What is the Procedure for an Extraction?

To remove a tooth, it is necessary to break the ligament that is holding the tooth in and expand the bony socket just enough to deliver the tooth out.

Of course the first thing you are going to need is some anaesthetic to make the tooth numb. Which tooth it is will dictate which injections are required. If it is a top tooth, this will require an injection into the gum on the outside of your teeth known as a ‘buccal infiltration’ and one on the inside known as a ‘palatal injection’.

The outside injection can be given virtually painlessly (with topical cream) but the injection in the roof of your mouth where the mucosa is tightly bound down, because there isn’t a lot of space for anaesthetic, can be quite sharp.

This is how I describe it to my patients “OK, so I need to pop a few drops of anaesthetic in the roof of your mouth. I’m not going to tell you it doesn’t hurt because it does- you will feel a sharp little scratch, but by the time you think… he wasn’t kidding (about one second), it is all over with.”

With children, we have a time- consuming ways of getting around this, but for adults, this is the best way to get it really numb.

On the bottom jaw, most of the time the dentist will give an injection at the back of your mouth called an ID block (that’s the one that makes your lip go numb) and in doing so, will also, as part of the same injection, reposition the needle to numb the nerve that supplies the gum on the inside and side of your tongue. You will feel this one a little, because it is slightly deeper, so the cream that numbs the outer surface of your gum has less of an effect.

For back teeth, the dentist will need to put an extra injection into the gum on the outside of the tooth. We call this a ‘long buccal infiltration’ because it targets the long buccal nerve. Whilst the cream can help, this tends to be a bit sharp for a couple of seconds too.

How much you feel the anaesthetic will depend on how good your dentist is at giving the injection, the temperature of the anaesthetic and how sensitive or nervous you are. Remember to breath, nice and slowly, big deep tummy breathes and focus on twiddling your toes or making a little circle with your foot.

How does the Dentist know the Tooth is Numb?

First, you will begin to feel a sort of pins and needles type effect, that will gradually be taken over by a loss of feeling or numbness.

The classic signs that the tooth is numb are…

• The pain has gone
• The tooth doesn’t hurt to press on like before
• Your lip goes numb on the one side
• Your tongue goes numb on the one side
• Your cheek goes numb.

Not all injections will cause ‘ your lip to go numb’ or ‘your tongue to go numb on the one side’, but most extractions on bottom teeth will. You may feel some numbness elsewhere such as your nose. It just depends on the site of the anaesthetic and your nerve supply.

A few minutes after the injections the dentist will start by asking you questions such as:

Do you feel any numbness? Does the tooth still hurt? Has your lip or half the side of your tongue gone numb?

This will give them a good idea of whether the injections have worked. Assuming they have, the next stage is for the dentist to have a good press around your tooth. I would say something like,“ I’m just going to have a press around your tooth, please tell me if you feel any sharpness or pain- the anaesthetic can take away all the pain, but you may still feel some pressure- a dull pushing- that is totally normal, but nothing sharp like a pin or prick.”

If you only feel pushing or feel nothing at all, then the dentist is good to begin removing the tooth. However, if it is still a bit sore or sharp in places, then some extra topping up with anaesthetic is needed.

This may be in the same position as before in which case you won’t feel much, or directly around the actual tooth. We call this an intra-ligamentary injection because we put anaesthetic directly into the ligament. It is a little sharp scratch and often a touch of anaesthetic escapes as we remove the needle, giving a bit of a bitter taste which you will want to rinse out.

Sometimes the tooth will need a few extra injections, or another type of anaesthetic to get it properly numb. In some cases when you start moving the tooth, it can occasionally become painful again. The anaesthetic may need topping up further, but it may just be the pressure of moving the tooth.

When the tooth is no-longer sharp the dentist can start the extraction.

It is not always that easy to tell the difference between pressure and pain (particularly for children). You will feel movement and pressure when the tooth is being removed, but it shouldn’t hurt- the size and shape of the roots and the density of your jaw will affect how much ‘pushing’ and ‘pressure’ you feel. The reason for this is, anaesthetic only works on nerve fibres, not on pressure fibres (proprioceptors).

Infection can sometimes neutralize the anaesthetic to the point where we can’t get the tooth numb. If you have a large abscess, whilst the ideal solution for removing the infection, is removing the source i.e. the tooth, antibiotics and draining the abscess (if possible) may be needed first, then another appointment to extract the tooth a week later.

If this situation happens whilst in the chair, as very occasionally it does, the procedure may need to be abandoned, suitable antibiotics prescribed and an appointment made for you to come back in a week.

Will I Feel Pain? What will I Feel?

The dentist will ensure the tooth and gum is really numb before starting, so you won’t feel any pain, only the pushing and pressure I have already described. If you do feel pain, put your hand up and tell the dentist where and what you are feeling. It is a strange experience that is difficult to put into words but it should not hurt.

How is the Actual Tooth Removed?

The dentist needs to expand the socket enough to deliver the tooth. They will use a combination of instruments called elevators, luxators and forceps to do this. Most of the time this part of the procedure is the quickest and only takes a few minutes. It is getting you numb and stopping the bleeding afterwards, which take the majority of the time.

Most commonly they will begin by levering the tooth with elevators to move it around in the socket, or try to break the ligament connecting the tooth to the bone with luxatorsto allow it to come out more easily. When it starts to move the dentist will progress to the forceps– these for want of a better word and believe me, I want a better word, are like special dental pliers.

They allow the tooth to be gripped firmly and provide leverage to move the tooth in any direction. You will feel a lot of pushing, pressure and movement at this point and the nurse may help to support your head. The dentist may swap back to elevators a couple of times until the tooth is loose enough that it comes out- usually using the forceps.

After the tooth has been removed, the dentist will squeeze together the expanded socket with some finger pressure to slow the bleeding. If there is any sign of any loose bone from the socket walls, this should be removed as it may slow healing (but will be pushed out by the body anyway).

A gauze will be rolled up and you will be asked to bite on it nice and firmly for a good few minutes to stop the bleeding. The dentist will only let you go when they are happy the socket has stopped bleeding (‘achieved haemostatis’). At this point they will go through how to care for your extraction socket and give you some written instructions and extra gauze to take away.

If a surgical extraction has been performed, you will need stitches and probably another appointment to remove them.

What I have just described is a simple extraction and applies to the majority of cases. With any extraction, complications can occur which may mean the dentist has to change his approach. A sectional extraction, or surgical extraction may be needed from the start, or because of complications or tooth fracture, progressed to during the procedure.

A lot of wisdom teeth require surgical extractions because they are impacted or not fully through the gum (particularly the lowers).

Will the Dentist put his Knee on my Chest?

I think this is an urban legend… I can’t imagine a dentist having either the flexibility, or the need to ever do this!

Why are there so many Different Instruments?

The roots on each of your teeth are all slightly different and instruments are designed to reflect this and make taking them out easier. Whilst there are exceptions, these teeth formations are pretty much consistent in each of us- for example, top molar teeth generally have three roots, but lower molar teeth have just two.

Premolars have one root, except the upper 1st premolar which has two, and all your front teeth (incisors and canines) have just one root.

The shape of the forceps, reflects the shape of the roots of the tooth they will be removing- they are designed to fit around the root as closely as possible.

The dentist knows not just the number of roots, but the shape of each of the roots too. They know how best to apply pressure to the tooth in question, in order to remove it.

For example, lower premolar teeth have mostly conical shaped roots so the dentist will twist (rotate) the tooth in one direction and then in the other, to break the ligament holding it in and remove it.

If they were to do this motion, with a lower incisor, which has a very flat (not conical) shaped root, then it would most likely fracture the root. Instead it must be moved with downward pressure and movement just in a forwards and backwards direction…. And to think you thought we just tugged at them ‘Willy nilly!’ There is always a method to the madness!

What Happens if my Tooth Fractures?

Sometimes fractures are unavoidable because of the decay in the tooth, or shape of the roots, meaning it’s simply not possible for the tooth to come out in one piece. Most of the time a rather scary ‘crack’ will be heard (not felt, because you are numb) that can make you jump a little. It’s normal!

The dentist will continue the procedure and remove the root, sometimes the remaining tooth fragment comes out easily and other times it can be very stubborn- it just depends. The dentist may need sometimes need to take an X-ray to see how much is left and sometimes a surgical approach will be necessary to remove it.

My Dentist left some Tooth in- is that Normal?

It is best to remove any fractured root if possible.

However, there are times when leaving a small amount of tooth root may be appropriate, such as when there is risk of causing more damage or complications by trying to remove e.g. if it lies close to your maxillary antrum, or inferior dental nerve.

The piece should only be left if it:

• Is smaller than one third of the root.

• It is not moved from inside the socket.

• There was no infection associated with that root.

Of course, if a piece is left in, the dentist should inform you. Most small root fragments that are left, do not cause any problems- they end up either being surrounded by bone and staying put, or being pushed up to the surface making removal at a later date very easy.

Sometimes bits of the socket wall, that have broken off during the extraction, will come up through the gum during the healing process and be mistaken by patients as bits of tooth that were left.This can happen up to a number of weeks after the tooth extraction.

These tiny bone fragments, ‘bone sequestra’ are normally resorbed and remodeled during healing and though sometimes a little rough on your tongue; they tend not to be painful. Bigger bits occasionally work their way up and may need a bit of encouragement from the dentist. The area of the socket will need to be made numb to remove these.

If the dentist cannot complete the procedure but the fragment needs to be removed, the socket may be dressed and a referral to an oral surgeon who is used to dealing with this kind of complication, completed.