THE OPERATION REMOVING TEMPORARY AND PERMANENT TEETH IN CHILDREN.

ODONTOGENIC PERIOSTITIS AND NEODONTOHENNYYJAWS.HOSPITAL ACUTE AND CHRONIC PERIOSTITIS. DIAGNOSIS,DIFFERENTIAL DIAGNOSIS. COMBINED TREATMENT, PREVENTION.

History

Historically, dental extractions have been used to treat a variety of illnesses, as well as a method of torture to obtain forced confessions. Before the discovery of antibiotics, chronic tooth infections were often linked to a variety of health problems, and therefore removal of a diseased tooth was a common treatment for various medical conditions. Instruments used for dental extractions date back several centuries. In the 14th century, Guy de Chauliac invented the dental pelican, which was used through the late 18th century. The pelican was replaced by the dental key which, in turn, was replaced by modern forceps in the 20th century. As dental extractions can vary tremendously in difficulty, depending on the patient and the tooth, a wide variety of instruments exist to address specific situation.

 

This picture of two to three centuries ago, shows what tooth extraction was like then.  The picture of the face contorted by extreme pain says it all.  It was also a common practice for tooth extractions to be performed on a stage in front of all passerby’s.  Perhaps great entertainment then, but today we can take comfort in pain killing drugs and the privacy of our dentist’s surgery, when a tooth needs to be extracted.

Reasons for tooth extraction

The most common reason for extraction is tooth damage due to breakage or decay. There are additional reasons for tooth extraction:

• Severe tooth decay or infection. Despite the reduction in worldwide prevalence of dental caries, still it is the most common reason for extraction of (non-third molar) teeth with up to two thirds of extractions.

• Extra teeth which are blocking other teeth from coming in.

• Severe gum disease which may affect the supporting tissues and bone structures of teeth.

• In preparation for orthodontic treatment (braces)

• Teeth in the fracture line

• Fractured teeth

• Insufficient space for wisdom teeth (impacted third molars). Although many dentists remove asymptomatic impacted third molars, American as well as British Health Authorities recommended against this routine procedure, unless there are evidences for disease in the impacted tooth or the near environment.The American Public Health Association, for example, adopted a policy, Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth) because of the large number of injuries resulting from unnecessary extractions

• Receiving radiation to the head and neck may require extraction of teeth in the field of radiation.

• Deliberate, medically unnecessary, extraction as a particularly dreadful form of physical tortur.

Physics Forceps – Standard Series

The Physics Forceps are a unique type of extraction system that provides:

• Predictable and efficient extractions in less than four minutes

• Atraumatic extractions where you preserve the bone

• Elimination of root tip fractures

• No need for elevating or laying a flap

• Very little operator movement (or strength) necessary

The unique design of the Physics Forceps allows for light but constant pressure to be applied to the tooth which leads to chemical changes in the PDL and subsequent release of the Sharpey’s fibers. Once the tooth releases, it can be removed simply with a rongeur or even just your fingers.

Standard Physics Forceps Set Includes
Four (4) Physics Forceps Instruments

• Upper Right – Teeth #2-5

• Upper Left – Teeth #12-15

• Upper Anterior – Teeth #6-11

• Lower Universal – Teeth #18-31

About the Physics Forceps

The Physics Forceps are an innovative design that provides a simple mechanical advantage by employing first-class lever mechanics. Utilizing the patented “beak and bumper” technique, you can simply and predictably extract virtually any tooth in any condition, while preserving the buccal bone and socket. The beak of the Physics Forceps is designed to apply controlled pressure parallel to the long axis of the root. The bumper acts as a simple fulcrum or pivot point. While traditional instruments grasp, squeeze and twist, the Physics Forceps employs a slow, steady force that releases the tooth from the alveolar bone. 

Why the Physics Forceps Are So Effective

By combining the biomechanical advantages of a first-class lever with the biochemical reaction that is occurring, extracting teeth has never been easier than with the Physics Forceps. When the periodontal ligament is traumatized with forceps or elevators, hyaluronidase is released. Once this chemical breakdown of the periodontal ligament by hyaluronic acid is sufficient, the tooth is released from its attachment to the alveolus and can be removed.

This explains why the Physics Forceps with its steady unrelenting trauma to the periodontal ligament quantitatively creates a greater release of hyaluronidase in a shorter period of time than traditional forceps or elevator extractions because the trauma from those techniques is intermittent. This is what makes the Physics Forceps more efficient, faster, and less traumatic to the alveolar bone. 

Preserving the Bone

By utilizing the Physics Forceps Technique (no squeezing, applying constant steady pressure with the wrist only and using the bumper as a pivot/fulcrum), it is uncommon to break the buccal bone or cortical plate. Think of the Physics Forceps as an elevator – all you want the instrument to do is move the tooth 1-3mm through constant steady pressure allowing the PDL to separate from the tooth. Once this chemical breakdown of the periodontal ligament by hyaluronic acid is sufficient, the tooth elevates coronally. You are now finished with the Physics Forceps. You can deliver the loose tooth with a traditional instrument. Also, the bumper is a compressive force that is holding the bone in place. Even though you are not squeezing, it is supporting the bone.

 

Instructions for Use

STEP 01

Separate the gingival attachment from the tooth. All upper teeth, including molars can be extracted without any sectioning. Lowers molars occasionally need to be sectioned (lingual buccal) to ensure a more predictable extraction, by significantly reducing resistance to extracting forces.

STEP 02

With the handles wide open, set the beak into the depth of the lingual or palatal sulcus on solid root surface. A secure purchase point on solid root surface is critical to successfully rolling out the tooth. Wheecessary, create a small trench with a small flame shaped diamond burr to engage the beak more securely on solid root surface.

STEP 03

Set the bumper perpendicular to the tooth at about the level of the mucogingival junction. Holding that position securely, freeze don’t squeeze the handles. Note: the greater the distance between the beak and the bumper, the greater the arc of rotation, consequently achieving vertical lift.

STEP 04

Separate the gingival attachment from the tooth. All upper teeth, including molars can be extracted without any sectioning. Lowers molars occasionally need to be sectioned (lingual buccal) to insure a more predictable extraction, by significantly reducing resistance to extracting forces.

STEP 05

Without squeezing the handles or moving your arm, begin to apply a steady, very slow rotational force in the direction of the bumper patiently, continue to apply this steady force for 30 to 40 seconds. This force or creep will continue to build, allowing time for the periodontal ligament to release, the bone to slowly expand & the tooth to disengage.

STEP 06

Initially, you may want to avoid unnecessary damage to the buccal plate by not proceeding with the Physics Forceps beyond the first sign of the tooth ‘popping’ loose. If the tooth has not elevated sufficiently to grasp it with your fingers, consider using a hemostat, rongeurs or conventional forceps to lift it out.

 

Tooth Extraction

Overview

Background

Tooth extraction is linked to dentists who perform oral surgery. Teeth that are embedded in bone (eg, impacted or wisdom teeth) must be removed by an oral and maxillofacial surgeon who is trained for 4-6 years after obtaining a dental or medical degree.

Compared with removal of an impacted tooth, tooth extraction appears to be a relatively simple technical procedure. However, both tooth extraction and removal of an impacted tooth must be performed in accordance with surgical principles that have evolved from both basic research and centuries of trial and error. Tooth extraction leaves a surgical wound, which has to heal. Accordingly, a basic understanding of wound healing is essential for performing this surgical procedure in the oral cavity.

Like any other minor surgical procedure, tooth extraction requires careful medical evaluation of the patient. Patients with diabetes, hypertension, renal disease, thyroid disease, adrenal disease, or other organ disease must be treated and their disease controlled before tooth extraction. Because the oral cavity is full of microorganisms, any surgical procedure in this area may give rise to postoperative infection, especially in immunocompromised patients.

Before, during, and after tooth extraction, pain management is an important issue. Medical, surgical, and legal considerations exist; for example, removing the wrong tooth is malpractice, as is breaking the jaw during extraction or causing paresthesia after extracting the mandibular third molar in close proximity to the inferior alveolar nerve without proper informed consent.

Indications

Teeth are important for aesthetic purposes and for maintaining masticatory function. Accordingly, all efforts to avoid tooth extraction must be exhausted before the decision is made to proceed with removal of a tooth. Nevertheless, there are circumstances in which it is clear that a tooth must be extracted, such as the following:

• A tooth that cannot be restored, because of severe caries

• A mobile tooth with severe periodontal disease, pulp necrosis, or periapical abscess, for which root canal treatment is required that the patient cannot afford (or for which endodontic treatment failed)

• Overcrowding of teeth in the dental arch, resulting in orthodontic deformity

Other conditions that may necessitate extraction include the following:

• Malposed teeth causing soft tissue trauma to the cheek

• Cracked teeth from trauma

• Supernumerary teeth

• Teeth adjacent to a pathologic lesion that must be excised

• Planned radiation or intravenous (IV) bisphosphonate treatment, warranting prophylactic extraction

• Teeth in the line of fracture

• Aesthetic considerations (eg, teeth with endogenous staining)

• Economic considerations (eg, teeth for which extensive restoration is required that the patient cannot afford )

Contraindications

There are few contraindications for tooth extraction, and most of those that do exist can be modified by additional medical consultation and treatment. Some contraindications can be so severe that extraction should not be performed until the severity of the medical condition has been resolved.

Essentially, contraindications may be divided into local and systemic. Local contraindications are limited to the extraction sites. An example is an extraction site that was heavily exposed to radiation; if extraction is performed in the irradiated area, osteoradionecrosis results. Other local contraindication is proximity to a malignancy; extraction in the area of malignancy may increase the chances of dissemination of malignancy.

Extraction may be contraindicated in an area of infection that has not been adequately treated (eg, an impacted third molar associated with pericoronitis that is not treated with an antibiotic). Extraction may also be contraindicated when it is adjacent to the site of jaw fracture, because the teeth may be required for stabilization of the fractured bone. If the patient has very limited mouth-opening ability, extracting a tooth may be extremely difficult because of limited access to local anesthesia.

A systemic contraindication systemic bisphosphonate therapy for malignancy. Extraction in patients receiving such therapy results in osteochemonecrosis, which is more severe than osteoradionecrosis and is more difficult to treat. Other systemic contraindications include brittle uncontrolled diabetes, end-stage renal and liver disease, uncontrolled leukemia, lymphoma, hypertension, cardiac dysrhythmias, and cerebrovascular accidents.

Pregnancy is a relative contraindication in the first or last trimester; extractions are deferred until after childbirth. Hemophiliac patients and those with severe platelet disorders or other bleeding diatheses should undergo extraction only after these coagulopathies have been corrected. Caution and extreme care are required before extraction in patients on long-term corticosteroids, immunosuppressants, or cancer chemotherapeutic agents.

Periprocedural Care

Equipment

Tooth extraction is performed either in a dental office by a dentist or in an oral surgery suite by an oral and maxillofacial surgeon. In either case, the suite is equipped with dental chair and a good source of operating light. The chair provides stability and support and affords the surgeon maximal control of the force being delivered to the patient through the dental forceps. The chair tilts to allow appropriate positioning for maxillary and mandibular tooth extractions.

The oral surgery tray is equipped with surgical instruments for soft tissue, such as the following:

• No. 15 scalpel

• Dean scissors

• Needle holder

• Curved hemostat

• Minnesota retractor

• Right-angle Austin retractor

• Weider tongue retractor

• Seldin retractor

• Molt periosteal elevator

• Suction tip

• Adson tissue forceps

• Allis tissue forceps

• Double-ended curette

• Small half-circle needle

• Suture materials

Other instruments included in the tray are for hard tissue, such as the following:

• Blumenthal rongeur forceps

• Bone file

• Burs

• Handpiece

• Hall drill

In the past, a chisel and mallet were used to remove bone and teeth; currently, however, the use of these instruments is limited to removal of excess bone.

Additional instrument are also included, such as rubber bite blocks and a Molt mouth prop, which are designed to hold the mouth open during extraction.

The key instruments used for extraction are also included in the tray. These may include small and large straight dental elevators (see the image below), left and right triangle-shaped elevators, a Crane pick elevator, a root tip pick, or an apex elevator.

Use of straight elevator.

Other important extraction instruments are the various dental forceps designed for extracting maxillary and mandibular teeth. Maxillary instruments include the No. 150 universal forceps, which is designed for extracting premolar and molar maxillary teeth (see the image below), the No. 53 right and left forceps, which are designed specifically for maxillary molars, and the No. 1 maxillary forceps, which is designed for extraction of maxillary incisors and canines.

No. 150 maxillary universal forceps in place.

Instruments designed for extracting mandibular teeth include the No. 151 universal mandibular forceps, the Ash forceps, and the cowhorn forceps (see the images below).

Lower universal forceps No. 151.

 

Cowhorn forceps No. 23.

 

Ash forceps.

Patient Preparation

Patient preparation includes adequate anesthesia and appropriate positioning.

Anesthesia

Local anesthesia is required for tooth extraction. It achieves loss of sensation by blocking action potentials and nerve conduction.Local anesthesia to the regional sensory nerves supplying the teeth eliminates pain, including that related to temperature and touch, but does not anesthetize the proprioceptive fibers of the involved teeth. For this reason (as well as out of anxiety), patients feel painful pressure during extraction. Consequently, many extractions are performed with local anesthesia along with intravenous (IV) sedation and inhaled nitrous oxide.

Local anesthetic agents commonly used in dentistry belong to either the ester group (eg, procaine) or the amide group (eg, lidocaine). Local anesthetics of the ester group are metabolized by plasma cholinesterase, whereas those of the amide group are metabolized in the liver by microsomal enzymes. Other local anesthetics included in the amide group are mepivacaine and long-acting bupivacaine.

Several local anesthesia techniques are used in the maxillary and mandibular regions. Maxillary techniques (see the images below) include the following:

• Single tooth – Local infiltration or supraperiosteal injection is achieved for a single tooth by inserting the needle in the mucobuccal fold adjacent to that tooth

• First, second, and third molars – Posterior superior alveolar nerve block anesthetizes the maxillary first, second, and third molars and the buccal mucosa surrounding the teeth; the needle is inserted above the second molar superiorly and medially at a 45º angle to the occlusal plane

• Maxillary nerve block – This is performed via the high maxillary tuberosity approach or through the greater palatine foramen; it anesthetizes all maxillary teeth, the surrounding bone and mucosa, the lower eyelid and nose, and the upper lip ipsilaterally

•  

• Insertion of local anesthesia needle into mucobuccal fold.

• Supraperiosteal placement of local anesthesia needle.

• Direction of superior posterior nerve block (arrow).

•  

• Maxillary divisioerve block.

•  

• Highlighted area is anesthetized by maxillary divisioerve block.

Mandibular techniques (see the images below) include the following:

• Inferior alveolar nerve block – This anesthetizes all mandibular molars, premolars, canines, and incisors ipsilaterally, including lingual mucosa; the needle is inserted from the opposite side, parallel with the occlusal plane, into the pterygomandibular raphe at the medial side of the mandible toward the mandibular foramen, which is located midway between the external oblique ridge and the posterior ramus

• Long buccal nerve block – This anesthetizes the buccal mucosa ipsilaterally, with the needle inserted into the retromolar region; it is usually given with the inferior alveolar nerve block

• Mental nerve block – This anesthetizes the premolar, canine, and incisor teeth ipsilaterally; the needle is inserted in the mucobuccal fold toward the mental foramen, which is located between and inferior to the 2 premolars

• Highlighted area where injection of inferior alveolar nerve takes place.

• Direction of needle for inferior alveolar nerve block.

• Site of needle insertion for long buccal nerve block.

• Insertion of needle in mucobuccal fold for infiltration of incisor teeth.

• Highlighted area is anesthetized by local mandibular infiltration.

As indicated above, local anesthesia alone may not be adequate for an anxious patient who may require additional sedation with inhaled nitrous oxide and oxygen. In the extremely anxious patient, IV sedation with midazolam and opioid analgesia are used.

Positioning

The surgeon and the patient should be positioned in such a way that the patient is comfortable and the surgeon can stand or sit in front of the patient without undue strain. Ideally, the surgical instruments (especially the needle) should be placed out of the patient’s sight (usually behind the patient but close to the surgeon).

For mandibular extraction, the positioning is as follows:

• Chair axis – The chair is positioned so that the mandibular occlusal plane is parallel to the floor

• Chair height – The chair is lowered to afford the surgeon the leverage and control needed for the extraction

• Patient head – The patient is asked to turn the head toward the operator

• Operator – The operator is at the 9 o’clock position relative to the patient

• Second hand operator – The second operator is at the 3 o’clock position to help the operator in retracting the cheek, lip, and tongue and stabilizing the jaw

• Assistant – The assistant places the suction tip in one hand and the soft tissue retractor in the other (and also helps with irrigation wheeeded)

For maxillary extraction, the positioning is as follows:

• Chair axis – The chair is tipped backward so that the maxillary occlusal plane is at an angle of about 60º to the floor

• Chair height – The chair is lowered to the height of the operator’s elbow

• Patient head – The patient is asked to lift the head and turn toward the operator for access and visualization

• Operator – The operator is at the 9 o’clock position relative to the patient

• Second hand operator – The second operator stands or sits at the 3 o’clock position and helps with retraction, suctioning, irrigation, and jaw stabilization

Ways Of Tooth Extractions

There are various procedures of tooth extractions depending upon the case to case. The dentist decides the best way after clinical examination and taking x-ray to see the position and condition of the tooth to be extracted and accordingly decides whether the tooth can be extracted simply or some surgical procedure for tooth extraction has to be adopted. There are two ways of extracting or pulling out the teeth. These two ways are:

1.   Simple extractions

2.   Surgical extractions

Simple Extractions

 

In simple tooth extraction cases, after giving the local anesthesia, the tooth is extracted / pulled out with the dental forceps. No afterward complications are expected if patient follows the post tooth extraction instructions given by the dentist.

Simple Tooth extraction

Simple tooth extractions are also known as closed extractions or intraalveolar extractions or forceps extractions. In simpletooth extraction cases, after giving the local anesthesia, the tooth is extracted / pulled out with the dental forceps. So they are known as forceps extractions. They are known as intra-alveolar extractions because no bone cutting is required and the tooth can be just removed from the socket with the help of forceps. No afterward complications are expected if the patient follows the post tooth extraction instructions given by the dentist. Simple extractions are performed in those teeth in which much of crown of the tooth is in good condition. General dentists commonly do the simple tooth extractions. Most of the times, there is no requirement of sedation or anti-anxiety drugs in doing simple tooth extractions. The tooth is grasped with forceps in this and then the tooth is loosened by moving the forceps back and forth and then the tooth is pulled out. Dental Elevators may be used for loosening the teeth.

 

Surgical Tooth Extractions

 

 

They are also known as open extractions or transalveolar extractions. Unfortunately all the teeth cannot be pulled out easily. In some cases the tooth is damaged to that extent that nothing is visible above the gum line or in some cases due to infection or root canal treatment the tooth becomes so brittle that the crown breaks as soon as it is held by the forceps leaving behind the root part. In such cases surgical extraction has to be done. In this type of extractions, incision is given on the gums and the flap is raised to expose the embedded part of the root of the tooth which is then removed. But sometimes bone has to be cut to fully remove the roots of the tooth. In case of surgical tooth extractions, the procedure is done under injections of local anesthesia and conscious sedation may also be given. In patients who are very apprehensive or have special medical conditions and in young children, the procedure may be done under general anesthesia.

 

If the tooth is being pulled out after receiving conscious sedation, then steroids may be given to reduce the swelling which occurs after the tooth extraction.

 

Surgical extractions are mainly performed by the oral surgeons and incision on the gums and/or bone cutting is required in thesekinds of extractions.  It is a more invasive procedure than the simple extractions. It is done in those teeth which don’t have much of tooth structure left and nothing much is visible above the gum line. There is comparatively more postoperative pain in cases of surgical extractions. Surgical procedures can be of 5types: Surgical, surgical root, soft tissue, partial bony and full bony.  
 

Impacted Teeth Extractions

 

Impacted teeth are those teeth which are embedded and do not erupt in the oral cavity. These teeth create lot of problems and have to be extracted. Most commonly seen impacted teeth are the lower third molars (wisdom teeth) followed by the upper third molars. Upper canines are also impacted in many cases.

 

The impaction can be soft tissue impactions or bony impactions.

If it is soft tissue impaction then the incision has to be given in the soft tissue above the tooth and then like simple extraction it can be pulled out by using the forceps. But if it is bony impaction then the bone has to be cut and sometimes the tooth is also sectioned.

 

 

The impaction can be vertical, horizontal or angular depending about the angle of the tooth. Depending on the angle of the tooth, the impactions can be Mesio-angular or Disto-angular. The most difficult kind of impactions is Disto angular impactions. Mesio-angular impacted cases are comparatively easier to remove as compared to the Disto-angular impactions.
 

Angular                             Partial Eruption

Horizontal                           Vertical

 

If all the four wisdom teeth are to be removed, then the upper teeth should be removed first and then the lower teeth should be removed.

 

Wisdom teeth can be –

 

1.   Erupted

2.   Soft tissue impacted

3.   Partial bony impacted

4.   Full-bony impacted

 

Wisdom teeth are said to be erupted when they are already in the mouth. They are called as soft tissue impacted when they are present under the gums. They are called as partial bony when they are partially stuck in the jaw and are called as full bony when they are completely in the jaw.

Technique

Tooth Extraction

For proper extraction of a tooth, the operator must elevate the gingival soft tissue attachment, luxate the tooth with small and large straight elevators, and adapt the forceps to the crown of the tooth. Luxation requires apical pressure, buccal force, lingual pressure, rotational pressure, and tractional forces. The operator continues to luxate the tooth with the forceps in a buccolingual direction with slight rotation until the tooth is removed from the socket.

Tooth extraction can be difficult in older patients with dense supporting bone, dilacerated roots, and broken crowns with extensive caries. Special attention should be paid to adjacent teeth and vital structures (eg, the maxillary sinus, the inferior alveolar nerve, and the lingual and mental nerves). To minimize the risk of pushing the tooth into the maxillary sinus or fracturing the mandible, extensive force should be avoided. The best and easiest way of managing tooth extraction complications is to prevent them.

Tooth extraction often leads to root fracture. A small envelope flap can be reflected to expose fractured roots, and a small straight elevator can be used as a shoehorn to luxate broken roots. The buccal beak of the forceps can be used to grasp a portion of the bone at the same time it grasps the root.

The extraction forceps is seated with strong apical pressure to expand the crestal bone around the root and allow root removal. A small root tip can be addressed by placing an endodontic file in the root canal and twisting it with a needle holder. The root can be removed with a No. 4 round bur in a dental handpiece or a small elevator, which displaces the root from its apex.

Teeth that are liable to fracture during extraction are those with large carious lesions, those that have been treated by means of root canal procedures, and those surrounded by dense bone or with ankylosed and dilacerated roots.

Although every effort should be made to remove fractured roots during extraction, there are some circumstances in which these roots are best left in place, as when the root is suspected to be on the verge of entering an anatomic space or when further instrumentation would cause damage to a vital adjacent structure, would result in uncontrolled bleeding, or might necessitate an inordinate amount of bone excision.

Extreme care is required in extracting maxillary teeth close to the maxillary sinus to avoid sinus exposure and subsequent oroantral fistula. Attention is also needed in extracting mandibular teeth close to the inferior alveolar canal and mental foramen to avoid paresthesia.

Complications of Procedure

The most common intraoperative complications of tooth extraction are injuries to the soft tissue resulting from lack of attention to the delicate nature of the mucosa and the use of excessive and uncontrolled force during extraction; examples include lip abrasions or burns from a retractor or rotating handpiece.

The next most common complications are injuries to osseous structures, such as fractures of the alveolar plate in the buccal cortex of maxillary canines, molars, and mandibular incisors.

The maxillary tuberosity is often fractured during the extraction of a difficult molar (see the images below), especially a difficult maxillary third molar. This complication can be prevented by performing a thorough clinical and radiographic examination and taking care not to apply an excessive amount of uncontrolled force. Fractured bone in the tuberosity can be carefully dissected from the tooth with a straight elevator; the bone and soft tissue can then be sutured in place and the extraction site closed primarily.

Radiograph taken before extraction of second maxillary molar.

 

Fracture of maxillary tuberosity occurred during extraction of second maxillary molar.

 

Maxillary tuberosity was adherent to extracted tooth.

Radiographically, the layers of the tooth are easily identifiable because they have different radiopacities. Enamel is the most mineralized of the calcified tissues of the body, and it is the most radiopaque of the 3 tooth layers. Dentin is less radiopaque than enamel and has a radiopacity similar to that of bone. The pulp tissue is not mineralized and appears radiolucent.^[10] For more information about the relevant anatomy, see Tooth Anatomy.

Extracting a maxillary molar tooth close to the maxillary sinus may result in oroantral communication, which in turn may lead to maxillary sinusitis and the formation of a chronic oroantral fistula.

Intraoperatively, sinus communication can be detected by performing a nose-blowing test to check for passage of air or bubbling of blood in the extraction site. A small communication (< 2 mm) may close on its own with the formation of clot and, subsequently, granulation tissue.

A moderate-sized communication (2-6 mm) necessitates the placement of a figure-eight suture to stabilize the blood clot. Postoperatively, the patient should be instructed to avoid nose-blowing, violent sneezing, and sucking on straws. The patient should be placed on an antibiotic for 7 days, a nasal decongestant for 3 days, and an oral decongestant for 7 days. A larger communication (> 7 mm) necessitates a flap procedure to close the defect.

Even with meticulous surgical technique, tooth extraction may result in injury to adjacent vital structures. Lingual nerve paresthesia may result after injection if the needle passes through the nerve, the distal incision is positioned too far lingually, or the nerve is cut during lingual bone removal.

 

Types of Dental Extraction

Extractions are often categorized as “simple” or “surgical”.
Simple extractions are performed on teeth that are visible in the mouth, usually under local anesthetic, and require only the use of instruments to elevate and/or grasp the visible portion of the tooth. Typically the tooth is lifted using an elevator, and using dental forceps, rocked back and forth until the Periodontal ligament has been sufficiently broken and the supporting alveolar bone has been adequately widened to make the tooth loose enough to remove. Typically, when teeth are removed with forceps, slow, steady pressure is applied with controlled force.

Surgical extractions involve the removal of teeth that cannot be easily accessed, either because they have broken under the gum line or because they have not erupted fully. Surgical extractions almost always require an incision. In a surgical extraction the doctor may elevate the soft tissues covering the tooth and bone and may also remove some of the overlying and/or surrounding bone tissue with a drill or osteotome. Frequently, the tooth may be split into multiple pieces to facilitate its removal.

When is tooth extractioecessary?

• in case of illnesses involving pain and extended inflammations, if there is no other solution

• because of the extended inflammation, the surrounding tissues have to be protected, along with the other teeth

• incase the disease is not painful, but the broken, loosened tooth cannot be use for further tooth replacement

• fortunately, most teeth deemed irredeemable by the patient can still be saved

 

Extracting wisdom teeth

Before extracting wisdom teeth, the doctor is informed of the condition of the tooth, and the surrounding anatomical parts by a panorama X-ray.

A wisdom teeth operation may involve a flap establishment or the unification of the scar margins with stitches. Of course, this is completely painless. The benefit of the adequate size of sawing pin is that it can be removed without pain in the end, it almost slips out of its place.

 

Preparation for a Tooth Extraction:

Tooth Extraction Pain

In preparing for a tooth extraction, anticipate one big thing, pain and controlling that pain. 

The morphine based drugs, if you can get them, appear to work well when the tooth extraction is less than three days old; such drugs also help to put you to sleep and can be taken every four to 12 hours, depending on the strength.  The active ingredient is called oxycodone and, being a narcotic, it is normally a prescription medication. 

  The second type of pain medication to have on hand following a tooth extraction is ibuprofen, around the 400mg strength, which one can normally take every eight hours.

  Paracetamol and codeine based pain killers can be taken according to directions, but wont likely help much with pain relief following a tooth extraction, if the pain is very great.

  Do not take aspirin pain relievers, unless the risk of bleeding has passed and you have stopped the ibuprofen.

Other Preparations to Make for a Tooth Extraction

In preparing for a tooth extraction, be aware that the above pain relievers may cause constipation and thereby play havoc withhemorrhoids, so taking some high fibre capsules, such as Metamucil, may be quite important, so have some of these ready to take as well.

Taking about three to five days off work following a tooth extraction is suggested due to the pain and discomfort following the extraction of a tooth.  So one may want to arrange this time off work beforehand.

Clean your teeth really well and have your mouth as hygienically clean as possible when the tooth is pulled.

 

Instruments for Tooth Extraction

Tooth extraction refers to removal of tooth from the socket. When an extraction has to be pain free then the right instruments have to be there. Extractions are recommended by the dentists for several reasons and one of the major ones is for tooth infection that is deep rooted. Tooth extraction may also be required for the braces treatment or may be required for giving dentures to the patient. In case of impacted infectious teeth also tooth extraction is required. There will be different instruments which will be used for tooth extraction. In case of simple tooth extraction, mainly forceps and elevators are used and in case of surgical tooth extraction, along with forceps and elevators, scalpels, dental drill, sutures are required.   

The main instruments that a dentist needs in times of an extraction are the Forceps and Elevators.

Tooth extraction forceps

Tooth Extraction Forceps are primary instruments to remove the tooth from the socket. The main function of forceps is expansion of the bony socket by the wedge shaped beaks of the forceps and movement of tooth with the forceps. Forceps are also used to pull out the tooth from the socket.

Maxillary Extraction Forceps

Forceps look like tweezers and have a firm grip which allows the dentist to exert sufficient force. The forceps allow the tooth to be held firmly and yet the dentist will be able to move it back and forth before it is plugged out.

Mandibuar Extraction Forceps

The tooth needs to be pulled out from the roots and for that the forceps are just the rightly designed instruments. They can also maneuver themselves into any part of the mouth in the most effortless of ways. If the dentist wants to perform a non-surgical simple tooth extraction or closed or intraalveolar tooth extraction then they will certainly need forceps.

Dental Elevators

In case of teeth that are deeply entrenched and embedded in the gums then the use of the forceps is just not enough. In that case what is needed are Dental Elevator tools that need to be used along with the forceps. Dental Elevator tools can act as levers and these are put between the tissues and in between the teeth. Elevators are used for luxation of teeth. Elevators are frequently used to mobilize the teeth.

Elevator tools look just like tiny screwdrivers. They are of three different kinds of elevators. They are straight elevators, apexo elevators and cryers.

                

Cryer’s elevatorStraight                            Hockey stick and Apexo elevators

The main function of dental elevators is to luxate multirooted teeth prior to forceps application. They are used to luxate and remove the teeth which can’t be engaged by the beaks of the forceps like the impacted teeth, malposed teeth or badly carious teeth. Dental elevators can also be used to remove fractured root stumps or apical tooth tips.

Scalpels for incision in case of Surgical Tooth Extraction

In case of surgical tooth extraction which is also known as open tooth extraction, apart from dental elevators and forceps, instruments are required for giving incision and bone cutting. In case of surgical tooth extraction, tooth is damaged to such an extent that nothing is visible above the gums.  For giving incision that is for making cut on the soft tissues, scalpel is used. Scalpel is used to cut directly through gum tissue down to the bone. Scalpel has 2 parts that are blade and blade handle. After giving the incision, flap is raised to expose the tooth.

Chisel and osteotomes for cutting or splitting bone in Surgical Tooth Extraction

Chisels are unibevelled instruments for cutting the bone and osteotomes are bibevelled instruments which split the bone. Chisels are used to remove chips of bone in case of surgical tooth extractions and to split the tooth in difficult tooth extractions.  

Mallet

It is made of steel, lead or wood and is similar to a hammer. It is used for giving controlled taps on the chisel or osteotome.

Dental drill and burs for splitting tooth and bone cutting

It is a quicker method of bone removal by drilling the bone at high speed. Burs are rotary instruments that cut the bone. They are made of either stainless steel or carbide. They are available in different lengths, shapes and sizes. They aid in bone removal or splitting the tooth during surgical removal of teeth. Hand piece and burs can also be used to round off the sharp margins after tooth extraction. Irrigation should be done during drilling with copious amount of saline solution. There should be as less damage to the alveolar bone during the surgical tooth extraction as possible.  

Rongeur Forceps, Bone file, Bone cutter

Bone file and Rongeur Forceps

Rongeur Forceps are used to nibble sharp bony margins after simple or surgical tooth extraction. Rongeur forceps have curved handles and have spring action. Bone file as the name suggests is used to smoothen any bony margins present in the surgical field. Bone cutter is similar to Rongeur forceps and is used to trim sharp bony margins after tooth extraction. 

Sutures or stitches after tooth extraction procedure

Stitches are given to approximate the margins. The two basic types of suture materials are resorbable suture material which the body is capable of breaking down easily and the non-resorbable sutures. Resorbable suture material includes gut, polyglycolic acid and copolymer of glycolic and lactic acid.

Non-resorbable suture material includes silk, nylon, polyester and polypropylene sutures. Non-resorbable sutures can be monofilamentous, multifilamentous or can be both.  

Apart from sutures, needle holder, tissue holding forceps and suture cutting scissors are also used to suture the tissues. Needle holder is a straight instrument with short working tip. Tissue holding forceps can be plain or toothed and are used to hold the tissues during the process of dissection or during suturing. Suture cutting scissors are used for cutting the suture ends and they may be straight or curved and angulated or nonangulated.

 

The tooth extraction:

You are now laying down on the dentist chair, mouth wide open, wondering how the dentist is going to get the tooth extracted.  Assuming nothing goes wrong with the tooth extraction, the likely procedure will be:

1..The dentist rubs a cotton bud soaked in anesthetic round the tooth to be extracted.  Front and back of the tooth.

2.. After a very little wait, he then starts a series of anesthetic injections around the tooth to be extracted.  A little bit of pain may be experienced with each injection.

3… After a slightly longer wait, another series of deeper anesthetic injections around the tooth to be extracted and if there is a tooth abscess, an injection will likely be placed into the abscess – an extremely painful injection for the most part.  I nearly flew through the roof.

4..If the dentist is caring, there may occur a minor wait, followed by another few deep anesthetic injections – the area is numb, so NO pain is likely to be felt.

5.. A small wait, then the dentist starts to peel down the gum from the tooth to be extracted, so that no flesh is left attached to the tooth – prevents the flesh being torn from the tooth when the tooth is extracted.

6.. The dentist uses a pair of purpose built pliers to grip the tooth to be extracted, then starts rotating the tooth in a figure 8 pattern.  The figure 8 pattern is repeated several times until the dentist feels the tooth will come out.

7.. The dentist then pulls the tooth out and the tooth extraction as such is over.

8.. The dentist will then clean up the area, squeeze the area hard to remove any puss, push the loose gum tissue into the hole that’s left and possibly crush the tooth socket to promote a firmer area – to encourage good healing.

9…  The dentist will place a wet cotton gauze, rolled up, across the hole left by the tooth being extracted, asking you to bite down on it hard for the next 30 minutes, so as to encourage a solid blood clot to form.  Being wet beforehand, the cotton gauze should leave the blood clot intact in the hole when the gauze is lifted out at home by your self.

A dental surgeon uses special forceps to pull out a tooth (A). In its place, a blood clot forms (B), which becomes new bone with gum tissue over the top (C). If the blood clot does not form or falls out, a dry socket occurs (D). No new bone forms, and the nerves are exposed, causing pain.

What To Do After The Tooth Extraction:

Tooth Extraction Care and Aftercare

The care and aftercare of a tooth extraction entails following the five suggestions below:

1.. DO NOT rinse your mouth out for 24 hours following a tooth extraction – doing so may cause the blood clot, that is sealing the hole and allowing healing to take place, to come away.

2.. NO SMOKING FOR 2 DAYS following the tooth extraction.  Some dental associations recommend no smoking for two weeks.

3.. Only warm, soft foods and drinks to be taken, and kept as far from the extraction hole as possible – Definitely no swishing in the mouth, as the blood clot may be removed or a piece of food may enter the hole and become lodged in causing much pain. After 7 days, you caormally return to a normal diet.

4.. The day following the tooth extraction and for at least the next 5 days, stir a teaspoon of salt into 250 ml – a glass – of warm water until dissolved.  Rinse the mouth GENTLY with the salt water and give the salt water a little time to be soaking the tooth extraction point.  Use after eating or drinking anything, as it keeps the extraction wound clean and the salt helps to keep the area sterile from germs.  Use the salt rinse every night before bed as well.

5.. Resume good teeth cleaning practices from about day 2 following the tooth extraction, but be careful near the extraction site.

Do’s And Don’ts After Tooth Extraction

Tooth extraction refers to painless removal of tooth or tooth roots with minimum trauma to the surrounding tissues so that the extraction socket wound heals uneventfully without any post-operative complications. Whenever any surgery  or Tooth extraction takes place the first thing we want is to let it heal properly ,quickly and smoothly. As a common practice, most of the dental surgeons have standard post surgery instructions printed which are handed over to the patient. One must follow these instructions given by the dentist. Apart from those instructions there are few things which need to be taken care post tooth extraction. Following all the post-operative instructions after tooth extraction reduces the incidence of infection and chances of dry socket after tooth extraction. If aftercare instructions are not followed after tooth extraction, then it can cause dry socket which can further lead to delayed healing of the tooth extraction socket. So patient is advised to follow certain do’s and don’ts after tooth extarction procedure.  

Try to take some rest after Tooth Extraction. You may feel great but don’t exercise at least for a day after tooth extraction.When taking rest,keep your head lifted on a pillow.

Let the clot be formed on the tooth extraction site

, which covers it and allow it to heal. Bite on the gauze piece after tooth extraction, which the dentist has put on the extraction socket,  minimum for an hour. Don’t chew on that gauze piece but put a steady pressure. This will help in stopping the bleeding and formation of clot  which acts like a cork on the bottle. Change gauze after every half an hour depending on the amount of bleeding. If clot is dislodged,the nerve endings are exposed,nerves and capillaries spasm and constrict,limiting essential blood supply which causes delay in healing. If the bleeding doesn’t stop one should try putting a wet tea bag in the site, as tannic acid present in black tea helps  stop bleeding.

Ice Packs

: Apply ice pack on the side where surgery was performed. All this is done to reduce swelling. Though on simple extractions, swelling isn’t accompanied but in cases requiring severe cheek retractions, swelling can occur after operation. Though the swelling will not occur immediately but will reach maximum at 2^nd or 3^rd day. So, to minimize this swelling immediately apply ice packs. Various methods of applying ice packs are:

• Sealed plastic bags filled with ice or

• A bag of frozen peas or

• Corn wrapped in a washcloth

Application of ice pack is most effective during the day of extraction as after 24 hours there is no significant beneficial effect. Ice packs should be applied 15 minutes on and 15 minutes off for 1-2 hours.

Blowing and sneezing: Make sure not to blow or sneeze after extraction as it creates a negative pressure thereby dislodging the clot and making the conditions favorable for dry socket.

Don’t spit minimum for 24 hours after tooth extraction because it can dislodge the clot. If the clot is dislodged you can have very painful condition known as dry socket. In case of dry socket, physiologic clot is lose both in quantity and quality. Afterwards one should spit 3-4 times in a day so that no food is lodged near the area where the tooth is removed. Dentist may advice CHLOROHEXIDINE mouth rinses as they kill bacteria.

Anesthetic feeling:

It shouldn’t be a matter of worry if you feel numb even after surgery, as the period of numbness depends upon the area and dosage where anesthesia was given. So, it may vary for 6 hours to as long as a day. Make sure not to chew or bite something from that area.

Nausea: Feeling of nausea is also common after extraction. There are situations when anything you eat goes out. To get rid of nausea, take a teaspoon of Jell-O mix and 4 ounces of water, every minute until the feeling is gone. Two tablespoons every hour for 4 hours of coca cola syrup can also be taken. These methods will give you necessary sugar and fluids. After this soup can be taken.

Don’t smoke for 48 hours after tooth extraction as the chemicals in the smoke can effect the clot and hence the chances of developing dry socket 3-4 days after tooth extraction increases.

Don’t take solids immediately after Tooth Extraction till the numbness

is there. When you start feeling your jaws you can start taking solids. After tooth extraction, take soft and liquid foods like soups, mashed potatoes, yogurts, milkshakes, smoothies etc.

Warm saline rinses:

The main aim of rinsing is to clean the area of extraction as it is not possible to brush the socket. We mix salt to make the solution isotonic and similar to natural tissue fluid and thus it is less irritating than water. Rinsing is usually advised 12 hours after extraction. So, warm saline rinses help in cleaning and maintaining the hygiene of that area.

Take your medicines as prescribed by your dentist. Don’t skip the medicines. If antibiotics are given they should be taken regularly. Pain killers and anti-inflammatory drugs are to be taken after tooth extraction. It help in reducing the pain and swelling. If the pain continues even after two days of tooth extraction and bleeding starts then you should call your dentist.

Avoid Aspirin:

Don’t ever take aspirin (Can take ibuprofen). Aspiring being a blood thinner will delay in clot formation thereby will prevent healing. Take the medications as prescribed by the physician and consult your dentist before taking any medicine.

Avoid Sucking of any type –  SMOKING, SIPPING, EATING HARD VEGETABLES are to be avoided after tooth extraction. Try taking soft and liquid food options such as soups, mashed potatoes, yogurts, milkshakes, smoothies etc. after tooth extraction.Avoid hot drinks, spicy foods, sodas, etc.

 

If you are daring enough to avoid these instructions, you may be a strong contender for some complications.

Don’t poke into the gap created: Though for initial few days, it will feel a bit awkward to have a gap but don’t poke that area with any toothpick or tongue as it may delay healing, may provoke bleeding and can also lead to dry socket. 

 

 

Tooth extraction refers to painless removal of tooth or tooth roots with minimum trauma to the surrounding tissues so that the extraction socket wound heals uneventfully without any post-operative complications. Whenever any surgery  or Tooth extraction takes place the first thing we want is to let it heal properly, quickly and smoothly. As a common practice, most of the dental surgeons have standard post surgery instructions printed which are handed over to the patient. One must follow these instructions given by the dentist. Apart from those instructions there are few things which need to be taken care post tooth extraction. Following all the post-operative instructions after tooth extraction reduces the incidence of infection and chances of dry socket after tooth extraction. If aftercare instructions are not followed after tooth extraction, then it can cause dry socket which can further lead to delayed healing of the tooth extraction socket. So patient is advised to follow certain do’s and don’ts after tooth extarction procedure.  

WHAT COMPLICATIONS CAN BE THERE AFTER TOOTH EXTRACTION?

1.     Bleeding

2.     Infection

3.     Dry socket

4.     Jaw fracture

5.     Sinus perforation

6.     Broken Bone Fragments (Sequestrii)

7.     Part of the Tooth Left (Retained Roots)

8.     Osteonecrosis

Bleeding After Tooth Extraction: If one follows the instructions of the dentist after Tooth extraction to take rest and to keep the gauze piece for 1 to 2 hours after extraction then the problem of bleeding is not there. The patients who are taking anticoagulants like Heparin or Coumadin or the patients who have bleeding disorders like hemophilia should give the history to the dentist. The patients who are taking aspirin or nonsteroidal analgesics have increased bleeding time.

Infection after Tooth Extraction:  Infection is the most common complication after tooth extraction. Our mouth Is full of bacteria. One cannot sterilize it. Dentist decides whether to give antibiotics after the tooth extraction or not. Normally for the simple tooth extractions antibiotics are not required but if patient has pain and swelling or pus then it is better to go for preventive antibiotics.  Bleeding continuing after 48 hours after tooth extraction, acute pain and swelling are very common signs  of infection after the tooth extraction and the patient must visit the dentist in such circumstances to avoid further complications after tooth extraction.

Dry Socket:  It is the most dreaded and painful condition which can happen after tooth extraction. For a day or two after dental extraction the patient is fine, and then he has acute pain and becomes very restless. Patient complains of bad taste in the mouth. It is more common after the dental extraction of lower teeth than the upper teeth. It can happen even after the simplest tooth extraction.

 

Healing of Extraction socket after Tooth Extraction

Jaw Fracture during Tooth Extraction: It can happen but very rarely and that too in lower jaw. The dentist who is doing the tooth extractions knows that how much pressure has to be put to pull out the tooth. But sometimes dentist before doing the extraction see the x-ray and tell the patient that the bone structure around the tooth has become fragile and chances of fracture are there. In such cases patient and the dentist are prepared beforehand to manage the situation.

Sinus Perforation during Tooth Extraction: The back teeth are in close proximation with the sinus. Sometimes if you see the x-ray it looks as if the roots of the back teeth are virtually in the sinus. It never happens. There is always a thin bone separating the sinus from the roots of the teeth. But sometimes during tooth extraction the piece of the bone comes along with the sinus. This normally happens when the tooth is close to the bone because of infection. In that case perforation occurs. If perforation occurs you cannot suck because in that case the air will rush from the nose to the sinus and through perforation to the mouth. If the perforation is small the patient complains of bleeding from nose. If the perforation occurs then the patient should follow certain instruction like:

1.     Do not suck anything till the tooth extraction socket heals.

2.     Do not do anything which will dislodge the clot. If the clot is not disturbed then no complication arises.

3.     Do not smoke at least for a week after tooth extraction because the chemicals in the smoke either dissolve the clot or dislodge it.

4.     Do not blow up the balloons or anything else, it will disturb the clot..

5.     Avoid aerated drinks instead you can take fruit juices.

6.     Don’t sneeze, it sneezing will surely dislodge the clot.

If the perforation is big and it does not heal by itself then another surgical procedure is carried out in which tissue graft is put to close the perforation.

Osteonecrosis: It is a rare dental condition which mostly occurs after dental extraction, implant surgery or other invasive dental procedure.

 

 

There is no sign of healing even after 8 weeks of dental treatment in case of osteonecrosis of jaw. The gums are worn away and the underlying bone is visible in this condition. It is mostly seen in cancer patients.

Complications During and After a Tooth Extraction:

Tooth Extraction Complications

1… Something goes wrong with the tooth extraction – the tooth may break up, which means the tooth extraction may take much longer to perform, as the dentist has to get it all out.  This complication may also mean more pain and swelling, as the area may become more damaged at the extraction site.

2.. Infection following a tooth extraction is a rare complication, but can occur.  The value of antibiotics perhaps should be sought if pain increases over the healing period, or if puss becomes noticed.  Obviously, if more than the root area was infected at the the time of the tooth extraction, then antibiotics should perhaps be prescribed by the dentist before you leave the dental surgery.

3.. Swelling may continue to increase for two days following a tooth extraction, but should start to reduce by day 5.  Ice packs can be used to help reduce swelling – 20 minutes on the cheek area next to the extraction site, followed by ten minutes off, then repeat.  Also, the swelling may cause trouble in opening your mouth, so when the swelling reduces, your mouth should work better as well. On another note, some bruising may appear as the swelling recedes.

4.  Pain and discomfort when trying to sleep.  Sleeping with head face upward helps to relieve pressure on the jaw, using two pillows may help also.  Certainly try and avoid laying down on the area of the tooth extraction site – to avoid pain and discomfort.

5… I personally found that I had heaps of referent pain going into the tooth above the extraction tooth, so when I clamped down for half an hour to keep the gauze in place on the extraction site, it turned very quickly into a living nightmare.

  The pain became intolerable from the tooth above the extracted tooth site – all I could do was walk hard up and down the hallway at home – yelling, screaming and crying from the intense agonizing pain.

  When the 30 minutes was up and I got the gauze out, the pain persisted at that level for hours.

  Eventually the morphine based pill kicked in and I remember going quiet sitting in the sun with the sun on my cheek, still in pain, I climbed onto the bed and went to sleep.  When I woke up the pain was all but gone, but once the pain medication wore off the pain returned. 

As the days progressed, the pain got less – I stopped the morphine based pills, but the ibuprofen, being 8 hourly, didn’t quite cover me for those eight hours, but definitely feeling much better and in much less pain.

Another item that really helped me with the discomfort of the pain, was using a hot water bottle filled with hot, but NOT burning water.  I placed this over the cheek of the tooth extraction site and found relief could be gotten that way quite well.  I used that hot water bottle whenever the pain killers didn’t work starting from day 2 and, whenever I had trouble going to sleep because of the pain and so on.

6… It is possible that when the tooth is extracted that it may affect the alignment of the teeth in some people, in which case the teeth will tend to hit in certain areas of the mouth rather than uniformly across all the remaining molars.  If this happens, further dental work will likely be needed to correct the problem, as if the teeth are left out of alignment, it is possible that the teeth that are taking the brunt of the force of the jaw will crack or splinter, cause pain, bruxism behavior – teeth grinding – cause pain in the jaw sockets and so on.

However, misalignment of teeth can be common in the first five days following extraction of teeth, as any swelling may cause some teeth to sit proud – be slightly elevated – causing them to hit the teeth above or below them when biting.

7… Following my tooth extraction, I also came down with an ear ache, which is also a common side effect of a tooth extraction.

8.. A little bleeding following a tooth extraction is common for the first day.  If bleeding following a tooth extraction continues or gets heavier:

a. Rinse gently around the extraction site with cold water and

b. With clean hands and clean gauze or hanky, place the gauze in a roll and place over the tooth extraction site the same way the dentist did it and

c.  Bite down gently for 60 minutes, with your head slightly elevated and rest.

If, after this, the bleeding persists or is severe contact your dentist straight away.  If dentist unavailable, try your hospital’s emergency department.

9… A dry socket following a tooth extraction is a common complaint afflicting about 5% of people who have a tooth extracted. The tooth extraction dry socket, is where the blood clot that seals the extraction site comes away and is not replaced by another blood clot.  The bone and nerves are exposed to air and anything else that may be in the mouth, thus causing pain and sometimes a foul odor as well.  A dry socket normally clears up in about 5 to 7 days.

  Following the “Tooth Extraction Care and Aftercare” section above, should minimize the risk of developing a dry socket following a tooth extraction.

10… Other teeth may become damaged, chipped or loosened during the extraction of a tooth or teeth, sometimes requiring more dental work.

11… If a top tooth, upper tooth was extracted, then a hole may have been made into one of the sinus areas.  It will normally heal quickly of it’s own accord, if it doesn’t, you may need to go back to the dentist.

The Long Term Complications of a Tooth Extraction:

Long Term Problems from extracting a tooth: Other teeth may tilt into where the tooth was extracted from, thereby making eating difficult and teeth that tilt to fill the gap are at greater risk of tooth decay.  The tilt is normally forwards.  That is to say, for example, the tooth further back in the mouth next to the tooth that was extracted, will likely tilt into the gap somewhat.

  Further, the cosmetic appearance of the mouth may be adversely affected by the extraction of teeth, particularly if the front teeth are involved. 

If it was a molar that was removed, chewing food may be difficult to achieve, particularly if it was a large molar that made up a large section of the chewing area.

  Further, when chewing food that is hard, like bread crust or an apple, pieces can be pushed down into the extraction socket by the tooth opposing it, causing pain.

  Your dentist may suggest that as the tooth has no opposing tooth to bite against, that removing  that opposing tooth could be considered.  This is because the tooth has nothing to bite against and is therefore useless.  However, without an opposing tooth, the tooth above or below the extraction socket will, over some years, like ten years, move out of it’s socket more and more, likely exposing it’s roots and becoming sensitive to variations in temperature and so on.  A tooth relies on it’s opposing biting tooth to keep it firmly in place.

Another of the long term problems is thinning of the jaw bone, particularly when several teeth have been extracted – when the side of the extraction site is not chewed on as much, if at all, for example, then bone loss from the extraction area can become significant over time, making it more easier to break.

If a nerve is damaged during a tooth extraction, it will likely heal in several weeks to a couple of years, sometimes the nerve will never fully recover.  Symptoms can include loss of feeling – numbness – and tingling in any of the parts of the mouth, including the tongue.

 

Tooth Extraction Healing + Warning

Tooth extraction healing takes only about five to seven days to be mostly complete.  After seven days the healing is good enough to eat the harder foods without causing pain.  Healing following a tooth extraction is rapid because the inside of the mouth is designed to heal quickly.  When my tooth came out the pain was so great I was skeptical that I would heal so quickly, but it did.  Healing can be delayed by smoking, so for a faster healing, try giving up the cigarettes.  The gum area should be fully healed in three to four weeks following a tooth extraction.  If the jaw was damaged during the tooth extraction, then it may take up to six months for full healing to take place.

WARNING:  If you are taking an osteoperosis medication, such as Fosamax, try and save the tooth if you can.  Some of these medications firmly attach the tooth and bone together and may also hinder the bone recovering from a tooth extraction – meaning you may be in pain for a lot longer thaormal.  Check it out with your dentist, prior to the tooth extraction.

Complications After Tooth Extraction

Complications may occur after tooth extraction procedure. Some complications after tooth extraction are common and some are not that common. Extraction is painless removal of tooth or tooth roots with minimum trauma to the surrounding tissues so that the extraction socket wound heals uneventfully without any post-operative complications.  Tooth extraction complication symptoms are prolonged pain; swelling, bleeding, bruising, limited mouth opening and many others.  Various Tooth extraction complications are discussed in detail in this article.

Pain as Complication after Tooth Extraction

It is the most common complication which occurs after the tooth extraction procedure. After the tooth removal, there is bound to be some kind of discomfort and pain.  The pain and soreness may last for few days after tooth extraction.  Painkillers are given by the dentist to control the pain. Pain meds such as Ibuprofen, Tylenol, Paracetamol, Solpadeine or Nurofen Plus can be used to control the pain.  The painkillers which are prescribed by the dentist are dependent on the medical history of the patient and the effortlessness with which the tooth was extracted.

Swelling as Complication after Tooth Extraction

Swelling after tooth extraction

Swelling is other common complication after tooth extraction. Swelling after tooth extraction procedure is a normal body reaction and is indicator of normal progress of healing of tooth extraction socket. If swelling persists beyond 1week, then the patient needs to visit the dentist.  After extensive surgical interference, simple inflammatory edema appears in adjacent tissues in most of the cases. This is unavoidable and is generally commensurate with the degree of surgical trauma. Swelling usually occurs after the tooth removal.  The swelling can be there for as long as few weeks.  The swelling can be treated by using an ice-pack or by pressing a bag of frozen peas against the cheek near the tooth which is removed. This will help to lessen the swelling.  Alcohol, hot foods and drinks and work out immediately after the tooth extraction can aggravate the swelling. Warm saline rinses and hot moist compresses 1-2 days after tooth extraction will further help in reducing the swelling.

Bleeding as Complication after Tooth Extraction

Bleeding after Tooth Extraction

Bleeding is other common tooth extraction complication. Slight oozing of blood may occur for up to 24 hours after the tooth extraction. It is considered as normal. If the bleeding is continuing after tooth extraction, then the patient can put a piece of gauze pad on the bleeding socket area with equal pressure without irritating the socket.

 Gauze pack to stop bleeding

Biting on tea bags may also stop the bleeding. If there is prolonged oozing of blood even after 24 hours or incases of heavy bleeding after 1-2 hours after the tooth extraction, dentist should be consulted.

Bruising Complication after Tooth Extraction

There are some people who are more likely to bruise than others after tooth extraction. These are usually older people, people on aspirin or steroids as they tend to bruise much more easily. Intermittent ice packs should be given for the first 24 hours after the tooth extraction procedure followed with intermittent hot moist packs. It is not a gangrenous process and discoloration is due to bleeding into the tissues. Accumulation of red blood cells and subsequent break down of hemoglobin causes discoloration. The bruising can look quite prominent and might take weeks to disappear in some cases.

Limited Mouth Opening which is called as Trismus after Tooth Extraction

 This is the normal mouth opening but in Trismus, there is inability to open mouth normally

Many a time’s the chewing muscles and the jaw joints are so sore after the tooth extraction that it becomes really difficult to open the mouth. This can happen for a few days after the extraction.

In case the patient gets an infection after the tooth extraction in the tooth socket then he will not be able to open his mouth for a much longer period say as much as a week. Although Pain is the most common tooth extraction complication, trismus can become one of the more chronic and complicated problems to manage. 

Post-operative infection Complication after Tooth Extraction

A person might also develop an infection in the socket after the surgical extraction of the tooth. This usually happens about 2 – 4 days afterwards and one knows of it from the deep-seated throbbing pain, the bad breath that the person emits and the perpetual unpleasant taste left behind in the mouth. Dry socket is a painful tooth extraction complication.  This kind of an infection is more bound to happen if a person smokes, use Contraceptive Pills or are on drugs such as steroids or if the bone cutting is done during the tooth extraction.

Secondary infection that is infection several days after tooth extraction may occur. It mostly occurs after surgical removal of wisdom tooth. The patient will have fever, abnormal swelling, pain or a salty or prolonged bad taste with or without discharge from the surgical site as post tooth extraction complication symptoms in case of secondary infection . To avoid this, patient has to maintain good oral hygiene and should avoid smoking and drinking alcohol. To treat infections, antibiotics are given by the patient.

Reaction to medications given after Tooth Extraction Procedure

The pain meds and antibiotics which are given after tooth extraction may have side effects. A patient may experience nausea, vomiting, drowsiness from the medicines which are provided. Patient can consult his dentist in such cases and can tell him to change his medicines.

Numbness / Tingling /Burning sensation after Tooth Extraction

Numbness and tingling sensation occurs when the nerve is damaged or is injured during the tooth extraction. Nerves are responsible for sensation in the tongue and lips and may get affected while giving the anesthesia.  The nerves may get squashed, bruised or stretched which could result iumbness.

This kind of nerve bruising is usually not permanent but in the rarest of rare cases it might be permanent as well. The temporary phase might go on for a long time and may last from several days to several months. No one can actually say how long the nerve will take to get rid of the nerve bruising and come back to its normal mode of functioning.

Bony Flakes Complication after Tooth Extraction

Sometimes, bony flakes also known as sequestra result from the sockets of the extracted teeth and the patient can feel the roughness with the tongue in the socket area. They may cause soreness and will interfere with the healing after tooth extraction. They need to be smoothened by the dentist. At times, the gums heal on their own whereas some times it becomes imperative to smoothen the underlying bone for healing to take place. 

Bleeding into Cheeks after Tooth Extraction

Bleeding into the cheeks can result in swelling after tooth extraction which may be hard to feel.  This could also go on to result in a difficulty in being able to open the mouth and also result in bruising at that particular spot.  The swelling, bruising and mouth opening will all get better with time and come back to normal.

Periodontal damage Complication after Tooth Extraction

Periodontal damage may occur after tooth extraction. Periodontal pocket may occur after wisdom tooth extraction if the tooth is deeply impacted and there is no bone between second and third molars. To treat periodontal pocket, scaling and root planning is done. Gum surgery may be required to treat it. Gum tissue may be deteriorated after tooth extraction.

Ludwig’s Angina Complication after Tooth Extraction

It is a rapidly spreading infection of floor of mouth and is life threatening. Fascial spaces are affected in this. Difficulty in breathing, difficulty in mouth opening, swelling and severe pain is Ludwig’s angina complication symptoms.  Though it is extremely rare but one still needs to take extreme care if one gets infected by Ludwig’s angina.

Osteonecrosis Complication after Tooth Extraction

 It is a rare dental condition which may occur after tooth extraction or other invasive procedure.  In this condition, there is no sign of healing even after 8weeks of dental extraction. The gums are worn away in this condition and underlying bone is visible. This condition is mostly seen in cancer patients.

Osteomyelitis Complication after Tooth Extraction

It is a rare Tooth extraction complication. Osteomyelitis may occur after tooth extraction. There is inflammation of bone and bone marrow in this condition.  In case of acute osteomyelitis, there is severe throbbing deep seated pain present along with swelling. The teeth may be loose and pus may extrude from the socket.  Fever and enlargement of lymph nodes may be present. In case of chronic osteomyelitis, there may be fistula and sinus tract formation on skin and mucosa.

Post extraction Granuloma Complication after Tooth Extraction

This complication happens four to five days after tooth extraction. The main reason for it to occur is a foreign body in the tooth socket that starts the infection and allows it to set in. This could be the result of e.g. amalgam remnants which is from the tooth filling, bone chips, small tooth pieces, calculus etc. The way this works is that the foreign bodies aggravate the area and this goes on to stop the post-extraction healing and suppuration of the wound happens.

It is treated with debridement of the socket and removal of any and every causative agent of the infection. This is the best and only way to go about it.

Temporomandibular joint (TMJ) dysfunction after Tooth Extraction

It may occur after wisdom tooth extraction. This tooth extraction complication is unusual and is temporary. To treat this condition, anti-inflammatory medicaments, heat therapy, rest and in some cases bite splint therapy is given.

Bleeding after Tooth Extraction

Bleeding refers to loss of blood or escape of blood which occurs from the circulatory system. Bleeding after tooth extraction procedure is normal. Gauze pack is given by the dentist after the tooth extraction to control the bleeding. The patient is instructed to bite on the gauze pad for 30-45 minutes after the tooth extraction procedure. 

Profuse Bleeding during Tooth Extraction Procedure

Excessive, profuse bleeding can occur during the extraction procedure if there is accidental tearing or cutting of the large artery or vein. Laceration of inferior alveolar artery or vein during attempted root removal can cause profuse bleeding.

The bleeding is also profuse in region of inflammation where the tissues are excessively hyperemic.

Profuse bleeding can occur during the extraction if there is injudicious use of suction apparatus or when the wound is wiped excessively which causes continual removal of blood clots.

Patients with high blood pressure and those with bleeding disorders bleed profusely after the tooth removal. That’s why in cases of elevated blood pressure and bleeding disorders, tooth extraction procedure is not performed.

Management of Bleeding after Tooth Extraction

Manual pressure on gauze pack placed over the area can be used by the dentist to arrest the bleeding. The gauze size should be small to just cover the extraction socket. The gauze which is used may be moistened so that the blood doesn’t coagulate in the gauze and blood clot is not dislodged when the clot is removed.

Gauze pack placed on tooth extraction site

If a large vessel is involved, then it can be clamped with a hemostat and is tied with resorbable stitches (3-0 cat gut sutures) If the bleeding is from bone, then absorbable haemostatic gauze or bone wax over the site of bleeding can be placed.

A small amount of blood is mixed with the saliva (Or spit).  So the patient should not freak out about the amount of blood loss he is having.

After the tooth extraction procedure, the patient is advised to firmly bite (not chew) on the gauze for at least 30mins. The gauze should be held in mouth for 30-45mins. The patient should not talk for a minimum of 2-3 hrs after the tooth extraction.

Slight oozing of blood may occur up to 24hrs after the extraction. It is considered to be normal. There might be some oozing of the blood at night from the extraction site and the patient may have blood stains on pillow after the tooth extraction. There is nothing to be worried about it. The bleeding will stop on its own.

After the wisdom tooth removal, bleeding may occur up to 3 days. Bleeding and oozing of blood from the extraction site, 3 days after the wisdom tooth removal is considered as normal. However after 3 days, the bleeding should be very less or barely noticeable. 

Precautions to be taken when Bleeding is continuing

1. Till the bleeding is continuing, one should avoid vigorous rinsing of the mouth as it can dislodge the clot formed at the extraction site. Warm saline rinses 3-4 times a day, 24hrs after the extraction should be done which will fasten the healing process of the extraction socket. 

2. If the patient is bleeding more, then he can keep a piece of gauze at the tooth extraction site again and keep it there for a minimum of 30mins for bleeding to stop. The patient should gently bite on the gauze pad with equal pressure but should not irritate the extraction socket wound. Pressure application is done to control the bleeding.

3. To control the bleeding, patient can also bite on a tea bag for 30mins. The tea bag is moistened with water and is then folded in half and then patient can bite on that.  Tannic acid which is present in the tea will reduce the bleeding by constricting the blood vessels.

What to avoid so that the bleeding is not aggravated

1.    The patient should not smoke minimum for 48 hours after the extraction which can interfere with the healing. Smoking can further create negative pressure which can dislodge the clot and can further lead to dry socket.  

 

2.    Patient is also advised not to suck or spit too much which creates negative pressure and may cause mechanical irritation to thetooth extraction site and will cause blood to move out. The patient should not drink cold drink with straw after the tooth extraction.

3.    Patient is advised to take rest and not to do heavy exercises up to 24hrs after the extraction which can elevate the blood pressure and may even stimulate the bleeding. 

When to Consult Dental Surgeon for Bleeding after Tooth Extraction

1.   If the patient bleeds heavily after an hour or two, then the dentist or the oral surgeon needs to be consulted.  

2.   If there is prolonged oozing of the blood, bright red bleeding or in case of large clots at the tooth extraction site after 24hrs of extraction, then the dental surgeon should be consulted. The dental surgeon will take measures to stop the bleeding after re-examining the area.

In case of wisdom tooth extraction or in cases of surgical extraction, bleeding up to 3 days after the tooth extraction procedure is considered as normal. However after 3rd day, the quantum of bleeding should go down and should be very less and barely noticeable.

Steps taken by Dentist to Control the Bleeding

1.     The dental surgeon will first irrigate the area with isotonic saline solution and then the excessive clots are removed.

2.     The patient is then instructed to bite on the gauze pack until the general condition has been evaluated.

3.     Patient’s blood pressure and pulse rate is checked.

4.     After that, anesthesia is injected to the patient. Anesthetic solution with small amount of vasoconstrictor should be used. Larger amounts can temporarily stop the bleeding and may result in bleeding later on.

5.     Once anesthesia is obtained, the extraction wound is examined to determine the source of bleeding. It is examined by the dentist whether the bleeding is there from the gums, the bone or both.

Bleeding from the Bone after Tooth Extraction

If bleeding is from bone, it may be arrested by approximation of the gums over the socket. The socket may be packed with an absorbable material and sutures or stitches are tied over the pack. A large gauze pack is placed over it and held firmly between patient’s teeth for 15 to 30mins.

Thrombin can be applied over the area. It promotes formation of the clot to stop the bleeding. Collagen plug can also be used to control the bleeding.

Bleeding several days after Tooth Extraction

Bleeding which occurs several days after tooth extraction is known as secondary bleeding. It is due to infection of the wound which causes loss of clot and erosion of vessels in the granulation tissue. Before suturing or packing the socket in case of secondary hemorrhage, the extraction socket wound is examined carefully for any foreign body. Antibiotics may be given to the patient when the socket is packed.

Healing Of the Extraction Socket

After tooth extraction, recovery of the extraction socket starts immediately. Bleeding occurs in the socket and nourishes the tooth socket. To control the bleeding, simple pressure is applied by the gauze. It also helps in formation of blood clot in the socket. Blood clot promotes the healing process. After 1-2 days, the socket is filled by soft tissue. Growth of the bone surrounding the socket occurs later and the socket is filled completely.

Tooth Extraction Recovery

In cases of simple tooth extraction, recovery occurs in 7-10 days whereas in case of surgical extraction, it may take 3 weeks to 3 months for recovery to take place depending on the degree of damage to the dental tissues. In cases of simple extraction, healing after 7-10 days is good enough that a person can eat hard and crusted food without any pain or discomfort. Healing in the oral cavity is faster as compared to the skin because of rich blood supply of the area. If a cut is there on the skin, then it takes longer time to heal than a cut in the oral cavity.

Healing of the extraction socket

There are 5stages of healing of the extraction socket:

• Stage 1- Hematoma and clot formation

• Stage 2- Granulation tissue formation

• Stage 3- Replacement of granulation tissue by connective tissue

• Stage 4- Replacement of connective tissue by fibrillar coarse bone

• Stage 5- Replacement of immature fibrillar coarse bone by mature bone

Immediately after the extraction, bleeding occurs in the extraction socket and there is clot formation inside the socket. Clot refers to the thick, viscous, coagulated mass of blood. There is vasodilatation of blood vessels of periodontal ligament and migration of leucocytes in and around the clot. As the clot contracts, the gum tissue which is unsupported after the extraction, cover and place the clot at its position. The hours after the Tooth Extraction are critical, for if the blood clot is dislodged, the Tooth Extraction  recovery  may be greatly delayed and may be extremely painful.

Within a week, granulation tissue is seen around the clot and there is proliferation of cells around the socket. There is organization of clot and alveolar socket margins are resorbed.
Healing is the body’s response to injury in an attempt to restore normal structure and function.

Healing occurs by 2 ways:

1.     Healing by first intention (Primary union) and

2.     Healing by second intention (Secondary union)

In case of healing by primary intention, there is not much loss of cells and tissues. The ends of the flap will approximate in some time and the tooth extraction recovery will occur in some time whereas in case of healing by secondary intention, there is extensive loss of cells and tissues. The ends of the flap don’t approximate and the healing occurs from bottom to the top and from margins inwards. Healing by secondary intention is slow as compared to faster healing by primary intention.

Healed Extraction Socket

Complications in Tooth Extraction Recovery:

Dry socket:

It is a post-operative socket which lacks the physiological clot both in quality and quantity in which the blood clot disintegrates exposing an infected necrotic socket wall.  

The condition derives its name from the fact that after the clot is lost the socket has dry appearance because of exposed bone.

It is also called as Alveolitis sicca dolorosa, Alveolalgia, Alveolar osteitis, Post-operative osteitis, Localized acute alveolar osteomyelitis.

 It may occur due to frequent and forceful spitting after extraction, smoking or excessive traumatic extraction. Disintegration of clot may be due to infection of the wound. Bacterial enzymes hyaluronidase and fibrinolysin causes lysis of clot.

The bone of the socket becomes necrosed, grayish bone is seen from the socket and bad odor is present at the socket and pus is minimal or not at all.

For the treatment of dry socket, dressing of Zinc oxide Eugenol is placed in the socket and repeated after few days. Antibiotics and analgesics are not effective if used alone because of poor vascularity of the necrosed bone.

Fibrous healing of the Extraction wound:

Fibrous healing of an extraction wound is an uncommon complication, usually following a difficult, complicated or surgical extraction of a tooth. It is found commonly when there is loss of periosteum along with loss of labial, buccal and lingual cortical plates.

This loss of cortical periosteum causes improper healing and scar tissues are found at the site. These fibrous connective tissue may ossify a little or not at all.

For the treatment, excision of the lesion for the purpose of establishing a diagnosis will sometimes result iormal healing and subsequent bony repair of the fibrous defect.

The various factors which affect the healing or the recovery of Extraction socket are:

1.     Smoking

2.     Alcohol consumption

3.     Diet of the patient

4.     General health of the patient

5.     Genetic predisposition

6.     Age of the patient

7.     Use of birth control pills

8.     Infection

9.     Length of surgery

10. Antibiotic prophylaxis

11. Degree of difficulty of extraction

12. Expertise of the surgeon

13. Oral hygiene maintenance by the patient

14. Certain medicaments

Smoking: Smoking decreases extraction socket wound recovery. it decreases the  blood supply to that area and brings toxic products to the area. Due to negative pressure because of smoking, the clot may get dislodged and cause dry socket occurs. That is why it is advised to avoid smoking for few days after the tooth extraction.

Smoking after Tooth Extraction and Delayed Healing

Alcohol consumption: Alcohol causes delay in the healing process. Alcohol consumption should be avoided by the patient few days after the tooth removal.

Diet of the patient: Protein, vitamins and minerals deficiency slows down the healing process.

General health of the patient: In cases of patients with diabetes, anemia, ischemia etc, the healing of the extraction socket will take place slowly than a normal healthy person.

Age: Healing is faster in young but is normal in old age unless associated with diabetes or ischemia.

Use of birth control pills: If a woman is taking birth control pills and gets her tooth extracted, then the chances of dry socket are more due to high level of estrogens. Dry socket delays the healing process.

Infection: In cases of infection like that in dry socket, delayed secondary healing occurs and it takes longer time for healing than the normal extraction socket healing.

Length of the surgery: The longer the surgery is, the more is the irritation to the gums and the surrounding tissues and more will be the healing time. Extraction socket with tooth removed with very little trauma to the surrounding tissues.
 

Tooth Removed with Little Trauma to Soft Tissue

Expertise of the surgeon: The aim of the dentist should be to cause as little laceration of the gums as possible. There should be minimum of trauma to the gums during the tooth removal. More is the trauma, more will be the time taken by the socket to recover after tooth extraction.

Oral hygiene maintenance: After the tooth extraction, the socket area should be kept clean. If there are food deposits around the socket, it will take longer time to heal. It is advised to maintain a good oral hygiene after the tooth removal, eat from the other side of the socket and keep the socket clean.

Medicaments: Certain medicaments like corticosteroids delay the healing process of the socket.

To promote faster healing and to avoid any complications, the patient should follow the instructions given by the dentist or the oral surgeon. Pain and discomfort occurs when the mouth heals. Following the instructions given by the dentist is all that is needed. The dentist should be informed if there is excess of bleeding, swelling, or persistent and severe pain or there is any reaction of the medications given by the dentist. The dentist should schedule a follow up examination to ensure that the socket is healing properly.

Swelling after Tooth Extraction

Swelling after tooth extraction procedure is normal body reaction. It is a good sign and indicator of normal progress of healing of tooth extraction socket. The degree of swelling and duration of swelling after the tooth extraction procedure varies from person to person. The degree of swelling which occurs after tooth extraction is generally in direct proportion to the degree of surgical trauma to the tissues. If the gums and the surrounding tissues are lacerated and damaged to quite an extent, then the swelling will be more after tooth extraction procedure.

Swelling occurs more commonly in case of wisdom tooth extraction or in case of surgical tooth extraction.  Swelling is comparatively less in case of simple or closed tooth extraction procedures. Laceration of soft tissue, trauma to the bone, careless retraction of the flaps and irritation by fragmented bone are common causes of excessive swelling.  After 2days of tooth extraction procedure, the swelling reaches maximum. The post operative instructions of the dentist explain about the ways to reduce the swelling after tooth extraction.

Swelling occurs more commonly in case of wisdom tooth extraction or in case of surgical tooth extraction.  Swelling is comparatively less in case of simple or closed tooth extraction procedures. Laceration of soft tissue, trauma to the bone, careless retraction of the flaps and irritation by fragmented bone are common causes of excessive swelling.  After 2days of tooth extraction procedure, the swelling reaches maximum. The post operative instructions of the dentist explain about the ways to reduce the swelling after tooth extraction.

After How Long Will Tooth Extraction Swelling Will Subside

Swelling usually lasts for 4-6 days. Normally, the swelling subsides completely in 7days after the tooth extraction procedure.  If it doesn’t happen within this expected time, then one should call the dentist for check up.

In some cases, swelling goes away initially and then sets in again. This occurs if there is infection tooth extraction socket wound.

Persistent post extraction swelling or development of swelling several days after tooth extraction surgery is usually due to infections. Swelling due to infections can be distinguished from post-operative swelling by:

1.     There is increased skin temperature in case of swelling due to infections.

2.     Greater redness of the overlying tissues occurs in them.

3.     Patient may be suffering from fever in case of infections

In case of swelling which occurs due to infections, external hot moist packs are given for 30 minutes every hour. The patient should do warm isotonic saline mouth rinses every 3-4 hours. Antibiotics are given to treat the infection. If pus develops due to infection, then the area is incised and is drained.

Steps to Control the Swelling after Tooth Extraction

1. Application of cold to the operated site decreases the amount of swelling which is present after the tooth extraction procedure. Cold acts by producing vasoconstriction (narrowing of blood vessels) and thereby reduces the exudation (oozing out) of blood and fluid into the tissue spaces. Cold application should be done intermittently as prolonged use of cold after tooth extraction procedure to reduce the swelling can cause compensatory vasodilatation. Cold application is to be done for 20 minutes and then break is taken for other 20mins. It is to be done for one hour within 12 hours of surgery.  During the first 36 hours, heat application should not be done. Ice can be placed in a rubber bag and can be applied.  If a rubber ice bag is not available, then ice can be placed in plastic bag. Cold can be applied intraorally by holding an ice cube in the mouth. Patient should keep the head elevated for first 12-24 hours after the tooth extraction surgery.

2. To limit the swelling after tooth extraction procedure, pressure dressings can also be given.

     a)  If the swelling is present in the front of the mouth, then folded gauze pads are placed on the outside of the lip and the gauze pad is held in position by crossed strips of adhesive tape or Elastoplasts.

     b)  If swelling is present in the back of the mouth after tooth extraction, then fluffed gauze can be placed on the face over the swelling and is held with an elastic bandage.

3. The swelling reaches its maximum in usually 1-2 days after tooth extraction. Cold application at this stage is not effective. Heat in the form of moist compresses should be applied after 1-2 days of tooth extraction. It causes vasodilatation and increases the circulation. More rapid removal of tissue break down products occurs by this. Heat in the form of moist compresses should be used for only 30minutes per hour. To avoid burning of skin, it should be lubricated with petroleum jelly. Intraoral heat is achieved by the use of hot isotonic saline rinses.

4. Many enzymes and hormone preparations are available commercially which have been suggested to treat the post-operative swelling. They should not be used routinely. The enzymes don’t prevent swelling but will redistribute the fluid over a wider area by breaking down the connective tissue and fibrin barriers. They may even allow spread of infection.

5. Corticosteroid hormones can reduce the swelling when they are used in high dosages. But they have many adverse side effects and should not be used after minor or simple tooth extractions.     

What to Avoid So That Swelling is Not Aggravated After Tooth Extraction

1. Do not disturb the extraction socket wound too much.

2. Patient should not smoke minimum for 48 hours after the tooth extraction.

3. Patient should not suck or spit too much or drink cold drinks with straw after tooth extraction procedure as it can dislodge the clot by creating negative pressure. The healing process is delayed which further leads to more swelling. 

4. Patient should take a diet of liquids and soft foods for the first 24 to 48 hours after tooth extraction. Puddings, yogurt, mashed potato, soups; smoothies can be taken by the patient. 

 

What is Dry Socket

The most common and painful complication in the healing of human extraction wounds is called as Dry socket. Dry socket is also called as Alveolar osteitis, Alveolitis sicca dolorosa, Alveolalgia, Post-operative osteitis or localized acute alveolar osteomyelitis.

Dry socket is a post-operative socket which lacks the physiological clot both in quality and quantity in which the blood clot disintegrates exposing an infected necrotic socket wall. It is known as dry socket as after the clot is lost, the socket has dry appearance because of exposed bone. The blood clot helps in stopping the bleeding and lays framework for new tissues to develop there but in case of dry socket, the clot is dislodged and the bone is exposed. This bare bone is exposed to bacteria in the saliva and the food which the patient consumes and the bone becomes infected and painful.

Initially, the clot has dirty grey appearance, and then it disintegrates, ultimately leaving a gray or grayish yellow bony socket bare of granulation tissue. When first seen, the socket may not be always completely empty and it may contain a partially necrotic blood clot.

The diagnosis of Dry Socket is confirmed by gently passing a small probe into the extraction wound. In case of dry socket, bare bone is encountered which is extremely sensitive.   

Causes of Dry Socket

Cause of dry socket is variably ascribed to:

1.     Pre-existing infection

2.     Trauma to the bone during the extraction

3.     Infection entering the socket after the tooth has been removed

4.     Loss of blood clot due to rinsing the mouth or sucking the wound or by smoking or by drinking any cold drink with straw which creates negative pressure in the mouth.

5.     Decreased bleeding due to hemostatic effect of epinephrine or other vasoconstrictor injected with the local anesthetic

6.     General debilitation

7.     Women on contraceptive pills have high chances of developing dry socket. High level of estrogen increases the chances of dry socket.

8.     Extraction of a impacted wisdom tooth increases the chances of dry socket.

9.     Too vigorous rinsing with warm saline water.

10. Taking medications like prednisolone, cyclosporine, azathioprine etc.

11. People within the age group of 40-50 years are also more prone to dry socket. 

None of these reasons is completely tenable. It is suggested that trauma and infection causes inflammation of the bone marrow which causes release of tissue activators.  Plasminogen which is present in the clot is converted into plasmin by the action of tissue activators. Plasmin is a fibrinolytic agent and will dissolve the blood clot. It will also release kinins which will cause severe pain to the patient.  

causes and pathogenesis of dry socket

The patient should not smoke minimum for 48 hours after the tooth extraction. Smoking in the first 48 hours increases the susceptibility to dry socket.  Smoking decreases healing and blood supply to that area and brings toxic products to the area. Due to negative pressure because of smoking, the clot gets dislodged and dry socket occurs. That is why it is advised to avoid smokingfew days after the tooth extraction to prevent dry socket.

Dry socket symptoms

Pain few days after the tooth extraction is normal. But the intensity of pain starts decreasing after some time. In case of dry socket,

1.     Dry socket pain usually occurs 3-5 days after the Tooth Extraction.

2.     There is severe throbbing pain present that is radiating to ear and neck.

3.     It is difficult to pin point site of pain in case of dry socket.

4.     If a person looks in the mirror, completely empty socket or partially necrotic blood clot is seen in the socket.

5.     If a probe is gently passed into the extraction wound, then bare bone is encountered which is extremely sensitive.

6.     Patient having bad breath, halitosis.

7.     Patient is not able to open the mouth.

8.     Dry socket is sometimes accompanied with fever, headache and insomnia. 

So, if a person has these signs and symptoms, then he is having dry socket. Dentist or the oral surgeoeeds to be consulted in case of dry socket.

Clinical Features of Dry Socket

It is more common in women as compared to men and is more common in lower jaw as compared to the upper jaw because of the poor blood circulation of the lower jaw.
Pain in case of dry socket is severe and is radiating. The pain is usually described as a throbbing ache and is caused by thermal and chemical irritation of the exposed nerve endings in the periodontal ligament and the alveolar bone. Because of the extreme intensity of pain, it is the most distressing post-operative sequel to tooth extraction. It occurs despite the most exacting operative techniques and aseptic procedure and regardless of the ability and the judgment of the surgeon.

Suppuration that is pus is generally absent but a foul odor is present in case of dry socket.  
The symptoms of dry socket generally start on third to fifth day after the extraction of the tooth and if the condition is left untreated, and then it may last for 7-14 days. It rarely occurs a week or longer after the extraction.
Sometimes, the dry socket may be associated with low grade fever and lymphadenopathy. The exposed bone is necrotic and sequestration of fragments is common.

The extraction socket wound normally heals in 7days after simple or closed extraction but in case of dry socket, the extraction socket wound may take 15days to 3months to heal completely.
 

Healing of Extraction socket after Tooth Extraction

Treatment of Dry Socket

Healing of extraction socket wound with dry socket is extremely slow and the treatment is directed primarily towards the relief of pain.

Pain relief is done by 2ways:

1.     Local therapy

2.     Antipyretic analgesic or a narcotic

Local therapy consists of irrigation of the socket with a warm sterile isotonic saline solution or a dilute solution of hydrogen peroxide to remove necrotic material and other debris followed by dressing of eugenol or some other dry socket paste which is available with the dentists which will relieve the pain. In 5-10 minutes, the pain will be relieved. First dressing relieves the pain for 12 to 24hours. After that, the procedure has to be repeated. Second dressing relieves the pain for longer duration. After three or so dressings, the tooth extraction socket wound starts healing from inside out and the bone is covered. After that, it is left open to heal.  

Antipyretics and analgesics (Pain relieving meds) are given along with the local treatment and not alone. They won’t be effective if used alone because of the poor vascularity of the necrosed bone.

Most of the patients become free from the symptoms after one or two dressings.
The routine use of antibiotics is not recommended in the treatment of dry socket because the major problem is of pain control rather than unlimited infection. The use of antibiotics alone is an ineffective method for relief of patient’s pain. In rare instance where suppuration does exist, the antibiotic should be used systemically rather than topically in the socket

The incidence of Dry Socket can be prevented by taking certain precautions like:

1.     Doing Chlorhexidine mouth rinses or rinses with some mild anti-microbial mouth wash 24 hours after the extraction, thrice a day. The rinses should be done gently so that blood clot covering the extraction socket is not dislodged. Excessive mouth rinsing for first 24hrs after extraction should be avoided as it can dislodge the clot.

2.     Patient should not smoke minimum after 48 hours of extraction. Smoking creates negative pressure in the mouth which can further dislodge the clot and increases susceptibility to dry socket.

3.     Patient should follow all the post extraction instructions like avoiding sucking, spitting, drinking through the straw after the extraction. Sucking and spitting will create negative pressure in the mouth and can dislodge the clot.

4.     If dentist feels and prescribe the antibiotics, patient should take them regularly.

5.     Patient should try to maintain good oral hygiene. There should be no food impaction in the socket area. The food should be chewed from the other side of the jaw after extraction.

 

Sutures or Stitches after Tooth Extraction

Suture literally means to join. Surgical suture is a stitch which is used by the dentists to hold the tissues together.  If the tooth comes out in one piece without much trauma to the surrounding tissues, then sutures/ stitches are not usually placed. Sutures are given after the surgical tooth extractions and in extractions where there is much of trauma to the surrounding tissues.

Sutures are made of variety of materials and come in several sizes. The two basic types of suture materials are resorbable that the body is capable of easily breaking down the material and nonresorbable sutures. In general, the resorbable sutures don’t require removal whereas the non-resorbable sutures do.

Suturing after extraction of Upper Wisdom Tooth

Resorbable sutures:

The resorbable sutures which are commonly used are: Gut, polyglycolic acid and copolymer of glycolic and lactic acid. Gut is fabricated from submucosa of sheep intestines or serosa of beef intestine. If prolonged suture strength is required, then gut is treated with basic chromium salts. These sutures are known as chromic cat gut suture.  Plain gut sutures retain their strength for 5-7days whereas the chromic sutures maintain strength for 9-14days.

 Resorbable sutures are highly reactive as compared to nonresorbable sutures and evoke an intense inflammatory reaction which may affect the healing.

Nonresorbable sutures:

The most commonly used non-resorbable sutures are: Silk, nylon, polyester and polypropylene.  Nonresorbable sutures are eithermonofilamentous, multifilamentous or both. Multifilamentous form increases the strength. Silk and polyester sutures are available in multifilamentous form. Polypropylene is the mono filamentous form.  Nylon comes in both mono filamentous and multifilamentous form.

Non resorbable sutures

All nonresorbable sutures have some reactivity. Silk evokes the most intense inflammatory response.  Polyester is much less reactive than silk and nylon is less reactive than polyester and polypropylene has least tendency to induce inflammation.   

When non-resorbable sutures are given by the dentist, then they are to be removed. They are mostly removed a week after theextraction.  Gut sutures are most commonly used resorbable sutures which may be there for couple of days to couple of weeks and then will resorb.

The most common problem with the dissolvable sutures is that they sometimes don’t dissolve even after few weeks. In such a case, the dentist can remove the stitches themselves if they don’t come out themselves.

Post-operative care of sutured wounds:

Postoperative care of sutured wounds is important. Sutured wounds within the oral cavity should be kept clean by having the patient rinse frequently with normal saline, hydrogen peroxide diluted with saline or fresh tap water. There should be no food deposits around the stitches. The teeth near the stitches can be brushed but don’t brush over the gum area.

If the stitches become loose or are dislodged before a week, then there is no cause for alarm. The most important thing is that the clot should remain in its position and there should be no excessive bleeding.

No pain during sutures removal

Many of people are worried that the removal of the stitches or the sutures will cause pain. Removal of stitches is an entirely painless procedure and there is no need of giving the local anesthesia and numbing the area before removing the sutures. The sutures are snipped using a pair of tiny tweezers. The tweezers will pull out the sutures with almost no pain and takes only few seconds. The patient just feels a small pinch while stitches removal but there is no pain.

Dental Implants after Tooth Extraction

Dental implant is a prosthetic device which is made of alloplastic material and is implanted in the oral tissues either below the mucosal layer or can be placed within the bone to provide support and retention for fixed or removable prosthesis. Dental implants are the best option for replacement of missing teeth.  

For the placement of dental implants, firstly case is selected and then implant is placed in the oral mucosal layer. Dental implant is placed in the bone.  After placing the dental implants, post operative evaluation is done of dental implant and then abutment is attached to it. Abutment is attached when adequate primary stability is obtained. After abutment attachment to the dental implant, dental crown is placed over it.

There are three different approaches to give dental implants after tooth extraction. Dental Implants can either be given-

1.    Immediately after tooth extraction known as immediate post-extraction implant.
2.    2weeks to 3 months after tooth extraction which is known as delayed immediate post extraction implant.
3.    After 3 months or more after tooth extraction which is known as late implantation.

After implant placement, loading is done. Loading can either be done immediately after placement of dental implant or can be done 1 week to 12 weeks after implant placement (Early Loading) or can be done after 3 months of dental implant placement which is known as delayed loading.  

Immediate Post Extraction Dental Implant

In case of immediate post extraction dental implants, Dental implants are given immediately after tooth extraction. Implant placement immediately after tooth extraction followed by immediate provisional restoration can be very rewarding to the patient. Before placing implants after tooth extraction, an implantologist will consider certain factors. There should be adequate bone present all around the implant covering to stabilize the dental implant and there should be no major infections or soft tissue inflammation present. If there is less of bone and grafting procedure is required, then loading is not done immediately after dental implant placement. Immediate provisional restoration is given to the patient if adequate primary stability is obtained after dental implant placement. If there is poor primary stability present, then the implantologist will place the cover screws and will submerge the dental implants. Patient will have to wait for 3-4 months for osseointegration before loading of dental implants.

       

                  Extraction of Fractured Tooth                         Tooth Extraction Socket

             

           Placement of Dental Implant                         Abutment attachment to Dental Implant

         

 Temporary Crown cemented on Implant          Temporary Crown after 1 Month

In cases when there is loss of alveolar bone due to disease, trauma or surgery, then bone grafting procedure may be required. Grafted bone is used as a scaffold to regenerate bone which is lost due to disease, preserve the extraction socket and preserve the ridges. Guided bone regeneration can be done before dental implant placement or can be done simultaneously with dental implant placement.

Various studies suggest that when dental implants are given to single rooted teeth which have healthy bone and mucosa around them, then the success rate is more as compared to delayed implant placement after tooth extraction.

Advantage of Immediate Post Extraction Dental Implant

1.    Reduces the treatment time and surgical steps– Immediate post extraction implantation reduces the number of surgeries and thus is beneficial to both the dentist and the patient.

2.    Preservation of soft tissue drape and bone – If the dental implants are given immediately after tooth extraction, then it preserves the bone which further provides good aesthetic results.

3.    In some situations, it can even result in avoidance of bone augmentation and soft tissue grafts.

Immediate implant placement can be done into extraction socket and provisional restoration can be given to the patient. It has an advantage that it gives immediate esthetics by fixed restoration and reduces the number of surgeries and time required for rehabilitation. It also prevents collapse of peri-implant soft tissues through support given by crafted provisional restoration.

Disadvantages of Immediate Post Extraction Dental Implants

Infections and dental implant failure can occur after immediate placement of dental implants after tooth extraction. After placingdental implant after tooth extraction, there might be some space or gap present between the socket bony walls and dental implant. Bone augmentation procedure is done in such cases.

Delayed Immediate Post Extraction Dental Implants

Delayed immediate post-extraction implants are given 2weeks to 3months after tooth extraction. This is done to allow for soft tissue healing. It further reduces the chances of wound dehiscence but prolongs the treatment time.  It gives a satisfactory aesthetic outcome in patients with thin gingival type. To gain more of bone thickness, bone graft may be used prior to or along with implant placement. After tooth extraction, provisional bridge or an acrylic removable partial denture can be inserted immediately for soft tissue healing to take place. After 8 weeks, you can consult an implantologist. Before placing the dental implants, he will do clinical and radiographic examination. An implantologist may also take 3DCT scan of the extraction site before implant placement. 3DCT scan will give exact dimensions of height, width and depth of the jaw bone.

Late Dental Implantation

Late implantation is given after 3 months or more after tooth extraction. If grafting is not done after tooth extraction, then bone resorption occurs after 3 months and bone becomes stable in 9-12 months. Within 2-3 months after tooth extraction, healing is adequate but bone resorption doesn’t take place.  In case of late implantation, bone replacement membranes and grafts are ofteeeded. Complete bone and soft tissue healing takes place in case of late implant placement. Because of long healing time, vascularization of previously grafted bone takes place. If the ridge is narrow, then guided bone regeneration with an autogenous graft and or connective tissue graft is given prior to or along with implant placement to create contour of the bone and the gingiva. Main drawback of late implantation is that it prolongs the treatment time and needs 2 surgical procedures.

On the basis of quantity and quality of bone left after tooth extraction, dentist will determine whether it would be appropriate to give dental implants immediately after tooth extraction or within 2 weeks to 3 months after tooth extraction or after 3months.

Resources

BOOKS

Harris, N. O., and F. Garcia-Godoy. Primary Preventative Dentistry , 6th ed. Englewood Cliffs, NJ: Prentice Hall, 2003.

Peterson, L. J. Contemporary Oral and Maxillofacial Surgery , 4th ed. Amsterdam: Elsevier Science, 2002.

Scully, C. Oral and Maxillofacial Medicine: A Practical Guide. London, UK: Butterworth-Heinemann, 2003.

Tronstad, L. Clinical Endodontics. New York: Thieme Medical Publishers, 2003.

PERIODICALS

Devlin, H., and P. Sloan. “Early Bone Healing Events in the Human Extraction Socket.” International Journal of Oral and Maxillofacial Surgery 31 (December 2002): 641-645.

Magheri, P., S. Cambi, and R. Grandini. “Restorative Alternatives for the Treatment of an Impacted Canine: Surgical and Prosthetic Considerations.” Practical Procedures and Aesthetic Dentistry 14 (October 2002): 659-664.

Moscovich, H. “Fitting Restorations from Extracted Teeth.” Journal of the South African Dental Association 55 (August 2000): 411-412.

Rosted, P., and V. Jorgensen. “Acupuncture Treatment of Pain Dysfunction Syndrome After Dental Extraction.” Acupuncture in Medicine 20 (December 2002): 191-192.