Surgical removal of teeth

Options to help make things more comfortable

Why do teeth need surgical removal rather than just forceps removal?

The majority of teeth are extracted using forceps and are considered “simple” extractions. There are some situations where a simple extraction may not be possible and surgical removal will be needed.

Reasons that surgical removal may be necessary include teeth:

• That are below or are only partially through the gum.
• Which are broken, brittle or cracked below the gum line.
• That have complicated long and / or curved roots and fractured root tips.

What is involved in the surgical removal of teeth?

The stages of surgical removal of teeth or roots of teeth commonly include:

1. Raising a gum flap
   
   A cut is made in the gum surrounding the tooth. The gum is then raised up and pushed back like the blind of a window in order to reveal the underlying tooth and bone.
   
2. Removing bone
   
   If necessary, bone is removed using a drill to provide access to the tooth or root and to make removal easier. The amount of bone removed is kept as minimal as possible.
   
3. Sectioning the tooth
   
   The tooth may be cut into smaller pieces, using a drill, to make it easier to remove it. This is often the case for teeth with more than one root, when roots are of a complex shape, or when roots are close to important structures like nerves.
   
4. Stitching
   
   Once the tooth has been removed the gum is repositioned and stitches are used to hold the gum in place during the early stage of healing. Most stitches are dissolvable and do not need to be removed.

What types of anaesthetic are available?

Local anaesthetic

An injection is placed in the gum around the tooth, similar to that used by the dentist when having a filling.

Following treatment you will be able to drive, return to work, and carry out other routine day to day activities, but we would advise against strenuous activities or exercise.

You may choose to attend alone and do not need to be accompanied to your appointment. Following treatment, advice will be given regarding the use of appropriate painkillers.

Local anaesthetic and intravenous sedation

This involves the placement of a small plastic tube (cannula) into a vein in the back of the hand or arm through which a sedative drug is given. This may help reduce anxiety and help you to relax. You will not be asleep, but may be less aware of your surroundings and remember very little.

Local anaesthetic, as described above, will be given after the sedation and before treatment starts in order to carry out the surgery.

Following intravenous sedation, you cannot drive, work, take care of children or adults, drink alcohol, or sign important documents for 24 hours. A responsible adult is required to accompany you for treatment, take you home after treatment and take care of you for the following 24 hours. Before treatment it is advisable to have a light meal.

This type of sedation is good for those adults who are anxious about dental treatment or the surgeon feels the procedure may be difficult.

For further information see ‘intravenous sedation for your dental treatment (adult)’ and ‘adults accompanying patients having intravenous sedation’ leaflets.

General anaesthetic or ‘going to sleep’

This involves drugs being given by an anaesthetist to put you completely to sleep in a hospital setting. Once treatment is complete the anaesthetic is reversed and patients recover under the care of a nurse.

Depending on your general health and social circumstances an overnight stay in hospital following treatment may or may not be necessary but a large proportion of patients who have no significant illnesses may return home on the same day.

General anaesthetic is usually only offered in more complex cases and your surgeon will discuss this option with you where appropriate.

What should I do after my surgery?

• No rinsing for 24 hours.
• No hot liquids or alcohol for 24 hours.
• No chewing for four hours.
• No smoking for 24 hours.
• No exercise or strenuous activity for 48 hours.

Maintain a high standard of oral hygiene to prevent infection. Brush teeth as normal simply taking care around the area of surgery.

After 24 hours rinse gently with a warm salt water mouthwash (one level teaspoonful of salt dissolved in a glass of warm water) every two hours and after every meal during the day for three to five days.

Blood stained saliva is to be expected, but if bleeding occurs bite on damp gauze for 10-15 minutes.

It is important to take painkillers before the local anaesthetic wears off. Pain for a few days following treatment is normal.

You will be advised if your stitches are not dissolvable and need removal. Three to four days following treatment it is important to start gently brushing around the stitches to minimise food trapping.

Infection following surgical treatment is a rare but potential complication. If symptoms including increased pain, swelling, fever and chills, bad taste occur contact the department for advice.

Antibiotics are not routinely prescribed following surgical treatment. At the time of the procedure your treating surgeon will decided if they are required or not. If antibiotics are inappropriately prescribed this may result in failure to work when they are necessary.

Detailed written instructions, including the emergency contact numbers both during and out of hours, will be provided following your treatment entitled ‘aftercare information for patients undergoing oral surgical procedures’.

What to expect following treatment

Pain

The pain experienced after treatment depends on the difficulty of the surgery and each individual. Pain is likely to occur for up to seven days following surgery. The local anaesthetic provided prior to treatment will last up to three hours preventing any pain.

Temporary swelling and bruising of the face

Swelling is common and occurs in the region of the cheek both inside and outside. Swelling increases two to three days following surgery then gradually reduces over the following week.

Restricted mouth opening

Pain or stiffness of the jaw is common following surgery especially if it has been prolonged or difficult. Mouth opening may be restricted for up to seven days but will gradually improve with rest and gentle daily stretching. Do not attempt to force your jaw open.

Bleeding

Avoid hot food and drinks for 24 hours following treatment to prevent bleeding reoccurring. If bleeding does occur, place the gauze provided or a clean damp handkerchief over the bleeding tooth socket and bite down on the handkerchief with steady pressure for ten minutes whilst sitting down.

Sensitivity of adjacent teeth

Teeth next to the wisdom tooth socket may become sensitive for up a couple of weeks following treatment.

Maintain a high standard of oral hygiene in the area and symptoms generally gradually improve with time. If they do not there are other measures that can be taken by a dentist.

Stitches

Stitches placed are often dissolvable and do not need to be removed. If you have non-dissolvable stitches you will be informed and an appointment made to remove them.

Three to four days following surgery start gently brushing around the stitches to reduce food packing and encourage the stitches to come away. However, be careful to not dislodge the blood clot from the tooth socket.

Exercise and sport

Exercise and strenuous activities should be avoided for 48 hours. It is advised to gradually increase the intensity of exercise over time.

Possible complications during or after treatment

There are a number of recognised complications that can happen during or following the surgical removal of teeth.

Your surgeon will discuss those, which may happen to you if they think that you are at risk.

Such complications may include the following.

Infection

Occasionally an infection may occur following tooth extractions or surgery. The surgeon will not prescribe antibiotics following treatment unless you have an infection. Giving antibiotics without infection may mean that the antibiotics may not work when they are needed.

Signs of an infection include:

• Pain
• Swelling
• A bad taste / breath
• Pus and a raised temperature.

If you feel you may have an infection, you should contact the hospital on the number provided as soon as possible and we will give you advice or arrange to see you.

Connection created between mouth and maxillary sinus

Upper teeth roots can be very close to, or even within, the naturally occurring air-space in your cheek-bone, the maxillary sinus (also known as the maxillary antrum).

Therefore when upper teeth are surgically removed, a connection between the sinus and the mouth can be made. If this connection, known as an oroantral communication or fistula, is left open then fluid and food debris would be able to flow from the mouth into the maxillary sinus and then drain away out through the nose, presenting a risk of infection.

Before treatment, your surgeon will assess the likelihood of an oroantral communication occurring; however, it is not always possible to predict when it will.

If a oroantral communication is identified immediately following the surgical removal of a tooth, or develops during the healing period, there are a variety of treatment options including:

• Watching and waiting as some smaller oroantral communications can heal spontaneously.
• Wearing a protective shield over the area in your mouth to protect the oroantral communication and allow it to heal
• Minor surgical procedures to move gum over the hole to close it.

To help healing, you will be told to: avoid nose-blowing and to sneeze with an open mouth.

• Avoid smoking.
• Avoid drinking through straws for 14 days.

The surgeon may recommend nasal decongestants, steam inhalations and antiseptic mouth-wash to prevent infection and minimise symptoms.

Very rarely portions of teeth (mental nerve) roots can also displace and pass up into the maxillary sinus during the surgical removal of teeth.

If this occurs we will inform you and an attempt will be made to remove the piece of root either immediately, or after a period of healing if this is more appropriate in the individual’s circumstances.

Temporary or permanent damage to nerves

A small nerve, the inferior dental nerve that runs through the lower jaw exits the bone next to the lower premolar teeth (mental nerve) to supply feeling to the lower lip and chin.

Surgical removal of the lower teeth may result in temporary, or more rarely, permanent damage to the nerve due to the nerve being bruised or stretched when lifting the gum or removing bone during surgery in the area.

Care is taken to avoid the nerve and to protect it throughout the procedure. Damage to the nerve may leave you with numbness, tingling, or, rarely, a painful itchy burning feeling in the lip, chin, or teeth. This change in sensation is usually temporary, although it can be permanent.

Occasionally numbness and / or tingling can occur in the tongue if the nerve to the tongue (lingual nerve) is damaged.

Rarely altered taste may also occur if the nerve to the tongue is damaged. Your surgeon will inform you if they feel you are at a particularly high risk of this occurring.

Damage to adjacent teeth

Very occasionally damage to the teeth next to the tooth being removed can happen.

This is more common where teeth are very tightly placed together for instance commonly impacted (unerupted) teeth such as the canine teeth (eye teeth), premolar teeth and wisdom teeth.

The type of damage that can occur includes dislodgement of fillings or crowns (caps) on adjacent teeth or damage to their roots which can lead to teeth dying.

If there is a risk of this occurring we will inform you, but sometimes this can be difficult to predict so if it does actually occur we will tell you and make appropriate arrangements to help rectify the situation as far as is possible.

Wisdom teeth

Wisdom teeth (third molars) are the last teeth to erupt and usually erupt between 18 and 24 years of age. There are normally four wisdom teeth, one on either side of the upper and lower jaw.

They may erupt into the correct position, or if there is insufficient space, may only partly erupt.

Why do wisdom teeth need to be removed?

Not all wisdom teeth require removal and they can be monitored by your dentist at routine check-ups. However, partly erupted wisdom teeth may be difficult to keep clean, which can lead to decay, gum infections (pericoronitis) and abscesses.

The National Institute for Health and Care Excellence (NICE) have written guidelines, which describe when wisdom teeth should be removed. The guidelines can be found on the NICE website.

Reasons why wisdom teeth may need to be removed include:

• Unrestorable tooth decay.
• Repeated episodes of infection or a severe infection of the gum surrounding the tooth (pericoronitis).
• Facial swellings as a result of infection (cellulitis).
• Damage to the adjacent teeth.
• Cysts or tumours involving, or next to, the tooth.
• To enable reconstructive jaw surgery as part of orthodontic and or orthognathic treatment.
• Fracture of the tooth due to trauma.

The lower wisdom teeth are very close to two important nerves: the inferior dental nerve which runs through the lower jaw and the lingual nerve that runs along the gum on the tongue-side of your lower teeth, passing the wisdom tooth.

The inferior dental nerve supplies sensation to your lower lip, chin and teeth on the same side as the nerve and the lingual nerve supplies sensation to the same side of your tongue including a small role in taste.

When you are assessed by the surgeon, you may be offered one of three options:

1. No treatment is required and your own dentist will be asked to keep checking the wisdom teeth. You may be advised on how to keep the area clean and free from infection.
   
2. Removal of the whole wisdom tooth
   
3. Removal of the crown (top white bit) of the tooth only leaving the roots behind. This is known as a ‘coronectomy’.

If treatment is required, the surgeon will discuss which options are available to you.

This will depend on how the tooth looks in your mouth and x-rays taken to determine how close the lower wisdom tooth’s roots are to the inferior dental nerve.

If the x-ray suggests that this nerve is very close to the roots, then you may be at higher risk of nerve damage during surgery, and permanent or temporary numbness or painful sensation of the lower lip, chin and teeth on the affected side.

The assessing surgeon may suggest a further 3D x-ray scan if they feel there is a high risk of nerve damage. This 3D scan, or cone beam CT, allows the surgeon to more accurately assess the relationship between the nerve and the roots.

Coronectomy

If the x-ray and scan demonstrates that you may be at high risk of nerve damage during surgical removal of the wisdom tooth, a coronectomy may be offered if appropriate.

What makes me a suitable candidate for a coronectomy?

Not all patients and wisdom teeth are suitable for a coronectomy.

For a coronectomy it is essential that:

• The patient is medically fit and well and not at risk of infection.
• The wisdom tooth is free from decay and infection of the root.
• There is an associated high risk of damage to the inferior dental nerve.

How is a coronectomy performed?

The procedure is similar to that described previously for a routine surgical removal of a tooth, however it involves only the surgical removal of the crown (white top bit of the tooth) of the wisdom tooth leaving the roots in situ.

Depending on the complexity of the treatment and anxiety of the patient, treatment can be provided under local anaesthetic, local anaesthetic and intra-venous sedation or general anaesthetic.

Complications following coronectomy

• If the roots of the wisdom tooth become loose after the crown is removed, the roots will need to be carefully removed despite the associated high risk of nerve damage.
  
• Infection of the retained roots may occur and if this is severe or repeated may require the removal of the retained roots.
  
• The roots may erupt through the gum into the mouth. In this case, the roots may have moved away from the nerve decreasing the risk of nerve damage on extraction.

How are wisdom teeth removed?

Each wisdom tooth and every patient are different and there is considerable variation in the removal of wisdom teeth, but the common steps of surgery are as explained earlier.

The procedure is routinely carried out under local anaesthetic injections in the gum around the tooth similar to a routine filling at the dentist, but as discussed earlier in the booklet other options are also available depending on the likely complexity of surgery (see ‘What types of anaesthetic are available’).

Possible complications following surgical removal or coronectomy of wisdom teeth

Other than the complications described earlier, the most common complications you may experience following surgical removal or coronectomy.

Dry socket (alveolar osteitis)

Loss of the blood clot following an extraction may result in a dry socket.

Symptoms include intense and persistent throbbing pain, which feels a bit like toothache. This pain begins between two to five days following treatment. A bad taste may also be present.

If you feel you have a dry socket please contact the department for advice. Treatment involves rinsing the socket with an antiseptic to remove trapped food and debris and a pack is then placed to prevent further food packing and help reduce the pain. This pack gently sheds over the next few days.

Temporary or permanent nerve damage

The inferior dental and lingual nerves that pass close to the lower wisdom teeth may be stretched and bruised during treatment.

This may result in tingling or numbness of the lip, chin or tongue, and rarely altered taste, on the affected side. Other altered sensations include burning, stabbing and shooting pain. In most cases this will be temporary however very rarely the damage may be permanent.

Further information

Contact details

Oral and maxillofacial surgery department
Level 3
Newcastle Dental Hospital
Richardson Road
Newcastle upon Tyne
NE2 4AZ

Telephone: 0191 282 4681 between 8.30am and 5pm, Monday- Friday (excluding bank holidays).

After 5pm an emergency service is provided by the oral and maxillofacial surgery senior house officer at the RVI, who can be contacted through hospital switchboard 0191 233 6161.

Useful sources of information

For further information, advice and questions ask the member of staff providing your treatment.

The Patient Advice and Liaison Service (PALS) can off on-the-spot advice and information about  NHS services. You can contact them on freephone 0800 032 02 02 or email [email protected]

If you would like further information about health conditions and treatment options, you may wish to look at the NHS Choices website at NHS www.nhs.uk

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