both during this first day and the days to follow.

Your trip home.

When you first get out of the dental chair after your extraction, you may find that you're a little unstable. If so, just ask to sit back down for a while until things return to normal.

The same goes for as you prepare to leave your dentist's office. If you need time to sit and adjust, or even ask for assistance, just do so. They fully expect that some patients will require more attention and aid after their procedure than others.

Per your dentist's permission, in the vast majority of cases where just a local anesthetic has been used you should be able to drive yourself home after your appointment. If some type of sedative has also been administered, another person's assistance may be required for your trip and afterward. See this page for further details.


Not all extractions are "simple."

a) Simple extractions.

Two teeth, one of which will require a 'surgical' extraction, the other a 'simple' one.

Surgical (#1) and "Simple" (#2) extractions.

A vast majority of tooth extractions are completed using the simple mechanics described above. Specifically:

  • The minor expansion of the socket and adjacent bone.
  • Separation of the ligament that binds the tooth in its socket.
  • The uncomplicated removal of the tooth using extraction forceps.

Actually, there's a name (a classification) for these types of cases. They're literally termed "simple" extractions.

An example.

Removing tooth #2 in our picture will likely be a "simple" extraction. Although it's severely decayed, it's erupted and has a normal positioning. It can probably be teased out just using the techniques described above.

b) Surgical tooth extractions.

There can be situations where some aspect of a tooth, such as its positioning, shape, brittleness or deteriorated state complicates its removal. If so, a "surgical" extraction will be required.

One interesting aspect of this process is that the surgical steps taken simply set the stage so the tooth can then be removed using the same basic principles explained above.

An example.

The impacted tooth (#1) in our picture will require "surgical" removal. (Use this link for details about this type of procedure.)

Our next page outlines extraction aftercare. ▶

 

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