The tooth extraction procedure. -

How dentists pull teeth- the steps, the instruments (forceps, elevators). | What it's like to have a tooth removed (pain, pressure, noises). | Definitions- Simple vs. surgical extractions.

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 picture of 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?

Takeaways from this section.

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 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.


An illustration stating that a tooth is held in its socket by a ligament.

Ligament fibers attach to both the tooth and the bone.

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.
 
Animation showing how rocking a tent stake back and forth enlarges its hole.

Rocking a tent 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.

Animation showing how 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 an elevator to extract a tooth.

Animation illustrating how using a dental elevator can extract a tooth.

The wedging action of an elevator tends to loosen up and lift the tooth out.

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. The action of the elevator tends to lift the tooth 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 with it and will then switch to using extraction forceps (see below) to complete the job.

Takeaways from this section.

A dentist will almost always begin the extraction process using an elevator. Their goal is to use it to loosen the tooth up as much as possible, before switching to the use of forceps (dental pliers).

A part of the reasoning behind this sequencing is that if a tooth breaks off when forceps are used (like flat across with the gum line), it may be much more difficult to access and grasp when trying to complete its removal.

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 somewhat. That can be a significant asset.

As a side note, it's a pretty talented dentist who is able to remove most teeth just using an elevator.

Extracting a tooth with forceps.

Animation illustrating the use of extraction forceps in removing a tooth.

Rocking the tooth back and forth with the forceps expands its socket.

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 slowly yet firmly rock it back and forth as much as it will. They may use quite a bit of force but it will be controlled and deliberate.

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.

Takeaways from this section.

You might be surprised to learn that dentists don't really "pull" teeth.

What we mean by this is that when a dentist uses their forceps, at least initially, they don't so much pull out on the tooth as push.

They know that just pulling outward won't work because at this point the tooth's ligament is still mostly attached and its socket hasn't been expanded enough yet.

They want 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.

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 can expect to feel (pain, pressure) during your extraction process.]

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.

An x-ray of a tooth's broken 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 resulted in tooth fracture was sometimes only 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).
  • A study by Bataineh (2016) placed the incidence of crown (the part of a tooth above the gum line) or root fracture at around 12% of cases.

[page references]

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. 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.

Picture of tooth sockets immediately after the extraction process.

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 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.
  • 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?

Details ...

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, and how to sell them.

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.

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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.


Not all extractions are "simple."

a) Simple extractions.

X-ray of 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 discusses extraction procedure pain. ▶

 

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Comments

Tooth Extraction

I had ALL my tops and bottoms pulled at once. All he gave me was the freezing. Please get your pain meds into you before you go for procedure and if you don't agree with your dentist how many teeth need to come out, you would be better off getting that second opinion. The bad teeth that needed to come out went easy and I dont feel a thing .. the good ones that he took out he had to PRY AND DRILL with a lot of effort because they were healthy and functioning teeth. I got my dentures in right after, very very painful. Lots of bleeding, discuss stitches before and get lots of advice about food because I cant wait to eat my next meal I should have ate just before.

Our interpretation.

For those reading this comment, we'll interpret what is being said, add some additional points and link to where you can find more information on our site:

"All he gave me was the freezing." - The "freezing" part refers to the use of a local anesthetic (just typical dental "shots") to numb up her teeth. And then as stated, no additional sedation technique was used in conjunction with that for the procedure.

"get your pain meds into you before you go for procedure" - This implies that this person took a pain reliever preemptively (before her appointment), as a way of aiding with pain control (both during the procedure and post-op).

This technique may have a place but only after consulting with your dentist. Some types of pain relievers can disrupt the blood clotting process and thus their usage is contraindicated prior to an extraction.

"PRY AND DRILL" - The "pry" reference refers to the use of dental elevators during the extraction process. Doing so is routine (and described above). "AND DRILL" implies that to remove some teeth that either some bone tissue needed to be removed or the removal of the tooth was aided by "sectioning" it (cutting it into parts and removing each piece separately). We describe these techniques on our Surgical Extractions page.

"Lots of bleeding, discuss stitches ... advice about food ..." - Generally, a patient needs to follow two sets of post-operative instructions. Those that apply for the first 24 hours, and then a second set for the period after the first day and beyond.

Extraction

I just got my tooth pulled 2 hours ago...I’m feeling a bit of pain, is that bad?

Ashley

In all cases a patient should feel free to contact their dentist about any concerns that they have. Responding to your needs is a part of their obligation to you as a treatment provider.

It seems possible that what you are experiencing falls within the realm of usual. Here's what our pages state about post-op pain during the same day of an extraction.

Dialysis and dentist

Iam on dialysis and don't have a good immune system and was wondering if that makes a difference with how dentist work on my teeth.. I may have to have all my teeth pulled.

Brian

Your extraction process itself will be similar to what we describe, simply because that's the only way there is to remove teeth. What will likely be unique to your situation is the planning that takes place before and after your procedure.

For example, your extractions will probably be scheduled for a non-dialysis day ("blood thinners" used during dialysis might cause you to have extra bleeding). Extra post-op steps might be used also to help to minimize your potential for bleeding complications.

In cases where a patient is at increased risk for infection (has a compromised immune system), antibiotics might be prescribed before their extraction.

All of these issues will be sorted out at your initial examination when the planning for your extractions are made, so to make your procedure as risk-free and routine as possible. Good luck, we're sure you'll find you're in good hands.

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

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.

Hi I'm due to have an upper

Hi I'm due to have 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

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.

Tooth Extraction

So I'm 11 and I'm getting my 19th molar taken because it has a infection and I was wondering how long would it take for the anesthesia to settle in and what are the tools used for the extraction

A.M

Good luck with your procedure. We anticipate that you'll find the process easier than you expect (we noticed that you placed your comment on our "extraction pain" page.)

This link: Time needed to numb a tooth for an extraction. will answer your first question. (The usual initial injection in preparation for extracting tooth #19 is an IANB.)

This link: The steps of the extraction process. explains the use of dental instruments during an extraction.

Partial plate

My dentist is going to extract a molar in a few days and then put in my partial plate....is this common practice?

Sharon

Yes, that's not uncommon. Your dentist is trying to save you from having to go for a period of time without having a partial to wear. We discuss immediate partial dentures here.

Braces

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

The stitches 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.

Bottom back tooth pulled

It’s been a week and I have exstream pain it feels like part of the tooth is still in the front is there any way to tell if it’s still in there it was infected when it was pulled and he had to drill to get it out took a very long time the pain is close to being as bad as before it was pulled

TS

You need to call your dentist's office and let them know that you require attention. They'll figure things out, and take steps that will help to keep you more comfortable in the mean time.

You mention ".. had to drill to get it out took a very long time..."

Difficult, traumatic extraction are more likely to result in dry socket formation. We wouldn't be surprised if you have developed one. Again, the solution lies with treatment from your dentist.

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. There are other complicating problems. I was hoping if the tooth is extracted, an implant, even a very small one, can be placed to close the space. My teeth are not straight. I was not a candidate for braces because the molar in back of tooth #20 is fused to my jawbone. Is there anyone out there that can help me? I have not eaten on that side of my mouth for over 9 months. I am located in Central NJ. A million thanks.

MN

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. (You state the filling is loose, if so, the root canal work is no longer protected by its seal, which is a common cause of root canal failure.)

With the exception that there's a medical issue involved, we're unclear why you anticipate problems with controlling bleeding after the extraction.

You mention you'd like an implant placed as a replacement tooth. It might be possible to place it during your extraction procedure, thus avoiding a separate surgical process.

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, proceding 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.


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