The tooth extraction procedure. –
This page contains 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.
- As added information, it also describes the routine sounds and sensations (both pain and non-pain related) that you’ll have the potential to experience as your procedure is performed.
The more you know about tooth extractions, the easier yours will be.
The process of pulling your tooth is more likely to go quickly and uneventfully if you, as the patient, contribute toward it. The contribution you have to offer is cooperation.
Patient cooperation makes all of the difference.
Patients who moan, flinch and squirm at every routine, non-issue sound or sensation are simply making their procedure more difficult and drawn out.
They’re taking their dentist’s attention away from the process at hand, and instead making them focus on the management of their patient.
Learn what’s normal, so you can signal if things aren’t.
Taking this approach will help to ensure that having your tooth pulled will go as easily, quickly and smoothly as possible. Something both you and your dentist want.
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.
Here’s more information about this subject. It may help to put your mind at ease: Will my dental injection hurt? Why some do.
FYI – As a test for numbness, a dentist will usually begin the extraction procedure by taking a semi-sharp dental instrument (often an elevator, see below) and pressing it on the gum tissue immediately surrounding your tooth.
The idea is that you should feel the pressure of this activity (that’s normal during an extraction, see below) but there should be no sharp pain.
FYI: They’re not just testing, they’re also using this step to start to peel away (loosen and detach) the gum tissue from around your tooth.
As a second test, your dentist may use their fingers and push firmly on your tooth from side to side, just to make sure that that kind of pressure doesn’t bother your tooth either.
Here’s more details about how a dentist tests for numbness before pulling a tooth What to expect.
Can you pull your own tooth?
We anticipate that for most people, their inability to fully anesthetize (numb up) their tooth would be their biggest obstacle in attempting to perform an extraction by themselves. We discuss the idea of a DIY extraction approach more fully here. Is it possible?
X-ray of a severely decayed molar slated for extraction.
B) The extraction process – What to expect.
- The general challenges that removing a tooth poses for a dentist.
- The kinds of extraction instruments that are usually used (along with the manner in which they are used to work the tooth loose).
- What the steps of the process are like for the patient, in terms of what they are likely to experience (feel, hear, etc…).
1) The overall game plan.
When a tooth is pulled, here’s the situation that a dentist faces.
Ligament fibers attach to both the tooth and the bone.
- 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 diagram).
- To remove the tooth, the dentist must both: 1) “Expand its socket” (widen and enlarge it, see next section) and 2) Separate it from the ligament that binds it in place.
- After working towards this goal, possibly using an assortment of instruments (described below), a point is finally reached where the tooth has been loosened up enough that it’s free to come out.
Rocking a tent stake back and forth “expands” its hole.
What does “expanding” the tooth’s socket mean?
Then, once the hole has been enlarged enough, the stake can be easily removed.
Rocking a tooth back and forth expands its socket.
Extractions are somewhat the same.
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.”
a) Periosteal elevator or desmotome.
As used with routine (simple, non-surgical) extractions, the use of either a desmotome or pointed periosteal elevator is generally interchangeable.
These instruments are used to loosen up and detach the gum tissue that surrounds the tooth that’s being removed. And also, to whatever extent possible, sever the tooth’s periodontal ligament (the ligament that runs from tooth to bone and binds a tooth in its socket).
How the instrument is used.
The pointed end of the tool is worked along each side of the tooth in the crevasse between it and its surrounding gum tissue in a downward motion. As the dentist pushes down they will also push the gums away from the tooth, thus detaching them.
FYI – As the actual start of the extraction process, this step also serves as a testing mechanism for your dentist. They’ll start off gently with their instrument, asking you if you feel any discomfort.
- If you do feel pain, they’ll give you more anesthetic.
- If all you feel is pressure, that’s a good sign. That’s what would be expected if the area has been numbed up successfully (so, so far so good).
(A patient being able to discriminate between pressure and pain is an important aspect of their role in the extraction process. We discuss this issue below.)
Once your dentist knows that you are comfortable, they’ll get more aggressive with the use of their instrument and complete their job.
b) Dental Elevators
Using an elevator to extract a tooth.
The wedging action of an elevator tends to loosen up and lift the tooth out.
How they’re used.
As this work is continued, the tooth gradually becomes more and more mobile, with the downward motion of the elevator tending to lift the tooth up out of its socket.
b) The other method is one where the elevator is wedged in between the tooth and the crest of the surrounding bone. The bone serves as the fulcrum point as the elevator is used to apply upward pressure on the tooth, thus lifting it out of its socket.
In some cases, the dentist may be able to completely remove the tooth just using an elevator. If not, they will choose a point where they feel they have accomplished as much as they can and will then switch to using extraction forceps (see below) to complete the job.
FYI – A dentist will almost always start the extraction process using an elevator. They’ll try to loosen up the tooth as much as possible before having to switch to using forceps (dental pliers).
A part of the reasoning behind this sequencing is that the possibility exists that the tooth may break once the pressure of the forceps is applied. If so, it may be more difficult to grasp and finally work free.
By using an elevator first, if the tooth does break, the dentist at least has the advantage that the portion that remains has already been loosened up some. And that can prove to be a significant asset.
As a side note, it’s a pretty talented dentist who routinely removes teeth just using an elevator alone.
Extracting a tooth with forceps.
Rocking the tooth back and forth with the forceps expands its socket.
c) Extraction Forceps
- The general shape of the tooth it’s intended to remove, like large or small, or rounded or flat profile.
The tooth’s root configuration will also play a role (the dentist wants to be able to firmly grasp and apply pressure low down on the tooth). For example, the design will vary depending on whether it is 1, 2 or 3 rooted.
- The location of the tooth in the mouth (such as front vs. back, or left vs. right side of the jaw).
How they’re used.
A dentist will grasp a tooth with their forceps and then slowly yet firmly rock it back and forth (side-to-side) as much as it will. They may use quite a bit of force as they do this but it will be controlled and deliberate.
Because the bone that surrounds the roots of a tooth is compressible, this action will gradually expand the size of the tooth’s socket. 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. As compared to the use of elevators, most teeth are ultimately taken out via the use of forceps.
FYI – You might be surprised to learn that dentists don’t really “pull” teeth. Instead, when a dentist uses their forceps, at least initially, they don’t so much pull out on the tooth as push in.
They know that just pulling out won’t work because at this point the tooth’s ligament is still mostly attached, and its socket hasn’t been expanded enough yet.
What they want is for the force they create to be directed more so toward the root of the tooth, which will tend to act as a pivot location for the expansion of the socket’s walls (see picture above).
Then yes, after the tooth is good and loose, the dentist will “pull” the tooth on out.
▲ Section references – Wray
C) What you’ll feel during your extraction.
[ We’ve updated our information and now have an entire page dedicated to the subject of what you might feel (pain, pressure) during your extraction process. What to expect.]
Background.
The local anesthetics that dentists use to “numb up” teeth are effective in inhibiting nerve fibers that transmit pain but not those that relay pressure sensations.
1) You will feel pressure.
That means you should expect to feel pressure during your extraction procedure (a slow steady force applied in a controlled and deliberate manner), and possibly even a whole lot of it.
But don’t assume that if you do that that is an indication that you’ll soon feel pain too because it doesn’t. Remember, that sensation is transmitted by different nerve fibers and they have been put out of commission by the anesthetic (“shots”) you have been given.
2) You shouldn’t feel any pain.
Pain shouldn’t be a significant factor during your procedure. But if you do feel some you should let your dentist know immediately 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 may place you at greater risk for 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 roots.
- Root fracture is the most common intraoperative (during procedure) complication, occurring in 9 to 20% of cases (Ahel).
- A study by Bataineh placed the incidence of crown (the part of a tooth above the gum line) or root fracture at around 12% of cases.
- Generally speaking, if a tooth fractures during its extraction process, it’s most likely due to grasping/applying pressure to it too high up (on its crown as opposed to its root). That’s why forceps are designed with tooth root morphology in mind. (Wray)
▲ Section references – Ahel, Bataineh, Wray
These statistics suggest that if some kind of tooth fracture does occur, your dentist no doubt has had plenty of previous experience in dealing with it.
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. As you’d expect, this is more likely to happen with larger teeth (molars) or those with longer roots (canines). (Wray)
▲ Section references – Wray
Tooth sockets immediately after the extraction process.
E) Multiple tooth extractions.
There may be some economies of scale involved for certain aspects of the procedure. For example, when removing multiple adjacent teeth, the dentist might detach the gum tissue from them all at the same time. And they might position their elevator so it loosens up the adjacent tooth simultaneously too.
Your dentist will choose a specific order.
▲ Section references – Wray
F) “Closing” the extraction site.
- 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 using a dental drill, bone cutting forceps (Rongeur forceps) or bone file.
- 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. Clotting aids.
- Placing stitches. How it’s done. This is most likely only needed 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?
Once your extraction process has been completed, your tooth and its restoration are still yours, just like they were before your tooth was pulled. So, if you want either of them, all you have to do is ask.
If you don’t, and your dentist thinks that there’s any likelihood that the restoration has any value at all, you can rest assured that they’ll add it to their collection of other dental work they’ve “inherited.” Later on, they’ll turn around and sell what they have to a scrap metals refiner.
Of course, you may not have any idea about which type of restorations have value and which ones don’t. If not, read this page: What can the value of scrap dental restorations be How much?, and how to sell them.
G) 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. (Be sure to follow these instructions. Nothing is more effective.)
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 about post-surgical swelling. What to expect. | How to manage.)
Postoperative instructions.
With both of the considerations above, your dentist will need to provide you with instructions (use their respective links for details). Beyond that, they’ll also need to give you a separate, more comprehensive set of postoperative directions. Example list. 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.
Additionally, they’ll also need to advise you about how much postop rest and recuperation time should be allowed. Jump to page.
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.
Can you drive yourself home after a tooth extraction?
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 (especially oral or IV ones), another person’s assistance may be required for your trip and for some hours afterward.
For details about what’s usually indicated with different sedation methods, see this page: Conscious sedation techniques. Needed precautions.
How long will your extraction take?
Most “simple” (see definition below) single-tooth extractions will take on the order of 20 to 40 minutes. We give a precise breakdown (type of tooth, procedure time, numbing time, etc…) on this page: How long does an extraction take? What to expect.
Not all extractions are “simple.”
a) Simple extractions.
Surgical (#1) and “Simple” (#2) extractions.
- 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 What is this? will be required. (As an example, the impacted tooth (#1) in our picture above will require “surgical” removal.)
Two interesting aspects of this process are:
- The additional steps taken simply set the stage so the tooth can then be removed using the same basic principles explained above.
- Despite the fact that the added steps are surgical in nature, using them may actually serve to decrease the overall level of trauma created by the extraction process.
Can you pull your own tooth?
Most humans no doubt have extracted one, and more likely several, of their own teeth. Of course, we’re talking about rootless baby teeth. And that situation is quite a bit different than extracting a “permanent” tooth. ( Here’s why baby teeth come out so easily.)
What about permanent teeth?
Every dentist has encountered some teeth that are so loose in their socket (gum disease is usually involved) that they offer little resistance to the extraction process.
However, even in cases where the physics of the extraction process seem as though they would be possible to accomplish (like with just finger pressure), there are a number of reasons why trying to remove a tooth on your own still doesn’t make a good idea. We discuss the various issues involved in our blog post: Can you pull your own tooth? Should you?
Our next page discusses extraction procedure pain. What to expect. ►
Page references sources:
Ahel V, et al. Forces that fracture teeth during extraction with mandibular premolar and maxillary incisor forceps.
Bataineh AB, et. al. Patient’s pain perception during mandibular molar extraction with articaine: a comparison study between infiltration and inferior alveolar nerve block.
Fragiskos FD. Oral Surgery. (Chapter: Simple Tooth Extraction)
Koerner KR. Manual of Minor Oral Surgery for the General Dentist.
Wray D, et al. Textbook of General and Oral Surgery. (Chapter: Extraction Techniques.)
All reference sources for topic Tooth Extractions.
Comments.
This section contains comments submitted in previous years. Many have been edited so to limit their scope to subjects discussed on this page.
Comment –
Removing premolar teeths.
Hey there.Im going to extract 4 premolar teeths(2 top and 2 bottom)and next week Im going to extract 2 teeths first one top and one bottom and Im nervous.Will it hurt when I extract my premolar teeths?
Tata
Reply –
From your question, it seems you haven’t found our “do tooth extractions hurt?” page.
It’d be our guess that your fears are unwarranted. But as that page describes, it’s your cooperation and communication with your dentist during the extraction process that goes a long way in helping to insure a pleasant experience. You should read it. Best of luck.
Staff Dentist
Comment –
I’m due to have an upper extraction.
I’m having an upper back tooth removed due to abcess.( Luckily I’m in the unique position of have a virgin wisdom tooth in the perfect position to fill the gap).
I have a lot of sinus pain and am just interested how the dentist checks the sinus cavity after extraction. I didn’t realise my sinus pain could be linked to the tooth.
Thanks for all the information. I feel prepared knowing exactly what to expect and how to manage my own aftercare
NG
Reply –
You state: “I didn’t realise my sinus pain could be linked to the tooth.”
It can actually work both ways. The bone that encases a tooth’s roots and also serves as the floor of a sinus can be paper thin. So, if there is an infection in the sinus, it can affect the nerve that runs through this bone and on into a tooth, thus causing tooth pain. Or the reverse, byproducts from an infection emanating from a tooth can spread to the sinus cavity and affect it.
We’re not so sure to what degree your dentist will “check” your sinus after your extraction (in terms of evaluating your original complaint). It seems they have found a clear problem with your tooth (an abcess) and that absolutely needs to be taken care of.
Since this problem lies in the region of your sinuses, it makes a logical assumption that it is also the cause of the problem with them. If it is, getting rid of the tooth (the source of the problem) will allow your body to resolve the sinus issue on its own (clear up the remnants of the infection). Only time will tell. It could be possible that another, purely sinus related, problem exists.
Other than that, there is a specific post-extraction sinus check that is routinely done by dentists after any upper back tooth is removed.
As mentioned before, the bone that encases a tooth’s roots can be paper thin, and therefore when an upper tooth is removed this bone might be damaged. If so, a hole would exist between the patient’s sinuses and their mouth (an oral-antral communication).
Small openings will usually close on their own during healing. With larger ones however, the dentist will want to close up the extraction site snugly so to aid with insuring this.
The way the opening is discovered at the time of the extraction is this: The dentist will hold the patient’s nose close and then ask them to gently blow air into their nose. If air escapes via the tooth socket (creates bubbles), the dentist knows an oral antral communication exists.
Not disrupting this fragile bone (whether or not and outright opening exists) is why as a part of post-op instructions patients are told not to blow their nose, and to sneeze with their mouth open (both as a way of preventing excessive pressure in the sinuses, see link above).
Good luck with your procedure. We hope it resolves both of your problems.
Staff Dentist
Comment –
Braces after extraction.
Hi, my orthodontist told me that my upper jaw was too wide, so I have to take out my upper premolars to make space and then putting braces to tighten it.
Do you know at what point or when after the procedure they’re going to have to place my braces ?
Do the stitches disappear or are they here forever?
Coco
Reply –
Any stitches that are placed will be removed or dissolve away on their own after a week or two. The space itself will be closed in, either fully or substantially, during your orthodontic treatment. Your braces can be placed fairly immediately, just a week or so after your extractions.
Staff Dentist
Comment –
Upcoming tooth extraction.
Tooth #20 has become a problem. It has cracked out the back and has a large filling which is loose. It has also had a root canal done a very long time ago. Many dentists have told me it should come out.
I am frightened out of my wits. I am so worried about the pain, possibility of swelling and bleeding. I truly do not know what to do with myself.
MN
Reply –
We just don’t see anything in your narrative that suggests that the extraction procedure you require will be especially difficult or troublesome.
In regard to the process of having your tooth pulled, tooth #20 is a single rooted (lower left 2nd) premolar. It has a location that provides a dentist with great access and visibility, which should help the procedure to more smoothly and quickly.
In regard to pain and swelling, we would think you have more to be concerned about by leaving the tooth in place rather than having it out.
With the exception that there’s a medical issue involved, we’re unclear why you anticipate problems with controlling bleeding after the extraction.
Something you don’t mention that you might consider is the use of sedation for your procedure. Doing so is frequently benefits both the patient and dentist.
As mentioned above, proceeding with your treatment almost certainly holds more benefits for you than not. Doing so will allow you to make decisions, rather than conditions with your tooth dictating the course of events. Good luck.
Staff Dentist
Comment –
First-time tooth extraction.
I want to know if extracting a tooth that had previous root canal treatment more difficult than extracting a normal tooth?
Tama
Reply –
A tooth that has had root canal treatment is generally considered to be more brittle than a live tooth, and as such more likely to fracture during the extraction procedure. However, if that type of event occurs, it may or may not add to the level of difficulty of removing it. It simply depends on the manner in which it has broken.
Staff Dentist
Comment –
Tooth pulled tomorrow.
I am 13 and I’m getting my very last baby molar tooth pulled out and I am nervous and scared. And it’s weird because that tooth is half out and half still in my gum according to the X Ray I got yesterday. I need advice please.
Sonia R
Reply –
You’re overlooking all of the things your comment states that are favorable for your procedure.
You state you are 13 yr. That is the normal age for this tooth to fall out on its own. Despite the fact that it hasn’t, there certainly is a chance that the root of the tooth has already resorbed significantly, thus making the extraction less difficult than it would have been at any time previously.
What you say about the appearance of the tooth on the x-ray suggests the same thing (the tooth is 1/2 out and 1/2 in).
Just concentrate on being a cooperative patient and no doubt your tooth will be out in a flash.
Staff Dentist