Will my Extraction be Difficult?

A common question we get asked is, “Will my extraction be difficult?”

There are a number of signs, which can suggest it may be a difficult extraction and these are discussed below. However, sometimes there is just no telling until you make a start and even then unexpected complications can occasionally arise that make life harder. See the previous chapter on Risks and complications of extractions for more information.

I have had situations where it looks simple and I know that the instant that I grip the tooth, it is not going to want to leave you, and other times where extensively broken down teeth that spell t.r.o.u.b.l.e. come out simply in a matter of moments.

The vast majority of teeth are removed fairly simply by a general dentist. Sometimes, the actual pulling part of the procedure takes less time than the ‘going numb’ bit and the ‘getting you to stop bleeding bit’ afterwards.

How difficult an extraction is will depend on you, your mouth, the tooth and the dentist. Here are some factors to think about:

• You

(i) Age. As you get older, your bone tends to be less forgiving and more brittle which can mean fractures become slightly more likely to both teeth and jaw.

(ii) Ethnic background. Heavily built men, particularly those from the Caribbean and the African continents, have very solid dense bone that can make for a real workout.

• Your mouth

(i) Access. The further back and the smaller your mouth, the more difficult the extraction is for the dentist. If the tooth is very out of position, then it can often not be gripped in the usual way. Impacted wisdom teeth, particularly lower third molars are often tricky because of their position at the back of the mouth. The size of the tongue and position of the other teeth will also have an impact on the amount of space for putting the instruments in.

• The tooth

(i) Lone standing molar. If a tooth has been standing on its own for some time and taking a lot of force- perhaps as support for a partial denture it can undergo a process called ‘ankylosis’ where the ligament (suspension for the tooth) becomes increasingly replaced by the bone, fixing it very firmly to the jaw and making its removal much more difficult. This can often be seen on the X-ray.

(ii) Type of extraction procedure. A surgical extraction is going to be more difficult than a sectional extraction and in turn, that is more difficult than a simple extraction. Indeed, depending on the situation it may be necessary to go from one approach to the other if complications arise.

(iii) Impaction. The tooth may be impacted- meaning not fully through the gum. This most commonly occurs with wisdom teeth but also with canines and other teeth that may have gone off track for one reason or another, when trying to come through.

(iv) Large abrasion cavities can be caused by excessive tooth brushing, extensively filled teeth and those which are cracked or showing signs of fracture. These are all more likely to fracture during extraction.

(v) Root filled teeth. Having had the nerve supply removed during the root canal procedure, the teeth become much more brittle and prone to fracture. Most of the more difficult teeth I have removed (aside from wisdom teeth) have been root filled, since they often decide to come out in a lots of pieces.

(vi) Lots of decay. Extensive dental caries throughout the tooth will make the tooth very weak and more likely to fracture. The site of the decay is also important. If it is where the forceps are placed, then the extraction is immediately trickier and fracture more likely.

(vii) Mobility. If your tooth is already moving because of bone loss from gum disease, the extraction is likely to be very simple. Sometimes this movement can be because of a fractured root, in which case the tooth is certainly going to come out in two parts- the top bit will be easy but the bottom half of the root may be trickier and require a surgical approach.

• The dentist

If the tooth looks particularly difficult, the dentist may refer you to an oral surgeon to remove it. This is generally the case with difficult impacted teeth such as a hard wisdom tooth. I say ‘hard’, because we take wisdom teeth out all the time ourselves, but what we ( general dentists) decide to attempt will depend on our experience, abilities, feelings about your comfort, the tooth or teeth that need to be removed, and the risk and potential for complications.

What is the Difference between an Impacted Tooth and an Un-Erupted Tooth?

An un-erupted tooth is a term used to describe a tooth that hasn’t yet come through the gum into its normal position. An impacted tooth, suggests the un-erupted tooth isn’t going to come through normally on its own because of the position of the tooth, the angle, or an obstacle preventing it from doing so.

The most common un-erupted and impacted teeth are your wisdom teeth or third molars, followed by your canines which can get lost and frequently require exposure and bringing down into line with orthodontic treatment. After this, your second lower premolars are the teeth next likely to hide or go walkabouts.

What are the Reasons Teeth Fail to Erupt?

Teeth can fail to erupt for a number of reasons, including:

• Not enough space (big teeth/little jaws)

• Early loss of a baby tooth and no space maintainer placed. The teeth either side of the missing milk tooth may tilt or drift preventing the normal eruption of the adult tooth underneath.

• Extra teeth- the presence of additional teeth (we call these supernumeraries and they are relatively common).
• They don’t exist (Hypodontia). Sometimes for whatever reason teeth simply don’t develop.

• Dilacerations are problems with the roots of the tooth being at a severe angle preventing normal eruption. This is often a result of damage during development.

• Tumours/cysts

• Other conditions such as cleft palate or cleidocranial dysplasia.

• Delayed development- there are rough ages at which we expect baby teeth to start getting loose, or being lost and adult ones appearing. There is however, quite a lot of variation in the timing of this and 6 months to one year would be considered normal. Where one side of the mouth has lost a tooth and the other hasn’t followed suit 6 months later- it’s generally time to take a closer look and an OPG X-ray will often be taken, to check in on your child’s stage of development.

If a tooth fails to come through normally, this can give cosmetic problems (e.g. canines), sometimes pain (e.g. wisdom teeth), or become the focus of infection. It can also resorb (wear away), loosen or push the roots of the teeth it impacts against. That said, if deeply buried and providing there is no other reason for removing them, they often remain quiet and can be happily left.

Each individual situation is unique and the benefits of removing them must be balanced against the risk of surgery. It is much easier to remove them in younger patients and once over 30 the chance of them giving rise to problems is considerably less anyway.

They are often discovered by the dentist on a routine screening X-ray like an OPG, which may be taken because a tooth that should have appeared, as yet has failed to do so. The dentist knows the timing and sequence of when teeth should erupt and if a space remains for too long, or a baby tooth isn’t being shed, then further investigation is warranted to check the cause and see what’s going on.