Is the extraction of canines painful

Extraction of teeth

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In dentistry, extraction (Latin for extra-trahere, “pulling out”) is the removal of a tooth without the need for a larger incision. It can usually be done by any dentist. Like any surgical intervention in the human body for diagnostic and / or therapeutic purposes, it is an operative intervention. The injection of the local anesthetic is also an operation in the narrower sense, because the mucous membrane is injured.
If a larger incision and the formation of a mucous membrane-periosteal flap is required, this falls under the term surgical tooth removal (osteotomy in dental jargon: "opening")

Indication for extraction

A distinction is made between absolute and relative indications.

Absolute indications for extraction

  • The tooth is extremely loosened (degree of loosening III) and regeneration of the tooth holding apparatus (reattachment) is not to be expected.
  • Longitudinal fracture of the tooth crown or the tooth root
  • Transverse fracture of the tooth root in the middle third of the tooth root
  • Massive apical periodontitis when surgical revision (apicectomy or hemisection) is not possible
  • Displacement of a tooth, as is often the case with wisdom teeth, or lack of space if this cannot be remedied by orthodontic measures.
  • Removal of surplus tooth structures (e.g. a mesiode), especially if they hinder the eruption of the normal teeth

Relative indications for extraction

  • Severe destruction of the hard tooth substances (tooth enamel, dentine) if tooth preservation by means of tooth fillings or crowns is only possible for a limited period of time.
  • The patient rejects tooth-preserving measures, but still needs to be relieved of his pain.
  • The patient cannot financially afford the costs for necessary tooth-preserving measures (e.g. a crown). (Social indication)
  • There is a disproportion between tooth and jaw size, so that not all teeth find sufficient space: Systematic extraction therapy as part of an orthodontic treatment.
  • As compensation extraction if a tooth is missing in the opposite half of the jaw and a (midline) shift should be avoided (e.g. tooth 35 is missing: tooth 45 is removed as part of a compensation extraction.)

Anesthetic procedure

Anesthesia in the upper jaw

In the case of extractions in the upper jaw, infiltration anesthesia (injection of a local anesthetic around the tooth) is usually carried out. The puncture is made in the envelope fold in the oral vestibule at the level of the root tip. The anesthetic diffuses through the bone, which is only about 1-3 mm thick vestibularly. The effect of the anesthesia usually sets in after one minute and reaches its maximum after 20 minutes. In practice, the tooth can be extracted after 3 minutes. In addition, the oral mucosa on the palate is anesthetized with a second puncture. For the posterior region (teeth 4 to 8), this palatal puncture is made at the level of the upper first molar, approx. 1 cm from the tooth neck. For the front teeth (teeth 13 to 23), the palatal puncture is made close to the incisal papilla (papilla incisiva) and not directly into it, as it is very sensitive to pain. The palatal puncture can also be made directly in the palate area of ​​the tooth to be extracted.

Anesthesia in the lower jaw

For extractions in the mandible, conduction anesthesia of the inferior alveolar nerve on the mandible foramen is usually applied. It is important to ensure that the inferior alveolar artery is not injected directly into the inferior alveolar artery by means of aspiration (sucking in the tissue fluid). By placing a small depot of the anesthetic at a distance of about 10 mm from the bone, the lingual nerve is also anesthetized. For anesthesia of the buccal nerve, a small amount of anesthetic is injected into the crease of the oral vestibule (i.e. vestibular) in the area of ​​the tooth to be extracted.
Conduction anesthesia usually lasts about 2 to 3 hours, but it can also last much longer or shorter.

Intraligamentary anesthesia

Another possibility of anesthesia is intraligamentary anesthesia, which is suitable for both mandibular and maxillary teeth - with restrictions for the mandibular-posterior region. “Intraligamentary” means: in the ligaments of the tooth support system, the Sharpey fibers. The anesthetic is injected into the periodontal gap with a particularly thin (0.3 mm) and pointed cannula. Because this requires very high pressure, a special syringe must be used (e.g. Citoject syringe or Soft-Ject syringe). At least one puncture is required per tooth root. The anesthetic solution penetrates the tooth holding apparatus including the bony alveolus to the tip of the tooth and there numbs the nerve fibers entering the pulp. In the case of intraligamentary anesthesia, less anesthetic is administered per tooth, which is particularly advantageous for high-risk patients (heart, circulatory system). Due to the skillful, slow approach of the practitioner, the pain for the patient is less than with other anesthesia.

Extractions under general anesthesia

In contrast to the local (local) anesthesia technique described above, general anesthesia also switches off the consciousness: you "oversleep" the procedure in a certain way. General anesthesia is beneficial for anxious patients and for very extensive surgical treatments. Since the risk of anesthesia is comparable to the risk of local anesthesia in otherwise healthy people. For patients who show severe, medically recognized fear reactions and therefore cannot be treated under local anesthesia, the statutory health insurance companies also count. Private health insurances almost always cover the costs in the event of a medical indication. If you are unsure whether general anesthesia is an option for you, you can also get personal advice via video consultation.


Tooth extraction tools and technology

Instruments

As with any surgical procedure, the instruments used must be sterile. Different shaped pliers are used for the extraction for the various tasks and groups of teeth. There are very different special designs within these groups.
There are also special forceps for extracting milk teeth.
Extraction levers (e.g. Beinscher lever or root elevator) are used to cut through the fibers of the tooth-holding apparatus and to loosen the teeth.


Tooth extraction technique

The term “pulling a tooth” is common, but it does not adequately describe the actual extraction technique. Rather, it is important to widen the tooth socket (alveolus) with sensitive, suitable lever and tilting movements (dislocation movements) and to "feel" where the tooth is most likely to give way. The alveolar walls must be prevented from splintering by supporting the bone with the free hand. In the vast majority of cases, it would be impossible to remove a tooth by simply pulling it, especially not from the (upper) molars, whose roots often diverge strongly. After the extraction, the alveolar walls are manually squeezed together again.
A normal side effect of every extraction is bleeding from the injured vessels of the gingiva, the gums and in the bone. Normally, the insertion of a sterile swab as a pressure bandage for about 30 minutes is sufficient postoperatively. The resulting blood clot (coagulum) is the ideal wound dressing. Surgical sutures can be used to reduce the open wound area. This should be done routinely when extracting multiple teeth in one session (row extraction). When extracting several teeth or foreseeably large extraction wounds, it can also be useful to incorporate a dressing plate. If necessary, pain medication can be prescribed. The pain reliever should not contain any acetylsalicylic acid (e.g. aspirin), as this has a negative effect on blood clotting.

Possible complications of tooth extraction

  • Breaking off the tooth
  • Break off the root
  • Pain, edema (swelling), hematoma (bruise)
  • Difficulty opening the mouth up to the jaw clamp, difficulty swallowing
  • Dry socket: Dry socket (Latin: alveolitis sicca): Clinical picture of a wound infection of the jawbone after tooth extraction as a result of the disintegration of the blood clot (post-extraction syndrome)
  • Rebleeding

Rare:

  • Opening of the maxillary sinus (mostly in the area of ​​the upper posterior teeth)
  • A tooth root (or part of it) enters the maxillary sinus
  • Side effects of the anesthetic
  • Irritation (irritation) of the inferior alveolar nerve or the lingual nerve from the anesthesia
  • Damage or loosening of other teeth
  • Injury to soft tissue

very rare:

  • Tear of the maxillary tuberosity (see figure for its position)
  • Fracture (break) of the lower jaw or the temporomandibular joint
  • Dislocation (dislocation) of the temporomandibular joint
  • Breakage of the injection cannula
  • Ingestion of teeth or parts of teeth
  • Aspiration of teeth or parts of teeth

Opening of the maxillary sinus and dentogenic sinusitis


Opening the maxillary sinus during extraction is not a medical malpractice. It is only important that the dentist recognizes the opening of the maxillary sinus. For this purpose, it is recommended that the nose blow test (Valsalva pressure test) be carried out routinely after the extraction of the upper teeth. However, it is more reliable to probe the alveoli with a button probe. A root dislocated in the maxillary sinus must be removed - if necessary, further treatment by an ENT specialist.
A perforation of the maxillary sinus (mouth-antrum connection = mouth-maxillary sinus connection) can be covered by a surgically experienced dentist, an oral surgeon or an oral surgeon with a vestibular pedicled expansion flap (plastic cover). To do this, the periosteum at the base of the flap is severed from the inside of the flap so that the mucosal flap can be sufficiently stretched (mobilized). The subsequent seam closure must be done very carefully.
As far as possible, the patient should avoid blowing his nose and sneezing violently in the first few days after the operation, as the pressure can tear open the closure of the maxillary sinus.
In inflamed maxillary sinuses (e.g. due to the infected root tip), the primary covering with a flap technique often fails because the secretion flowing out (from the nasal cavity via the alveolus into the oral cavity) paves the way for a connection even with good wound closure. In this case, the inflammation in the maxillary sinus should heal before the plastic covering. If necessary, the maxillary sinus is rinsed over the opened alveolus. The support of an ear, nose and throat specialist should be sought on a case-by-case basis. Only after the inflammation has subsided can a plastic cover take place.
In the case of complicated tooth removals, all tooth parts must always be collected to ensure that no tooth parts have been swallowed or aspirated.
Swallowing teeth or parts of teeth poses only minor risks.
On the other hand, a dangerous complication is aspiration of teeth or tooth parts. It is imperative that further treatment be carried out quickly and by a specialist (ENT doctor).

Conversely, sinusitis can be caused by damaged teeth. The professional dental treatment - in extreme cases also the extraction can then bring the mostly unilateral sinusitis of the maxillary sinus to complete healing.


Aftercare

In general, the practitioner will check the wound the following day.
If the wound has been sutured, the sutures must be removed after a few days - in the case of a plastic covering, after 10 days at the earliest.
In alveolitis sicca, wound revision by curettage and subsequent multiple tamponade is the method of choice (secondary wound healing).


Behavior after the operation

The wound usually closes within the first few weeks after treatment. (Primary wound healing)
In the first time after the operation, the right behavior is important for good wound healing and the reduction of the unavoidable sequelae.
Driving vehicles and operating machines is not permitted during the anesthesia period.
The wound should be cooled for the first 24 hours. This causes less swelling. Cool packs or wet washcloths or ice can be used for this. Sucking ice cubes also reduces the temperature in the mouth, and the wound is also cooled from the inside.
Some dentists and pharmacists also recommend taking arnica preparations to reduce the swelling of the wound area more quickly.
If there is no allergy to chamomile, it can be rinsed with chamomile after eating to support wound healing and disinfect the wound.
Dairy products should be avoided as the lactic acid bacteria they contain would attack the blood clot that forms. The consumption of caffeine (coffee, black tea, energy drinks), nicotine or alcohol should be restricted because these encourage the bleeding tendency. Whole grains and foods that have crumbly ingredients can also be problematic as the crumbs get into the sore and cause inflammation.
It is also important to ensure that the teeth and the wound area are carefully brushed with a small, soft toothbrush (children's toothbrush) after every ingestion of food. Alternatively, a mouthwash can be prescribed for oral hygiene, which can be more pleasant, especially in the first few days. Otherwise, “contamination” of the wound can lead to inflammation, which interferes with wound healing.
Soaring blood pressure can also be problematic. It is therefore advisable to exercise restraint when exercising.