Typically, the tooth is extensively decayed or
fractured and is causing chronic infection and

Sometimes, the tooth has to be removed surgically.  
Surgical removal is needed when simple extraction is
not possible because of the condition of the tooth

This list of warnings might seem excessive to some
however the legal ruling in the case of
Chester vs Afshar
would suggest that it is quite prudent / necessary
to list them.  Others might say that there isn't enough
information but where do you stop?  

The following list of warnings regarding
tooth extraction is
neither exhaustive nor is it predictive.  The most pertinent
warnings have been included here
Tooth Removal Warnings
Less Common Surgical Consequences:

Numbness / Tingling / 'Burning' of the Lip, Chin and/or Tongue.  The nerves that
supply feeling to the tongue, lower lip and the chin run close to the root-ends of the
lower molar teeth and exit onto the gum close to the roots of the
premolars /
.  There is a risk that when back lower teeth (wisdom teeth especially)
are removed, these nerves can be crushed, bruised or stretched resulting in
numbness (at the worse end of the scale) to altered sensation (at the other end of
the scale) in the region of the lower lip, chin and/or tongue.

This nerve bruising tends to be temporary (rarely is it permanent) but ‘temporary’
can stretch from several days to several months.  It is hard to predict who will get
nerve bruising and if it will be temporary / permanent and if temporary, how long for.

Left Behind Tooth Tips.  In rare instances, the very ends of the teeth may be left

In the lower jaw, this is done because in trying to remove these root tips, the nerve
supplying feeling to the lip, chin & tongue may be damaged.  If they are left behind,
there is not likely to be any problems associated with this.

In the upper jaw, these root tips may stay where they are in the socket or may be
pushed into the sinus or into a local blood vessel network (pterygoid plexus).  If
these tips are left behind in the socket, there is not likely to be any problems
associated with this.  However, if the root tips have gone out of the socket into the
local anatomy, they will need to be recovered.

Bony Flakes.  Occasionally, bony flakes (sequestra) from the sockets of the
extracted teeth can work their way loose and through the gums.  These can be
quite sore.  They often work their way loose without any problems but may need to
be teased out or even smoothed.  If a number of teeth are removed at one go, the
resulting gums may feel a bit rough.  In many cases, the gums become less rough
with time however, it may be necessary to smooth the underlying bone for this to

Failure of Anæsthesia.  In rare cases, the tooth can be difficult to ‘numb up’.  This
can be due to a number of reasons.  The more common ones include inflammation
± infection associated with the tooth, anatomical differences & apprehension.  If the
tooth fails to ‘numb up’ then its removal will be rescheduled with antibiotic cover or
perhaps done under sedation or even a GA.

Bleeding into Cheeks.  Swelling that does not resolve within a few days may be
due to bleeding into the cheek.  The cheek swelling will feel quite firm.  Coupled
with this, there may be limitation to mouth opening and bruising.  Both the swelling,
bruising and mouth opening will resolve with time.

Mouth-Sinus Communications.  Upper molar and premolar teeth often have their
roots in close proximity to the sinus.  In removing these teeth, there is a chance
that a ‘hole’ can be made between the mouth & the sinus (this is sometimes not
evident at the time of operation but may develop several weeks afterwards).  If this
’hole’ persists or is left un-repaired, every time you drink, fluid can come out of the
nose and you may develop a marked
sinusitis.  This ‘hole’ if small enough, can
spontaneously close.  It can be assisted in this by ‘cover plates’ that prevents food
& fluids going into the sinus allowing the hole to close naturally.  However, ‘holes’
above a certain size need to be surgically closed.

Fractured Tuberosity.  The upper molars can, from time to time, be fused with the
bone around them so that in removing the molar tooth, the bony socket within which
the tooth sits (
tuberosity) comes with it.  This can make the mouth-sinus
communication larger (see above) and sometimes, the adjacent teeth and their
bony sockets comes attached with the extracted tooth.

Closure of the ‘hole’ is
followed with antibiotics, painkillers & decongestants.

Nose-blowing is forbidden for a week afterwards (at least).

Rare Surgical Consequences:

Prolonged Period of Disability.

Prolonged Pain.

Prolonged Limitation of Mouth Opening (Trismus).

Prolonged Bleeding from the Extraction Site.

Prolonged Swelling.  Discomfort, swelling and œdema are normally considered
inevitable consequences of wisdom tooth removal but as part of general
improvement in patient care, all reasonable steps would have been taken to
minimise them.

Excessive operative time, difficulty of extraction (such as bone removal) and flap
retraction increase the swelling associated with surgery.

Periodontal Complications.

Systemic Medical / Surgical complications / Death during Operative / Post-
Operative Period

Complications associated with Local Anæsthetic, Sedation or General Anæsthetic.

Development of Excessive Blood Clot / Bruising.  Development of excessive blood
clot (
hæmatoma) in chewing muscles, tissue spaces etc may manifest itself on the
face and slump into the
submandibular region and then down the neck onto the

Also, effects of blood clots being converted into scar tissue – prolonged
Hæmatoma formation outwith the socket can occur and may require drainage.

Unscheduled Secondary Surgical Procedure.

Ludwig’s Angina.  This is a potentially fatal infection that involves the fascial spaces
of the floor of the mouth and neck.  Now rare but still needs to be taken seriously.

Acute / Chronic / Local / Systemic Infection including Development of Osteomyelitis.

Persistence of / Development of New Pathology (eg. recurrent or residual cyst or

Sub-Cutaneous (Surgical) Emphysema.  Very rarely, air can enter the skin around
the operation site and become trapped.  This can lead to swelling, especially
around the eyes or over the cheeks.  This can be quite disconcerting however it
slowly subsides and there is nothing really to worry about.

Post-Extraction Granuloma.  This complication occurs 4 – 5 days after the
extraction of the tooth and is the result of the presence of a foreign body in the
tooth socket e.g. amalgam remnants (from the tooth filling), bone chips, small tooth
fragments, calculus etc.  Foreign bodies irritate the area, so that post-extraction
healing ceases and there is suppuration of the wound.

This complication is treated with debridement of the socket and removal of any /
every causative agent.

Lingual Plate Fracture.  This is seen with:

  • horizontally / mesially impacted lower wisdom teeth that have been partially
    erupted for awhile together with
  • low-grade infection associated with them (such as pericoronitis or
  • root forms that make the tooth more resistant to extraction
  • large roots
  • the sudden application of force
  • African origin (denser bone)
  • the more mature patient (sclerotic bone)
  • fusion of the tooth to the surrounding bone (ankylosis)
  • the use of chisels / osteotomes, utilised in the decoronating of lower wisdom
    teeth (Lingual Split Technique used to ‘saucerise the socket’).

The plate fragment is often adherent to the wisdom tooth.  Dependent on its size, it
can be dissected out.  The socket will need to be ‘tidied up’ (the archaic term
wound toilet” is used).  It is possible that the Lingual Nerve may be traumatised
whilst this is being done.  This will result in nerve damage that ranges from
numbness of the tongue to '
pins and needles' or 'burning' of that side of the tongue
as the extraction to loss of taste.

Introduction / Displacement of Tooth, Tooth Fragments or other Foreign Body /
Bodies into Adjacent Anatomical Zones.

Jaw Dislocation.  It can be extremely uncomfortable having a lower molar tooth
extracted, not because of pain at the surgical site but because of traction on the
temporomandibular joints (TMJ) / jaw joints, consequent to the oral surgeon
pushing down on the tooth with the extraction forceps.  It is important that the
surgeon fully supports the lower jawe during extractions in order to relieve stresses
on the TMJ.

Where extractions are performed under General Anæsthetic, it is all too easy to
forget the TMJ.  On completion of treatment, immediately prior to removing the
throat pack, the oral surgeon should manipulate the lower jaw into centric occlusion
to ensure that it is not dislocated (i.e. the lower jaw has gone back into its correct
position).  If it is not, then the dislocation should be reduced before the anæsthetic
is reversed and the patient woken up.

Removal of wisdom teeth may cause / exacerbate a pre-existing
TMJ problem.  
This complication is best prevented by allowing the patient to bite on a prop and
rest every few minutes if the procedure is prolonged.  If TMJ problems do occur
following wisdom teeth removal or other oral surgical procedures, they
must be
treated in the normal way utilising predominantly non-surgical modalities, such as
rest, heat, muscle relaxants and possibly, bite-raising appliances / occlusal splints.

Exposure of an Inappropriate / Unplanned Operative Site (eg. incorrect side)

Extraction of the Wrong Tooth.

Fractured Upper / Lower Jaw secondary to Tooth Removal.

Fracture / Failure of Instrument with Retention of Instrument Fragment within Bone
Soft Tissue.

Soft Tissue Damage.

Aspiration.  All tooth extractions carry the risk of aspiration (the tooth is inhaled).  
The use of sedation compromises the protective reflexes of the airway.  
is usually the result of a patient coughing or gagging.    

Orbital Abscess.

Buccal Fat Herniation.

Brain Abscess.


Sub-Dural Empyema.

Paroxysmal Vertigo.

Herpes Zoster Syndrome.

Retrobulbar Hæmatoma.
Useful Articles:

J Oral Maxlllofac Surg 1985.  A Prospective Study of Complications Related to   
Mandibular 3rd Molar Surgery

J Oral Maxillofac Surg 1986.  Complications Following Removal of Impacted 3rd  
Molars.  The Role of the Experience of the Surgeon

J Can Dent Assoc 2002.  Life-Threatening Hemorrhage after Extraction of 3rd   
Molars.  Case Report & Management Protocol

J Oral Maxillofac Surg 2003.  Types, Frequencies & Risk Factors for   
Complications After 3rd Molar Extraction

J Oral Maxillofac Surg 2007.  Severe Third Molar Complications Including Death -  
Lessons from 100 Cases Requiring Hospitalization

JOMS 2007.  Age as a Risk Factor for 3rd Molar Surgery Complications

J Oral Maxillofac Surg 2010.  Control of Life-Threatening Head & Neck Hemorrhage
After Dental Extractions. A Case Report

J Can Dent Assoc 2010.  Ontario Girl Suffers Septic Shock After Third Molar

J Oral Maxillofac Surg 2011.  Extensive Maxillary Necrosis Following Tooth   

J Ind Acad For Med 2011.  Case Report.  Fatal Haemorrhage Following Extraction  
of 1st Molar

Cochrane Review 2012.  Review.  Antibiotics to prevent complications following
tooth extractions

JOMS 2012.  Exsanguinating Hemorrhage Following 3rd Molar Extraction - Report  
of a Case & Discussion of Materials & Methods in Selective Embolization

JOMS 2013.  Sudden Hearing Loss After Dental Treatment

In Tech 2013.  Complications Following Surgery of Impacted Teeth & Their  
Last Updated 28th September 2018
Common Surgical Consequences:

Pain.  As it is a surgical procedure, there will be soreness after the tooth removal.  
This can last for several days.  Painkillers such as
Ibuprofen, Paracetamol,
Solpadeine or Nurofen Plus are very effective.  Obviously, the painkiller you use is
dependent on your medical history & the ease with which the tooth was removed.

Swelling.  There will be swelling afterwards.  This can last up to a week.  Use of an
ice-pack or a bag of frozen peas pressed against the cheek adjacent to the tooth
removed will help to lessen the swelling.  Avoidance in the first few hours post-op,
of alcohol, exercise or hot foods / drinks will decrease the degree of swelling as

Bruising.  Some people are prone to bruise.  Older people, people on aspirin or
steroids will also bruise that much more easily.  The bruising can look quite florid;
this will eventually resolve but can take several weeks (in the worst cases).

Stitches.  The extraction site will often be closed with stitches.  These dissolve and
‘fall out’ within 10 – 14 days.

Limitation of Mouth Opening (Trismus).  Often the chewing muscles and the jaw
joints are sore after the procedure so that mouth opening can be limited for the
next few days.  If you are unlucky enough to develop an infection afterwards in the
socket, this can make the limited mouth opening worse and last for longer (up to a

Post-op Infection.  You may develop an infection in the socket after the operation.  
This tends to occur 2 – 4 days later and is characterised by a deep-seated
throbbing pain, bad breath and an unpleasant taste in the mouth.  This infection is
more likely to occur if you are a smoker, are on the
Contraceptive Pill, on drugs
such as
steroids and if bone has to be removed to facilitate tooth extraction.

If antibiotics are given, they are likely to react with alcohol and / or the
Contraceptive Pill (that is, the ‘Pill’ will not be providing protection).

Adjacent Teeth.  The surrounding teeth may be sore after the extraction; they may
even be slightly wobbly but the teeth should settle down with time.  It is possible
that the fillings or crowns of the surrounding teeth may come out, fracture or
become loose.  If this is the case, you will need to go back to your dentist to have
these sorted out.  Every effort will be made to make sure this doesn’t happen.  In
very rare instances, the surrounding teeth may actually come out as well as the
intended tooth.

Surgical Removal.  To ease the removal of teeth, it is sometimes necessary to cut
the gum and/or remove bone from around the tooth.  If this is the case, you can
expect the extraction site to be more sore afterwards, the swelling to be greater
and more likely to become infected.  Hence, stronger painkillers are needed; use of
icepacks necessary and antibiotics will probably be prescribed.  The bone grows
back to a greater extent.  Care though will be taken not to be ‘wasteful’ in bone
removal as this effects afterwards the provision of dentures, bridges and implants.
Indications for Tooth Removal