Tooth and bone fragments (following a tooth extraction). - Why do they appear? | What do they look like? (pictures) | Removal by your dentist. | How to remove them yourself. | What causes bone sequestra (fragments, spurs) to form?

A fairly common postoperative complication associated tooth extraction healing is that of discovering one or more small hard, often sharp, fragments (splinters, shards, slithers, spurs, chips) of tooth or bone that have worked their way to the surface of your surgical site and are now sticking partway out of your gums.

The scenario.

Following your surgery, the healing of your wound has been progressing normally and uneventfully.

After some days or weeks, your tongue suddenly discovers a tiny hard object sticking out of your gums.



What you feel may be a small rounded lump, or a sharp-edged splinter.

This scenario is more likely to take place after relatively more difficult or traumatic tooth extractions, especially surgical ones (this includes the type of procedure used to remove impacted wisdom teeth).

What you need to know.

This page explains why these hard bits and shards (tooth fragments / bone sequestra) form, and gives pictures of what they look like.

It also outlines how they are usually removed, either by your dentist or, in the case of the smallest splinters or spurs, own your own as self-treatment.

We also include discussion about how cases involving larger and/or multiple fragments are managed by dentists.

What types of fragments are involved?

Any slivers or pieces you discover sticking out of your extraction site have come from within it. These bits can include:

Tooth pieces / Root tips. - It's not terribly uncommon for a tooth to break or splinter during its extraction process. For example, root fracture is the most common intraoperative complication and estimated to occur in 9 to 20% of cases. (Ahel)

Or before a tooth does break, a dentist may strategically decide to cut it up into parts (referred to as "sectioning" a tooth The rationale.). Doing so can make it easier to get out. Whatever the case, if bits or shards are created during the extraction process, some of them may get left behind.

- It's not terribly uncommon for a tooth to break or splinter during its extraction process. For example, root fracture is the most common intraoperative complication and estimated to occur in 9 to 20% of cases. (Ahel) Remnants of the tooth's dental restoration. - The forces used to remove a tooth may dislodge or break its filling. If so, they may find their way into the empty socket and get left behind.



- The forces used to remove a tooth may dislodge or break its filling. If so, they may find their way into the empty socket and get left behind. Bone fragments, spurs, bony flakes. - Two different scenarios may be involved when these types of objects form.

1) Broken bone - Bits of a tooth's bony socket may break off during the extraction process. 2) Damaged bone - Bone is living tissue, and if it's traumatized enough during the extraction process aspects of it may die (see below). These types of fragments are called "sequestrum" (singular) or "sequestra" (plural).

▲ Section references - Ahel, Sigron

Is it normal to have fragments appear after a tooth extraction?

No, it's not "normal" to discover pieces of bone or tooth coming to the surface of your extraction site during its healing process (the vast majority of extractions are not accompanied by this complication). But at the same time, having this experience certainly isn't uncommon.

It is a phenomenon that's more likely to be associated with comparatively more difficult extractions. But even then, you don't have to expect that it will occur.

Occurrence statistics.

A study by Sigron placed the incidence rate of sequestra formation (bone fragments) following the surgical removal of lower wisdom teeth at 0.32% of cases.

(Since this can be one of the most challenging types of tooth extractions, it might be expected that experiencing fragments would be comparatively more likely with this type of procedure.)

In regard to routine extractions, we could find no statistics to report.

Your potential for experiencing this phenomenon would be multifactorial, with issues such as the skill of your dentist, the extraction process used, your age, and the quality of bone all being considerations.

▲ Section references - Ahel, Sigron

What do the fragments look like?

You may be able to visualize the spur of bone or shard of tooth sticking out through your gums. But if you can't, don't be too surprised.

The location of the protruding bit may be such that it's essentially impossible to view it without aid (such as the good light source and small oral hand mirror that your dentist has to use).



The sharpness or irritation that your tongue feels and interprets as being caused by something large may in reality be caused by an object so small that it's difficult to visualize.

How the lesion looks in your mouth.

In response to the presence of the (foreign) object, the soft tissues that surround the fragment will characteristically show signs of redness (erythema), and maybe even some minor, very localized level of swelling (edema). The area may be tender to touch.

In some cases an ulceration may form, especially when larger bone fragments are involved. These lesions typically display a whitish surface membrane surrounding a hard center section of exposed bone.

Any exposed or protruding bone is usually non-responsive to touch (its dead or dying) but the surrounding tissue may be extremely sensitive (Farah). Likewise, tooth fragments themselves will be non-sensitive to touch but their surrounding tissue may be.

▲ Section references - Farah

Post-extraction bone sequestrum and tooth fragment.

Inspecting the fragment.

No doubt the piece that has surfaced or has come out will be a curiosity to you.

Bone bits (sequestra) - These items are usually very irregular in shape, with rounded or sharp edges. Their color is usually light tan to white. Their surface will look smooth but lobulated (not perfectly flat but bumpy).



- These items are usually very irregular in shape, with rounded or sharp edges. Their color is usually light tan to white. Their surface will look smooth but lobulated (not perfectly flat but bumpy). Tooth fragments - These slithers can be very shard-like (pointed, sharp edged, etc..., just like you'd expect a piece of broken tooth to be). However, if the aspect you're looking at is the tooth's original outer surface, that side will have contours that are smooth and rounded.

Those portions covered with dental enamel will be white and have a shiny appearance when dry. Aspects involving the inner portions of the tooth or its roots (both composed of dental dentin) will have a more yellowish tint, and a dull appearance when dry.

The size of the fragment can be quite variable. And like an iceberg, what you see sticking through your gums may in no way correlate with the full extent of what lies underneath (be it large or small).

Why do these bits and slivers come to the surface?

You might find that discovering pieces of tooth or bone coming from your extraction site to be somewhat disturbing. But experiencing this phenomenon is actually a fairly common occurrence, and it's easy enough to understand why it needs to take place.

Why it occurs.

From your body's perspective, these pieces of tooth and lumps of dead bone (sequestra) are foreign objects.

(They aren't healthy, live tissue that can once again be a part of your body. To the opposite, their presence complicates and delays your wound's healing process.) Since these objects have no beneficial value, and in fact are instead a complication, your body's goal is to eject them.

What takes place.

Fragment migration.

The path of least resistance for these pieces is through the newly forming tissues of the healing socket. Then, once they've migrated to the surface of your jawbone, they begin to penetrate into the gum tissue that lies over it, until they ultimately wind up poking through and sticking out of its surface.

Shard discovery.

In cases where the object is somewhat rounded and relatively smooth, and especially if there's a substantial portion of it still not sticking through yet, these pieces may feel like a small (possibly movable) lump in your gum tissue.

If instead the fragment has any degree of roughness or sharpness, it won't take long for it to cut through. And it won't take long for your tongue to find it, and probably be quite annoyed by its presence.

Exfoliation or removal.

If given enough time, most small fragments can be considered self-limiting, in the sense that they will ultimately work their way on through the gum tissue and at some point finally fall out (exfoliate) on their own.

For most of us however, their presence is too much of a novelty or irritation, or the process simply too drawn out, and going ahead and removing the item (discussed below) is desired.

If this root fragment is not removed at the time of surgery it may eventually come to the surface on its own.

Post-extraction fragment timing.

When do the pieces first start to appear?

Routine bone sequestra and tooth fragments can come to the surface of an extraction site at any point during its healing process. Extraction healing timeline.

But in most cases, you're most likely to start to notice these bits sticking out of your gums during the first few weeks after your tooth was removed.

Some bits may take longer.

Some tooth fragments, especially root tips, may prove to be an exception to the above general rule. These shards may not surface for months (or even years later, if at all) following your surgery.

Risk factors / Prevention.

The likelihood of experiencing tooth and/or bone chips after an extraction is most likely to occur after those where the surgery involved has been relatively difficult or traumatic in nature. The paragraphs below explain why.

[And no, despite their best efforts no dentist can prevent them from occurring 100% of the time.]

a) Bone fragments (sequestra).

Bone is a living tissue and if it has been traumatized enough during the extraction process portions of it may die. (When a sequestrum comes out, the piece you are looking at is literally a chunk of dead bone.)

What your dentist can do.

Your dentist's overall goal will be to minimize the level of trauma that's created during your extraction procedure. With this in mind:

They'll take great care whenever working directly with bone tissue, like during those times when the gums lying over it have been flapped back The procedure. so they have direct access to it.

This includes completing your procedure as quickly as possible, and keeping the exposed bone moist.

so they have direct access to it. If trimming bone tissue with a drill, they'll constantly flush it with water so it doesn't become overheated by the process.



They'll limit the degree to which they continue to wrestle the tooth back and forth during the extraction process. That's because the continued use of heavy forces may damage the bone surrounding the tooth, thus leading to its demise and ultimately sequestrum formation.

A paper by Early suggests that excessive deformation of the bone and/or bone trauma created by the use of rotational movements of the tooth during the extraction process are actions that tend to contribute to sequestrum formation. And in cases predisposed to the use of these techniques, that performing the extraction as a surgical one probably makes the better choice because it will likely result in less bone trauma.

▲ Section references - Early

b) Broken bone.

The bone that makes up a tooth's socket is fragile, and aspects of it may break during the extraction process. If this occurs, a major issue is whether or not the blood supply to the fragment has been compromised or not.

If it is still intact, the fractured piece may heal. If not, it will become necrotic (die), and ultimately be ejected as a sequestrum.

Your dentist will thoroughly flush out your tooth's socket to remove any loose debris.

Complete breaks.

Any pieces that have broken free entirely and are noticed by the dentist can be picked out or washed away when the tooth's empty socket is "irrigated" (flushed out with water or saline solution).



Some bits may go unnoticed but will get flushed away anyway during the socket's post-extraction irrigation.

Any fragments that have broken free that aren't removed from the socket will ultimately be ejected as bone sequestra during the healing process and following.

Attached bone fragments.

Those broken pieces of bone that are still attached to tissue (still have a relationship with surrounding bone and/or gum tissue) and still maintain an adequate blood supply (the broken bit's source of nourishment), may ultimately heal and therefore may be left in place by your dentist (this is a judgment call on their part).

If they don't survive, they will become bone sequestra.

c) Tooth pieces.

Routine fragments.

Anytime a tooth does splinter or break, a dentist will make sure to thoroughly irrigate (wash out) the tooth's socket with water or saline solution in an attempt to flush away any and all remaining loose bits.

A broken root tip remaining in the tooth's socket.

Root tips.

While never a first choice, a dentist may decide that leaving a broken root tip leaves the patient at less risk for harm than the damage that might be caused by trying to retrieve it.

As general rules:

If a tooth remnant 4mm or less (which is on the order of 1/8th inch) lies in close proximity to a vital structure (e.g. nerve bundle, sinus floor, etc...), the risk vs. reward (see below) of removing it as compared to just leaving it alone should be carefully evaluated.

Unless infected (a judgment based on the reason for the extraction), leaving behind a small fragment is usually of no consequence.

Any pieces of broken tooth root that do remain should be periodically monitored via x-ray examination.



Over time, there is a chance that the broken fragment may migrate to the surface of the bone where it can be removed, possibly quite easily.

▲ Section references - Koerner

Possible complications with removing root tips. (Risk / reward considerations.)

As you might imagine, the tips of some broken roots can be hard to visualize and access. And if so, they can be a challenge to remove.

In their zeal to remove a fragment, a dentist may inadvertently use more force than what the sometimes very fragile surrounding bone can bear. If so, the root tip may be pushed beyond the tooth's socket and into an adjacent anatomical space (like the patient's sinus area).

While this type of event isn't necessarily common, it can occur. And in situations where the potential for a complication occurring seems relatively possible (in this case the displaced piece will need to be retrieved), leaving the broken fragment alone in the first place may make the most prudent choice.

d) Your part.

There's really not much you the patient can do to prevent extraction fragments other than giving your dentist your full cooperation so they can complete your procedure under as ideal circumstances as possible. (In more straightforward terms, make it so your dentist is able to focus more so on the process of performing your extraction, instead of managing you.)

Removing bone fragments and tooth pieces.

a) Treatment performed by your dentist.

It's your dentist's obligation to provide the assistance you require during your extraction site's healing process.

So, if you've found anything hard or sharp sticking out of your gums, you should never be hesitant to ask for their attention and aid.

What your dentist needs to do.

In short, your dentist simply needs to remove the shard. With the small types of fragments that are the focus of this page, the procedure is usually quite easy. However, and as explained below, larger bits may offer your dentist more of a challenge and require a more involved procedure.

How they'll do it.

With most cases, removing the offending piece usually just takes a quick flick or tug using a dental instrument or a pair of tweezers, with no anesthetic required.



In some cases, the spur or sliver might be large enough and/or still buried under your gums enough that a longer, harder tug or push is required. If so, the use of some type of anesthetic might be in order.

▲ Section references - Wray

Anesthetic options.

A dentist has two types of numbing agents that might be used:

Topical anesthetic (i.e. benzocaine) - This type of product is usually a gel that's smeared on the patient's gums around the protruding fragment.

Generally speaking a topical anesthetic is only able to numb up the surface of the gum tissue. But since that's where the bulk of the fragment likely (hopefully) resides, its effects are usually sufficient.

(i.e. benzocaine) - This type of product is usually a gel that's smeared on the patient's gums around the protruding fragment. Local anesthetic (i.e. "Novocain") - This type of anesthetic is given via injection (a dental "shot").

This method of anesthesia provides a deeper, more profound level of numbing. The trade-off is that you're likely to feel the pinch of the shot Why some shots hurt. as it's given.

You'll simply have to rely on your dentist's judgment as to which method is needed for your procedure. They'll base their decision on their interpretation of how small the object is and how quickly they expect it to flick out. Your concerns can be an important part of this calculation too, so let them be known.

Situations involving relatively larger fragments.

In some cases your dentist may determine that the shard is relatively immobile. This might be because a substantial portion of it is still buried below the surface of the gum tissue. Or in the case of a sequestrum, it has yet to fully separate from associated bone tissue.

If this is the case, an alternative plan will need to be formulated.

a) Allowing the fragment more time.

Since your body's goal is to completely eject the surfacing shard, allowing this process more time may provide a simple solution.

A plan might be formulated where the piece is checked by your dentist periodically (every few days to a week). And at that point when its removal seems possible, they will.

b) Surgically removing the fragment.

It may be decided that going ahead and removing the offending piece via a minor surgical procedure makes the better plan. To do so:

After administering a local anesthetic, your dentist will make an incision in your gums along what they interpret is the object's longer axis.

(A clean incision will heal more quickly than tissues that have been ripped or torn during the removal process.)

Now that your dentist has adequate access to the piece, they'll go ahead and hopefully tease it out easily and quickly. (But even your dentist won't know exactly how much of a wrestling match it will be until they're finished.)



Once removed and depending on the extent of the incision made, placing a stitch or two may or may not be required.

▲ Section references - Farah, Wray

Taking an x-ray.

Your dentist may feel it's necessary to evaluate your tooth's socket by way of taking a radiograph.

Since live and dying bone (sequestra) will both have a similar level of mineral content and therefore similar density, early on it may be difficult, if not impossible, for your dentist to precisely distinguish one from the other on an x-ray.

In more chronic situations, differentiating between the two can be expected to be easier. Although with very small shards, probably still a challenge.

As tip-offs to your dentist: Your body may encapsulate the fragment in tissue, thus giving it a distinct appearance. Or because it has begun its migration, the bony piece may appear as an object out of place.

Since tooth shards, root tips and pieces of filling material each have a different density (and density pattern) than bone, they are much more likely to be visible on a radiograph.

Proactive treatment.

For small, routine shards, a dentist will usually just provide treatment for their patient on an as-needed basis (as each bit surfaces and is discovered sticking out of the gum tissue).

Less common is the scenario where the dentist goes after the pieces surgically before they surface. Here are some reasons why:

As we've just explained, some types of fragments can be hard to identify on dental x-rays. And even if seen, routine x-ray imaging only provides a two-dimensional representation, which means that it can still be difficult to know exactly where the offending shard(s) lies.

Visibility in an extraction site can be limited. Bleeding can further complicate this issue. Overall, especially when smaller, multiple fragments are involved, locating all of the offending bits may not be simple or entirely successful.



Probably the biggest question is simply, why create a whole new surgical wound just to remedy a situation that your body will most likely handle relatively uneventfully on its own?

Having stated the above, when the fragments are relatively fewer and larger, or it's your dentist's interpretation that a piece will not shed so easily or uneventfully, the case for surgical intervention can make a lot of sense.

b) Do-it-yourself treatment.

You may be able to remove very small tooth and bone splinters that have worked their way to the surface of your gums (are poking through) on your own.

These bits can usually be flicked out using your fingernail, pulled out with tweezers, or pushed out by your tongue.

It may take working the bit repeatedly over the course of a day or two until it finally gets to a point where it's loose enough to come free.

When it finally comes out, you'll probably get a little bit of bleeding but it should be very minor. (Bleeding is best controlled by biting firmly on gauze. What to do. )



) If a portion of the shard hasn't yet penetrated through your gum tissue (so you can get at it and manipulate it), you'll simply have to wait until it has.

The only other option would be to request your dentist to remove it surgically (described above). After evaluating your situation, they can then determine if that option seems reasonable at this point. Or if instead, the fragment should be allowed more time to work its way through the tissue before it's challenged.

Anesthetic.

If you're squeamish about the way it feels to wrestle one of these fragments out, you might consider using an over-the-counter gum-numbing product.

Look for products (liquids, gels) that contain the anesthetic benzocaine (ask your pharmacist). These are the same types of products that are often used with children to control teething pain.

Best practices for at-home treatment.

Do-it-yourself treatment is fine for emergencies and when the bit comes out easily. But overall it just makes good sense to touch base with your dentist when any fragments show up. (It's your dentist's obligation to provide you with the post-extraction follow-up care you require.)

Here's why ...

If you're generally a healthy person, and the area where the fragment has appeared was involved with a challenging extraction (which can be an explanation for its presence), then what's discussed on this page likely applies to your situation. But for others, the event may be an indication of more serious issues.

As examples, people who have a history of taking bisphosphonate medications (like Fossmax®) or those who have had head and neck radiation treatments are at risk for serious complications with bone tissue healing. And therefore, the apparently minor shard they notice may instead be an indication of a more serious underlying condition.

COVID-19 / Treatment access considerations.

Special circumstances, like the 2020 Coronavirus pandemic may complicate the process of seeking attention from your dentist since their office may be closed and social distancing encouraged.

With this scenario, it's still best to contact them first. (Even if their office is closed, all dentists should still have some mechanism in place for handling emergencies. Providing for post-operative care is part of the obligation they've accepted by agreeing to perform your procedure.)

Since they already know the particulars of your case from having extracted your tooth, telephone consultation may be all that's needed. After considering what you report, they may then go ahead and ask you to remove the bit yourself, with them on stand-by for additional assistance if needed.

Healing following fragment removal.

Since the wound that remains after removing a small fragment will primarily lie within the thickness of your gum tissue, once it's gone you can expect healing and pain reduction to progress rapidly, with complete healing occurring within 7 to 10 days.

The actual time frame you experience will, of course, be influenced by the initial size (diameter) and depth of the wound that was left behind.

Larger, more involved fragments.

As stated initially, the contents of this page apply to small isolated pieces of tooth or bone tissue that have suddenly appear through the gum tissue surface of an extraction site following an otherwise uneventful healing process. Towards identifying cases that lie beyond the routine, we have a page that outlines the expected healing timeline for extractions. What's normal?

If what you have experienced varies from the norm, you need to be in touch with your dentist for evaluation. Assisting you with any and all post-extraction complications is their obligation to you.

Beyond the routine causes we describe on this page, some post-extraction fragments (bone sequestra especially) form for other reasons (pre-extraction bone infection, history of taking bisphosphonate drugs, history of radiation treatment involving the jaws, ...), and therefore require more involved treatment.



When larger and/or multiple fragments or chronic symptoms are involved, a dentist's evaluation will be needed to determine how the patient's case is best treated. Close monitoring, medication, and/or surgical intervention may be indicated.

Bone fragments not associated with a tooth extraction.

The contents of this page address the subject of small, routine bone spurs that rise to the surface of a patient's gum tissue following a tooth extraction. Possibly producing a similar experience is the condition referred to as "uncomplicated spontaneous sequestrum."

Just as above, the word "sequestrum" as used here (the plural form is sequestra) refers to dead, ejected bits of jawbone. However, with this condition the cause of the sequestra is unrelated to the removal of a tooth. And in fact, the precise cause of the bone tissue's devitalization (death) frequently remains unexplained.

A common location for the formation of these bone bits is the tongue side of the lower jaw in the area of the molars.

Why they form.

The usual explanation given for the formation of these sequestra is local tissue trauma.

The idea is that the gum tissue in the affected region has been traumatized to the point where there is a disruption to its blood supply. This might take the form of continuous low-grade trauma, or a more substantial event.



Due to the blood supply loss, the soft tissues that lie over the bone are less capable of protecting it, and as a result it necroses (dies), ultimately resulting in the formation of a sequestrum (the body's ejection of dead bone tissue).

Some suggested causes of continuous, low-grade trauma include abrasion associated with eating foods (in cases where there's a less than ideal teeth-jawbone relationship or jaw shape, or an area of missing teeth) or trauma caused by repeated activities such as tooth brushing.

Treatment and concerns.

After evaluation, with very minor cases a dentist might conclude that the event has been a self-limiting condition that lies within the normal limits of what a person may experience.

With these minor cases, once the sequestrum has been lost (either spontaneously or assisted) the patient's pain relief and healing will progress rapidly, with complete healing occurring within 7 to 10 days.

With more involved cases, the potential for contributory systemic health factors may need to be considered and evaluated. Additionally, the size of the affected area/lesion may be large enough that your dentist feels that surgical intervention is required.

▲ Section references - Farah

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Authorship: Written by Staff Dentist