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.

Wedging the elevator between the tooth and its surrounding bone loosens up and drives 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.

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.

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 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.

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, possibly even a whole lot of it. But don't assume that doing so indicates that you'll soon be feeling pain because it doesn't. That sensation is transmitted by different nerve fibers and they have been put out of commission by the anesthetic.

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.
  • 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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