Surgical extraction (also called "open extraction") is a tooth removal procedure in which surgical access is required to completely remove a tooth. Even if the tooth is visible in the mouth without surgically exposing it, surgical techniques may be necessary to remove the tooth. This includes sectioning the tooth into two or more pieces, whether or not a soft tissue incision is made. Surgical extraction includes removal of impacted wisdom teeth (third molars), but this does not mean that all wisdom teeth requiring removal are required to be removed surgically. Removal (extraction) of a tooth is prescribed if the tooth is too extensively damaged from decay or trauma to be fixable, or if it is infected and the patient is not a candidate for endodontic (root canal) treatment. Wisdom tooth removal is frequently recommended, and ideally prescribed in the late teens to early twenties, if it is apparent that these teeth will not fit in the jaws in a normal bite relationship with normal gum tissue contours. Extensively damaged teeth, and teeth with multiple curved roots frequently require extraction by surgical technique when removal
is necessary. Teeth which have been endodontically treated and later need to be removed for some reason, frequently require surgical technique as their roots tend to be more brittle.
Steps invlved in Surgical Tooth Extraction
When you have invasive dental procedures like tooth extractions done, the dentist will review your health history. If you have replacement joints (e.g. total knee, hip, etc.), you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure. If you take blood thinning medications like warfarin (the generic name for Coumadin® and others), or drugs that inhibit platelet aggregation like clopidogrel (the generic name for Plavix®), particularly if you take either with aspirin, your dentist and/or physician may require you to suspend those medications temporarily to have any oral surgical procedures, including simple tooth extraction. This is due to the possibility for prolonged bleeding from tooth extraction sites. The following describes the typical simple tooth extraction process in detail. Your procedure may vary from the procedure described.
The tooth to be removed is usually anesthetized by injecting local anesthetic around the nerve(s) that supply sensation to the tooth. Discomfort from the injection can be minimized by use of a topical numbing gel for a minute or two prior to the injection.
Incision and flap elevation to expose tooth
If the tooth is not visible, or is only partly visible in the mouth, it will be necessary to gently expose the tooth by elevating a surgical flap. An incision is made, and the gum tissues are gently reflected to expose the tooth.
Release periodontal ligament fibers
Teeth are not normally fused to bone. Instead, they have a shock-absorbing ligament that suspends them from the bony tooth socket. The ligament is called the "periodontal ligament", and the first step in removing a tooth is to release it. This can be done very atraumatically with a thin-bladed instrument called a periotome. It may be necessary to remove enough bone from around the tooth to allow its removal (full- and partial-bony impactions). This is generally done with a surgical handpiece that is specially designed for the removal of bone.
Sectioning of the tooth
Whether or not a surgical access flap is required to expose the tooth, it may be necessary to section it into individual pieces to remove it safely and atraumatically. That step would usually be accomplished next. How many pieces the tooth is divided into depends on many factors, including the number and shape of the roots, as well as any nearby anatomical features that may be of concern.
Luxation and elevation of the tooth
The tooth is (or individual pieces are) loosened (the dental term is "luxated") within the socket by applying leverage with an instrument called an elevator. There are several types of elevators, depending on the shape and size of tooth to be removed, and its location in the mouth. When the tooth has been sectioned, the socket generally isn't enlarged much, if any. The tooth fragments are removed in an ordered sequence that usually involves curved roots being removed last.
Ridge preservation via socket graft (optional)
If the tooth being removed is going to be replaced, the dentist may recommend placing bone graft material in the tooth socket to significantly decelerate the bone resorption process and preserve the height and width of the bony ridge at its pre-extraction level. If ridge preservation is not done, the height and width of the bony ridge will immediately begin to deteriorate with the healing process.
Placement of an immediate dental implant (optional)
Certain teeth may be candidates for immediate replacement with dental implants. If no acute infection is present (i.e. one that has drainage and swelling), and the bony socket is intact, you and your dentist may plan for immediate placement of the dental implant upon removal of the tooth. A bone graft may be required simultaneously.
Post-operative instructions and care
Your dentist will give you specific post-operative instructions, taking into account your unique medical and dental situation. Although they may seem simple at the time of your appointment, questions frequently come up later.
Benefits of Surgical Tooth Extraction
1). Removal of infected teeth eliminates the source of the infection, and generally brings fairly rapid relief from pain and swelling.
2). Removal of teeth from severely crowded dental arches provides more space in which to move the remaining teeth to straighten and better align the dental arches.
3). Removal of teeth having a questionable long-term prognosis can lead to a much more successful treatment outcome.
4). Removal of wisdom teeth can prevent the start of periodontal disease, avoid damage to the adjacent molars, and promote a more "stable" dentition that is easier to maintain.
5). Surgical removal of teeth is generally less traumatic to the jaw bone than intact removal of the tooth. In some cases surgical removal can significantly reduce the risk of surgical complications like nerve injuries and development of an oroantral fistula (i.e. an opening between the mouth and maxillary sinus caused by removal of an upper back tooth)