Surgical Tooth Extraction

A surgical extraction is needed when a tooth cannot be removed with forceps and fine instruments alone. The gum is opened with a small incision, a little bone around the tooth is removed if necessary, the tooth is divided into pieces and the area is closed with stitches. The name sounds more dramatic than it is: it is done inside the mouth under local anaesthetic, and you go home the same day.

We explain why teeth are taken out, and the basic aftercare rules, on the tooth extraction page. Here we focus on what makes an extraction "surgical", how the procedure goes and what to watch for while it heals.

What makes an extraction surgical?

In a simple extraction the tooth is loosened in its socket and comes out in one piece. That may not be possible when:

• The crown has broken off or been destroyed by decay. With nothing left to grip, the roots are removed from beneath the gum.
• The roots are curved, splayed or hooked. Trying to take the tooth out in one piece breaks the root or costs more bone than necessary.
• The tooth has fused to the bone (ankylosis). The thin layer of connective tissue between root and bone has disappeared, so the tooth cannot be loosened.
• The tooth had root canal treatment long ago. It is more brittle and tends to break into pieces during removal.
• A root tip was left behind after an earlier extraction.
• The tooth is still inside the bone or only partly through the gum. The commonest examples are wisdom teeth and impacted canines; both have their own pages.

We see most of these on the X-ray before the extraction. Sometimes an extraction that starts out simple becomes surgical because the tooth breaks; that is not a mishap, just a change of plan.

When an X-ray is not enough: CBCT

For most surgical extractions a panoramic or single-tooth X-ray is enough. If the roots of a lower molar look very close to the nerve canal in the jaw, or the roots of an upper molar very close to the sinus, we ask for a 3D cone-beam CT (CBCT) scan. That lets us plan in advance where to make the incision and how to divide the tooth.

With upper molars, the floor of the sinus is sometimes separated from the roots by only a thin layer of bone. If a small opening between the mouth and the sinus appears after the extraction, it is closed at the same appointment; for about two weeks you will be asked not to blow your nose hard and to sneeze with your mouth open.

The procedure, step by step

1. Anaesthetic. The area is numbed with local anaesthetic. If you are very anxious, we can discuss sedation beforehand.
2. Flap. The gum is lifted back through a small incision so that the tooth and bone can be seen.
3. Bone and tooth. If needed, a small amount of bone is removed with a water-cooled bur. Multi-rooted teeth are divided into their separate roots and each root comes out along its own path; this costs less bone than forcing the tooth out in one piece.
4. Cleaning. The socket is rinsed and any sharp edges of bone are smoothed. If an implant is planned for later, a bone graft can be placed at this stage.
5. Stitches. The gum is stitched back into place. Dissolving stitches fall out on their own; non-dissolving ones are removed after 7–10 days.

How long it takes depends on the tooth: a single tooth with a broken root may take 20 minutes, while a deep, multi-rooted tooth can take up to an hour. You usually feel no pain during the procedure; you will feel vibration and pressure while the tooth is being divided.

How healing progresses, day by day

When	What to expect
Day 1	The numbness wears off within a few hours, and there is some oozing of blood. Taking the first painkiller before the numbness wears off helps.
Days 2–3	Swelling is at its most noticeable; you may not be able to open your mouth fully, and bruising may appear on the cheek.
Days 4–7	Swelling and pain ease noticeably.
Days 7–10	Stitch check; daily life is largely back to normal.
The following months	The socket gradually fills in with bone.

Holding something cold against the outside of your face, on and off, for the first 24–48 hours limits the swelling. Put off strenuous exercise for a few days; it raises your blood pressure and can start the bleeding again. Not every surgical extraction needs antibiotics; if you need them, we prescribe them.

Dry socket (alveolar osteitis): how to recognise it

If the blood clot in the socket breaks down early or is dislodged, the bone is left exposed. This is called dry socket, or alveolar osteitis. It is better thought of as a hitch in healing than as an infection.

The most typical sign is the timing: pain that was easing over the first days gets worse again on day 2–4, radiates to the ear and temple, and responds poorly to painkillers. There is a bad taste or smell in the mouth and the socket looks empty. It is more common in smokers, after difficult lower molar extractions, in people who have had dry socket before and in women taking the contraceptive pill.

Treatment is simple but has to be done by a dentist: the socket is gently rinsed and a soothing dressing is placed inside it. The pain usually eases noticeably within a day; the dressing is changed a few times if needed. Do not poke at the socket yourself. The most effective prevention is not smoking, not using straws and not rinsing vigorously in the first few days.

When to call without waiting

• Bleeding that does not stop even after biting firmly on gauze for 30 minutes
• Swelling that increases instead of going down after the third day
• A temperature above 38 °C, or shivering
• Swelling spreading under the eye, to the neck or to the floor of the mouth; difficulty swallowing or breathing

The last two are emergencies: if you cannot reach your dentist immediately, go to the nearest emergency department. If you had the extraction at our clinic in İzmir, call us first about the other signs; we can settle most questions by phone and, if you need to be examined, see you the same day. If you have already left İzmir, have the nearest dentist examine you.