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”Surgical” Extractionsfor the

General Dentist

Part 1 .

Dr. Karl R. Koerner 90 dental students/class.

Picture from a window in the front of the building looking East.

3 surgery suites

6 open bay operatories

All for dental students.• Not OMS residents• Not GPR or AEGD

residents

Surgical extraction, root tip removal, socket bone graft with

barrier membrane, cross and interrupted sutures.

Surgical extraction, root tip removal, socket bone graft with

barrier membrane, cross and interrupted sutures.

Partial bony impaction

(mesioangular).Flap with distal

and buccal releasing

incisions, follicle removal, root

retrieval.

Partial bony impaction

(mesioangular).Flap with distal

and buccal releasing

incisions, follicle removal, root

retrieval.

Maxillary (vertical) third

molar impaction,

with flap and buccal bone

removal.

Maxillary (vertical) third

molar impaction,

with flap and buccal bone

removal.

Multiple extractions

(4) with alveoplasty,

root retrieval, continuous-

lock suturing.

Multiple extractions

(4) with alveoplasty,

root retrieval, continuous-

lock suturing.

Maxillary surgical extraction with crown sectioning, root sectioning, root retrieval, Hedstrom endo file application, preventing root from going into the

sinus on the model.

Maxillary surgical extraction with crown sectioning, root sectioning, root retrieval, Hedstrom endo file application, preventing root from going into the

sinus on the model.

Incision and drainage of

lesion.

Incision and drainage of

lesion.

Frenectomy.Frenectomy.

Excisional biopsy.

Excisional biopsy.

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ST reflectionNo elevatorCowhorn, 151”sustained” pressureAvoiding “excessive” forceSection off crown?Section between roots?Luxator (periotome bur)

1 monthpostop

Expanded lingual plate.Severe pain for one month.

“It will heal on its own.”“Maybe I can pull the piece out.”“Let me try to push it back in.”

Really?

Before Treatment

• Patient of record

–Current health history reviewed -- including all meds, even over-the-counter

– Base-line vital signs, pre-op vital signs

– Treatment plan (considers alternatives)

–Consent form filled out and reviewed

– Sedation requirements/options: nitrous oxide, oral sedation, IV sedation (may need referral)

–Adequate radiographs

Before Treatment–Other:

• Infection, previous problems numbing, how wide can they open, pre-existing TMJ issues

• Crown weakness, decayed/fractured to bone, root configurations, endo-treated, proximity to anatomical structures…

• STILL in your comfort zone?

65 y.o. male.Given amoxicillin by physician 2

days earlier. Severe trismus. Can open about 15 mm.24 hours away from toxicity, Ludwigs, ERTooth extracted.20-25cc of purulent drainage from socket.Post op metronidazole, continuing the

amoxicillin. Warm saline rinses.AbscessAbscessCellulitisCellulitis

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Purulence(X 8)

1 week post-op selfie.“I feel 90% better…”

Pre-op.

Surgery Dilemma

• Many general dentists:

– Elevator: no problem

– Forcep: no problem

– Luxator: no problem

– Handpiece/bur: hesitate

• Do I have to?

• How long is this going to take?

• What’s our schedule like?

Level of competence….• Recent graduate: minimal experience.

• Recent graduate: experience with “surgical” extractions.

• Surgery oriented GPR, AEGD, or being taught clinically by an experienced “mentor”.

• Years of experience doing and learning from many extractions.

What should you refer? Ask yourself:

• What is your level of competence with exodontia?

• How stressful does it become?

• How long does it take you to remove a difficult tooth?

• What is in your comfort zone?

So, when do you refer?(Depends on your level.)

• Seriously medically compromised patient.

• Anxious patient, requiring IV sedation.

• Likely to take too much time.

• Likely to become “surgical” and outside your capability and “comfort” level.

• Predisposed to various complications.

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If only they were allthis easy…

but they’re not.

Step-by-step “surgical” extraction of a brittle non-vital tooth, broken at the bone level, in the dense bone of a 60 year old.

“Surgical” extraction.

1. Anesthetize

- Mandibular block, long buccal injection

2. Reflect soft tissue coronally.

Use scalpel / periosteal elevator.Periostealelevator

Suctiontip

Retractor

NEVER AN ELEVATOR HERE

NEVER AN ELEVATOR HERE

Five minutes& $5.00

2 appointments &$900.00

3. 301 elevator (don’t use where there is a crown [prosthesis] on the adjacent tooth)

- mesial and distal, clockwise, counterclockwise,

sustained pressure (8-10 seconds each direction)

- don’t fulcrum against adjacent tooth

- Luxate for a few minutes

4. 151 forcep

– buccal – lingual, sustained pressure

- for a few minutes

CROWN BROKE OFF

AT CRESTAL BONE LEVEL

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151 Forcep

301 elevator

Periosteal elevator

Some of the instruments used so far.

5. 3 mm wide straight Luxator. - push and wiggle vertically

into the PDL space about 4 mmdeep

- mesial and distal only- turn clockwise and counter-

clockwise with “sustained”pressure

- for a few minutes

It worked here, but the patient was 30.

Elevator Luxator

roo3 mm luxator with the MB

root of an upper 1st molar.

Luxator Elevator

Don’t try one modality for too long. When things aren’t working for you (after 2-3 minutes), do something

different.

Oral surgeons pride themselves in taking out teeth quickly.

When rules change that you can’t remove facial boneto extract a tooth, how can you still do it in a short time?

You need a viable alternative to facial bone removal.

Solution: Periotome (skinny) bur vertically into the PDL.

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6. Use 700 (or 701) bur intothe PDL

mesial and distal 2/3 to 3/4 of root length.

- half root, half bone removal- only cut as wide as the bur

7. Then Luxatorto depth (white lines)- turn clockwise and counter-

clockwise (sustained pressure)

- for a few minutes

Only on mesial and distal..

Which handpiece is easier to cut apically along the tooth toward the apex?

RPMs don’t matter.

“Another removal technique is to take a long, thin diamond [or carbide] and go around the tooth on the mesial, distal, and the palatal (if the bone is thick).”

“To preserve bone, it is preferable when creating a trough around the tooth, to cut slightly into the tooth rather than the adjacent bone.”

Cavallaro JS, Greenstein G and Tarnow DP.

Clinical pearls for surgical implant dentistry, Part 3. Dentistry Today. Oct. 2010.

Cavallaro J, Greenstein G, & Greenstein B. Extracting teeth in preparation for dental implants. Dent Today (Peer reviewed article for CE credit). Oct. 2014. Pp 92-99.

Cavallaro J, Greenstein G, & Greenstein B. Extracting teeth in preparation for dental implants. Dent Today (Peer reviewed article for CE credit). Oct. 2014. Pp 92-99.

Authors suggest: “Bur into the PDL --up to three-quarters of the root length.”

Be careful.

The 700 or 701 bur is slender and effective but is also weak

and cannot be moved“off-angle” without

breaking. It is not a “default” bur for surgery.

That would be the 702.

Be careful.

The 700 or 701 bur is slender and effective but is also weak

and cannot be moved“off-angle” without

breaking. It is not a “default” bur for surgery.

That would be the 702.

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5-8,000 rpm 60-100,000 rpm

5-8,000 rpm

GPSlowspeedstraight

OMShandpiece + = Another

way.

ROOT FRACTURED, LEAVING A 7 MM LONG ROOT TIP.

9. With 701 bur in a straight handpiece, trough around the root cutting about 2-3 mm apically.

Be careful of the mental nerve.

10. Then Luxator, elevator, root-tip pick, mini Cryer, Molt #2 curette OR….

8. Root tip deep in the socket. Try removing with some handinstruments first. But if it doesn’t work…

8. Root tip deep in the socket. Try removing with some handinstruments first. But if it doesn’t work…

Heidbrink root tip pick

Some other instruments used.

#2 Molt curette

Successfully and smoothly removed.Buccal bone totally preserved.

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Moore PA, Hersh EV. Combining ibuprofen and

acetaminophen for acute pain management after

third-molar extractions: translating clinical research to

dental dental practice.

JADA 2013 Aug; 144(8):898-908.

Post-Operative Pain Control (moderate to severe)First day: Take two or three 200 mg ibuprofen (Motrin) tablets (400-600 mg) with one 500 mg acetaminophen (Tylenol) tablet every 4-6 hours.Second day and thereafter: Take two 200 mg ibuprofen tablets (400 mg) with one 500 mg acetaminophen tablet ever 4-6 hours as needed for pain.(Do not exceed 3000 mg of Tylenol or 2400 mg or Motrin PER DAY.)

Step-by-step for difficult single roots.

• Good x-ray• Sever soft tissue attachments• Elevator• Forcep• Luxator or similar instrument

(4 mm deep)• Periotome bur THEN Luxator

(mesial/distal)

• Root tip? Hand instruments. (elevator, Luxator, Molt #2 curette, root tip pic, or small Cryer….)

• If does not work then periotome bur: – One side– Two sides– Circumferentially – Cut root tip in half

• Followed by a hand instrument again.

MonitorMonitor

Jamaica Patient-participation.

oralsurgeryeducation.com

Oral sedation, sublingual.

Noticeably working in less

than 10 minutes.

Not 8-5.

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The following are alternatives to the Luxator and periotome bur for removing a root. They were not presented first (above) because they:

Use devices that are too expensive, or Are too slow, or Are somewhat unpredictable, or Are somewhat ineffective, or Have a more difficult learning curve

• Double-ended periotome

• Straight periotome• mallet?• Spear-point

• Leverage device 1-3• Bone-cutting piezo• Autotome• Physics Forceps

Double-ended Periotomes(also have single-ended that can be

hand-held or malleted.)

Straight “periotomes”.More effective than

double ended.

Picos spear

3 devices where you screw a drill into the root and leverage the root out.

Pry-bar: The one shown here. 2 other types…

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SD 70Z SD 70

Piezo-type bone-cuttingdevices taken intothe PDL.

Autotome. Similar tothe PowerTome.Pneumatic.

A “beak and bumper” – type device for tooth removal.

Infection not removed.

6 months later,infection replaced with fibrous tissuethat had tobe removed leaving abig defect.Grafting done.

Post-op.

Highspeed friction-grip burs:For a General Dentist highspeed:

700 surgical length (25 mm) Brasseler701 surgical length (25 mm) Brasseler702 surgical length (25 mm) Brasseler

700 XXL extra long (30 mm long) (from Sabra Dental Products and Salvin)

1702 (round end) extra long (30 mm) (from Sabra Dental Products)

-------------------------------------------------------------------------------------

Straight Handpiece Burs (Brasseler 5-packs)For a General Dentist straight handpieces

702 001220U0 44.5 mm long701 001219U0 44.5 mm long700 001218U0 44.5 mm long One hour attempt by a dentist - and still not out.

Removed in 1-2 minutes with bur/Luxator.

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Main surgical suction tip: 3.0 inside diameter.

“ Special” surgical suction tip: 2.0 inside diameter.

Wire to clean it out.

3.0 mm (15P3A)

2.0 mm (03EA)

(Also 1.0 mm diameter: 02BA w/wire too.)

Which is better?

“Surgical” highspeed:

no air.

“Surgical” highspeed:

no air.

Lower 1st molar extraction.Tooth sectioning with regular highspeed handpiece.Acute subcutaneous swelling.Extension to contralateral side, crepitus. Hospitalized, IV antibiotics, discharged in 2 days, swelling down in 1 week.Can go to thorax and mediastinum.TX: Observation, diagnosis, may want referral, CT scan, hospitalization, IV antibiotics.

Mandible and neck.Mandible and neck. Sinus and orbit level.Sinus and orbit level.

Gen Dent.May-June, 2016.

45° angle Internal, self-generating LED lightTitanium coating4-hole or KAVO attachment

Example of a “surgical”

highspeed.

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No air in the

water is best.No air in the

water is best.

Can’t find a rear-exhaustair-turbine highspeed (surgical) without the 45 degree head.

Mini Cryers.

“Small”Cryers Not as effective.

Very effective.

Crown decayed/fractured to bone? Narrow cut. LuxatorSever gingival attachments. Not into buccal/lingual plate.

Divergent roots? Section. Into bifurcation.Follow-up with straight elevator.

continue to loosen roots

Is it malpractice to leave a root?