| The tooth above was extracted because of
gum
disease. The dark material on the root is not decay. It is
calculus (hardened plaque) which built up on the root because the bone has
been reabsorbed by the body below that point. If the bone had been
surrounding the root as it would in the healthy state, plaque could
never have reached this far down on the root surface. This tooth was
loose because, as the x-ray shows, only the very tip was held in place by bone. Click
on the left-hand image above for more information about the root of a tooth
extracted because of gum disease. The types of extractions
1. Simple extractions
A Simple extraction is one in which the dentist can remove the
tooth simply by loosening the gums around it, grasping the crown above the
gum line with a plier-like forceps and then moving it side to side until it
loosens from the bone. Teeth are normally held into the bone by a thin sheathe
of soft tissue that separates it from the bone like a sock separates a
foot from a shoe. This sheathe is called the
periodontal
ligament, and it is this structure which ultimately enables the dentist to
remove the tooth. The key to simple extractions is to rock the tooth side
to side slowly enlarging the socket in the bone while at the same time breaking
the ligament which binds the tooth in the socket.
2. Complex (surgical) extractions
Unfortunately, not all extractions can be done by simply
grasping the tooth with forceps and rocking it out. What if there is nothing
left above the gum line to grasp? Or what if the crown breaks off leaving the
roots still in the bone? These things can and do happen, and any dentist that
extracts teeth will have to deal with them routinely. In these cases, it
becomes necessary to surgically remove the tooth. This is
frequently accomplished by prying the root out using a sharp instrument that can
be forced between the root and the bone surrounding it. This technique is
called "luxation". In the case of multiple rooted teeth, the roots
are first separated so they can be removed individually. Unfortunately,
not all roots or root fragments may be removed in this fashion. This means that the
dentist must make an incision into the gums around the tooth and raise a flap of
tissue exposing the tooth and its surrounding bone.
Sometimes, after the flap is raised, there is enough tooth
exposed to grab and remove it as in a simple extraction (#1 above).
Sometimes, the technique described above as luxation may successfully remove the
tooth. If luxation fails, the dentist must take
a handpiece (drill) and cut away some of the surrounding bone in order to gain a
purchase on the tooth. After the tooth has been pried out of the artificially
enlarged socket, the dentist then sutures (sews) the flap of tissue back in
place so that healing can proceed normally.
3. Impacted teeth
When a tooth does not fully erupt into the mouth, but remains
below the gums, it is said to be impacted. Impacted teeth can present
special health problems for most patients, and they are generally removed to
prevent future difficulties. The extraction of such teeth proceeds like
the surgical extraction explained above with a few modifications.
Sometimes, the only surgical procedure is the raising of the soft tissue flap.
If after raising the flap, the extraction can proceed as a simple extraction,
the tooth is said to be a "tissue impaction" because there was enough
of the crown left above the bone to grab and extract with forceps.
But many times the crown is submerged below the level of the
bone. The tooth may even be lying on its side under the bone which
complicates the extraction further. In these cases, not only must the
dentist remove surrounding bone in order to expose the tooth, but he must cut
and break the tooth itself into sections so that each section can be removed
separately. Teeth in this condition are said to be "bony
impactions" and are further classified as vertical, horizontal or angular
depending on the angle of the tooth under the bone.
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What
happens to your jaw after an extraction?
When a tooth is extracted, the hole left in the jawbone is called a
socket. Left alone, the socket fills with blood which clots
and helps to form a matrix for healing. After this happens, a sort
of race begins. Cells called osteoclasts and osteoblasts
begin to infiltrate the clot and begin the process of remodeling the
socket and building bone from the bottom up in the space formerly
occupied by the tooth. At the same time, epithelial cells
from the inside of the mouth begin to infiltrate the clot from the top
down and begin to fill the socket with soft tissue. In the end,
over a period of a year or so, the socket heals over having lost between
50% and 75% of the height it would occupy if the socket had filled
entirely with bone. This process, carried out tooth after tooth,
over the course of a lifetime causes the jawbone to atrophy (wither
away), making it more and more difficult for the patient to wear full
dentures. To learn more about the process of bone atrophy after
extractions, click on the toothless skull above.
Until fairly recently, this process was impossible to stop. The
jawbone would begin to atrophy as soon as the first tooth was extracted,
and the process continued on and on until by the time a person reached
late middle age, a person who had lost all their teeth would find that
wearing their denture could be next to impossible.
Socket Preservation--preventing
jawbone atrophy
Today, things can be different, and the bone loss from tooth
extraction can be prevented. This is done by the dentist at the
time of the extraction. For and extra fee, the dentist can place
one of three fillings into the socket which prevent the epithelial cells
from the inside of the mouth from populating the socket, and encourage
the osteoclasts and osteoblasts to rebuild bone in the entire socket.
- Rootform implants
When
a tooth is extracted, it is possible to replace it with an
artificial tooth root called an implant. An implant is the
most expensive form of socket preservation, but it is always
considered the best thing to do after extracting a functioning
tooth. The implant may be placed at the time a tooth is
extracted. The dentist drills a perfectly shaped and sized
hole in the empty socket, and screws a titanium "root" into it.
This implant is then covered by suturing the gums over it, and
allowed to heal for about six months. At the end of the
healing period, the dentist uncovers the implant and attaches an
abutment to it. The abutment sticks up out of the gums and
serves as an anchor for a crown. This combination of
implant, abutment and crown serves as a very firm
and permanent tooth. With good hygiene, a crown/abutment
placed on an implant can last as long as a healthy natural
tooth.
The popularity of rootform implants is growing at an exponential
rate. It is beginning to become popular to extract seriously
damaged teeth that were formerly restorable and replacing them
immediately with implants which have better long term prognoses.
Implants have the additional benefit of not being susceptible to
decay like a natural tooth.
- Bone grafts
Bone grafts are
the best non-implant form of socket preservation. Bone grafts
are very effective at preserving bone height, and they also create
more bone for an implant later on. Bovine (cattle) bone is
processed in such a way that all protein is removed leaving only the
hydroxyapatite component. This is freeze dried and sold to the
dentist as a coarse, granulated powder. The dentist mixes this
powder with the patient's blood and forces it into the socket
immediately after the tooth is extracted. The mixture is held
in place either by tightly suturing the gums over the socket, or by
suturing a collagen membrane over it. Over the course of six
months, the patient's body resorbs the artificial bone and replaces
it with his or her own. A bone graft is nearly 100% effective
at preserving bone height. Click on the toothless skull above
to read about bone grafts and collagen plugs in more detail.
- Collagen plugs
Collagen is a component of connective tissue. The dentist
places a spongelike material made of specially processed bovine
collagen into the socket and sutures it in place. A collagen
plug is a good deal less expensive than a bone graft, and the
procedure for placing it is easier. This procedure
generally preserves between 60% and 80% of the original bone height.
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Note:
Each of these methods of socket preservation are also
effective in preventing
dry sockets! |
Can an abscessed tooth kill you?
Ludwig's angina
A
bacterial infection any place in the body causes a localized
inflammatory reaction. Inflammation is characterized by
four things: swelling, pain, heat and redness. An abscess is
an inflammatory reaction surrounding a localized pocket of pus.
When a localized inflammatory reaction happens in most areas of the
body, it is not generally immediately life threatening, however when
it happens in the lower jaw, the resulting swelling can place
increasing amounts of pressure on the internal structures of the
floor of the mouth, throat, and neck. This includes the
trachea (windpipe). If the swelling becomes too severe,
the trachea can become so severely constricted that the patient is
unable to breathe, and may consequently die. Prior to 1942
when penicillin was first marketed (it was discovered in 1928, but
not available to the public until 1942), this was a very
common cause of death in persons of all ages. In 1836, a
doctor named Wilhelm Frederick von Ludwig was the first to describe
this condition as a scientific entity, and it was named Ludwig's
angina in his honor. The term angina comes from the Greek word
"ankhon", and means "strangling".
Cavernous Sinus Thrombosis

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Upon occasion, especially in the case of an untreated
abscess of an upper front tooth, the patient can get a brain abscess which can kill him.
This brain infection is called cavernous sinus thrombosis. Click
the image to the left to see my page explaining the mechanics of cavernous
sinus thrombosis and its relationship to the "dangerous triangle". |
Next page>>Wisdom
teeth |