The removal of a tooth is the oldest form of dental treatment and is still useful in many instances.
However, in the popular imagination, removing a tooth is a simple procedure that anyone can do and the result is the same.
Like any procedure, an extraction can be done very well, or very poorly.
Will you ever want to replace the tooth ever again in your lifetime?
The first thing you need to know about extractions is that they can be done in largely two ways. Preserving the bone. Removing the bone.
A tooth is held in by the bone that surrounds it. This bone is crucial for almost all types of tooth replacement. Dentures. Partial dentures. Bridges. Implants.
All of these do better when the bone that held the tooth in is preserved as much as possible.
In many of the older extraction techniques, the tooth was wriggled side to side and eventually leaned outward toward the cheek. This fractured the plate of bone on the cheek side of the tooth that was holding the tooth in. This immediately released the tooth and made it come out quickly.
It also makes the area heal quickly and usually without pain.
Unfortunately, the removal of the bone plate from the outside of the socket causes the socket to immediately fill with gum tissue causing major loss of bone volume and eventually gum volume. This has the following effects;
- It causes a shadow above the replacement tooth if you replace it with a bridge or an implant.
2. It may mean you need large bone grafts to correct the defect if you are having an implant or a bridge placed.
3. It may mean you need large soft tissue grafts if you are having an implant or a bridge to replace the tooth at some point in the future.
- It can make it more difficult to get a stable denture in the long term.
- Loss of bone or gum tissue can make dentures painful to wear as the thin flimsy remaining gum tissue gets pinched between the denture and the sharp blade of bone remaining from the inside of the extraction socket.
How to avoid bone loss with extractions?
In the vast majority of cases, a tooth can be removed without damaging the surrounding bone. However it takes more time, and a lot more attention to detail.
Usually this is done by spending more time loosening the tooth with luxators (special fine instruments that slip down beside the tooth loosening it up) or by sectioning (dividing the tooth into little pieces that are easily removed from within the socket without having the wriggle the tooth from side to side at all.
Many of the front teeth are round, so they can be removed without damaging bone quite easily.
However most of your back teeth have two or three roots and cannot just be “pulled out” without breaking something.
These teeth almost always should be sectioned (divided so that each root is like a single extraction rather than trying to remove two or three roots together) if you don’t want to fracture a lot of bone off.
My last extraction was so easy. Why was this one so difficult?
Some teeth are very easy to remove. If your tooth is wobbly from gum disease, then the gum disease has removed most of the bone around the tooth. So it will usually take longer to get numb than to get out.
However, some teeth are very difficult to remove.
Extractions that are difficult
- Back teeth are almost always more difficult than front teeth. Back teeth have two or three roots (sometimes four) whereas front teeth have one. These roots often are curved in different directions effectively locking the tooth into the bone. They cannot be removed unless you fracture/remove the bone, or divide the tooth into individual roots.
- Thick bone. Some people have very thick bone around the teeth and some have thin. If the bone is thick, your tooth will be hard to remove as the bone will not flex much.
- Ankylosed teeth. Ankylosis is a condition that affects some tooth where the bone actually fuses with the tooth. They are very difficult to predict and will involve dividing the tooth into about 20 pieces to take out. They always take a long time.
- Fractured teeth. Some teeth are fractured at gum level and there is not much to grab. In most cases, these teeth are infected and easy to remove. In a few cases, they are not easy to remove. If they are not infected, and in thick bone, expect it to take a while.
Will my extraction be painful?
Extractions are generally easier to get a patient numb for than a filling. However there are exceptions depending on which tooth and whether you have toothache or not.
Most upper teeth are easy to get numb for an extraction. Most lower teeth are also easy except the back molars.
The lower back molars are much more difficult to get numb because the bone is so thick around them that anesthetic has trouble soaking through and there are several different nerves that go to them.
However, by far the most important reason for how difficult it is to get the tooth numb is whether it is inflamed or infected.
When you have a severe toothache, the pain signal going to the brain is so much stronger that it is very much more difficult to stop. The tissue around an infected tooth also becomes very acidic which partly neutralizes the anesthetic.
So when your tooth is very painful, the difficulty in doing a painless extraction is many times higher.
Some things that a dentist might do to prevent pain when you have a toothache and need an extraction;
- Sedation or anxiolysis. As you become more nervous or anxious, you feel pain even more. By giving the patient preoperative sedatives like Lorazepam, it increases the pain threshold and much less pain is felt and the memory of it is much more pleasant (if you remember at all).
- Preop pain killers. Some pain killers, if given before the appointment, help to dramatically improve how numb the patient feels. Don’t self prescribe though as some painkillers will make you bleed a lot.
- Most anesthetics will take longer to work if you have a lot of pain preoperatively. It can take up to half an hour to go completely numb, particularly if you have a lower molar involved.
- Multiple techniques. There are five different types of local anesthetic techniques that can be used for lower molars. Sometimes the normal ones work. Sometimes we need to use all five.
The most important thing to understand is that it can take time to go numb and not all teeth are the same. You might have had a front tooth out in five minutes but that does not mean a lower molar will be as fast or as easy.
In most cases, if time and care is taken, the tooth can be completely painless when having an extraction. In some cases, where the patient has swelling of the face, which can be life threatening, the tooth will be removed even if there is some residual pain. This is because if it is not, the patient might end up in hospital with a tube down their throat trying to prevent them from dying through swelling closing their airway (never take swelling of the face lightly).
You will feel pressure even if you are numb. Please note that teeth are designed to withstand huge forces when you bite on them. Not surprisingly, they need quite a lot of force to lift them out of the bone. Even if you are numb, you will feel the dentist pushing or pulling quite firmly. This is normal unless you have severe gum disease and your tooth is near falling out.
What is a surgical extraction?
In some teeth, it is not possible to remove the tooth without removing surrounding bone.
This may be done by lifting the gum tissue and removing bone, or by using a fine vibrating instrument called a piezo to remove a tiny channel of bone around the tooth.
Many wisdom teeth are buried in the bone and can only be removed surgically. The removal of bone usually causes very little pain or swelling. However, if the gum tissue has to be lifted to see the tooth or the surrounding bone, you can expect a lot of swelling post operatively. Sometimes a steroid tablet before the procedure can prevent most of the swelling.
Since the skin and flesh of the face is quite thin, a small amount of swelling will look very dramatic.
If there is even the tiniest amount of bleeding under the gum tissue after an extraction, it will show up as a bruise. It will slowly drift down the face and fade away on the neck.
This has no relationship with whether the dentist was rough or gentle. It has more to do with the patient’s clotting ability and how difficult the extraction was.
In most cases, blood thinners won’t matter much for a single extraction. And the risk of a clot being fatal is always higher than a bleed.
However if you take warfarin, be aware of your INR. Usually, if it is below 2.5, it is quite safe to have an extraction.
The new class of blood thinners such as Xeralto can result in very large bleeds from simple procedures. Thankfully they wear off quickly. If your extraction is an emergency, have all the information at hand about any blood thinners you take.
Bisphosphonates and Anti-osteoporosis drugs.
Drugs such as Fosomax and Actonel are very important to mention to your dentist as in some cases, they can result in a non-healing wound that results in death of the surrounding bone. This is called osteonecrosis of the jaws. It can be debilitating.
Never assume a medication is not relevant to your dentist.
How much does an extraction cost?
How much an extraction costs is mostly dependent on how much time a dentist will allot to the procedure.
If you do the injections very fast (which also makes them very painful) and then remove the bone adjacent to the tooth if it does not come out very quickly (called a surgical extraction) or just fracture the bone off with the tooth, or don’t wait until the patient is fully numb, then the time taken can be just a few minutes. In this case, even at a lower fee, the procedure will be very profitable.
If the dentist takes great care to make sure your injections are not painful, your tooth is fully numb, and the bone around the tooth is preserved, then the extraction will take longer, and cost more.
Extractions where the tooth is divided into pieces normally cost more than those where they are not. Surgical extractions are those where the gum needs to be lifted.
Cost of an extraction in our practice ranges from $290 to $563 (surgical).
In some cases, an extraction will be less expensive if other procedures are being done at the same time.
In some cases, a simultaneous bone graft will be placed for later implant placement.