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Surgical Extractions: Faster,Easier, and Less Stressful

Dr. Karl Koerner

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.

Originally developed for an ADA Meeting with my denture lab technician, Gerry Bryant in Logan, UT (he now lives in St. George, UT)

Case Report85 y.o. lady

“Surgical” Extraction

Tooth #30How much time for the procedure?• Cannot use an elevator on the distal. • An elevator won’t work very well on the mesial.

Step-by-step instructions from Dr. Karl Koerner for the clinician performing the case.

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Soft tissue reflection• scalpel in sulcus• periosteal elevator in sulcus• enough room to slip in

forcep beaks down to bone(Most likely cowhorn.)

Section cut.

How deep is the section cut?

How wide M-D?How wide B-L?

Crown part breaks off.

• Luxator into mesial PDL• Push and wiggle 4 mm down• Turn clockwise/counterclockwise

Hold for 8-10 seconds(sustained pressure)

• Don’t pry back

• Periotome bur in PDL• 6 mm past Luxator depth• Turn clockwise/counterclockwise

Straight OR highspeed!

• Then Luxator into mesial PDL 10 mm• Turn each way and hold 8-10 sec.• Try larger instrument

(34 elevator)

3 & 5 straight(3 & 5 curved)

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• Inter-radicular bone removal - if necessary and• Instead of buccal bone removal….

• Then Luxator at 10 mm again.

Mesial root.

• Mini-Cryer• Fulcrumed against

bone, not soft tissue• Cryer point into root

• Mini-Cryer• Fulcrumed against

bone, not soft tissue• Cryer point into root

Tried to remove distal root with:• The same mini-Cryer within the socket• Luxator from the distal of the distal rootDIDN’T WORK

• Removed more interradicular bone with a 703 – starting at the apex of the empty mesial root socket and as wide as the distal root, over to the distal root. See video clip.

Then…• Mini-Cryer from within

the socket, and• Luxator in the PDL on

the distal of the distal root

THEN SUCCESS!

Mesialroot

Roots out, BUT buccal plate fractured in theprocess. See video clip below.

Bone was attached to the periosteum so the rootwas kept and not removed.

“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.

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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.”

Elevator Luxator

roo3 mm luxator with the MB

root of an upper 1st molar.

Luxator Elevator

StraightStraight(for anterior)

Curved(for posterior)

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

different.

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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.

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

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.

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.

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

5-8,000 rpm

GPSlowspeedstraight

OMShandpiece + = Another

way.

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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.

Algorithm for difficult single root.

• 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.

Extractions and the

Maxillary Sinus

Dr. Karl Koerner

Treatment based on the size of the sinus perforation.

Gauge treatment according to the size of the opening:

• If 2 mm or less: no further treatment – than precautions and medications

• If 2-6 mm:– figure eight suture over socket – collagen plug could be placed in the socket– try to get better closure

• If over 5-6 mm: get primary closure

• With a chronic sinus condition, get primary closureregardless of size of opening.

Hupp J, et al. Contemporary oral and maxillofacial surgery., 5th ed. Mosby. St. Louis, MO. 2008.

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Sinus precautions:

Avoid:

1) blowing the nose,

2) sneezing, or

3) coughing

with the mouth closed.

Also, don’t smoke or use a straw.

Medications (for 7-10 days):

• Antibiotic

–Example: Amoxicillin 875 mg, bid

• Oral decongestant:

–Examples: Sudafed 120 mg

sustained release, bid

– Claritin D (alternative)

Recommendations:• If perforation suspected, don’t enlarge

probe, or irrigate .• Less than 2 mm: suture to support clot,

sinus precautions.• 3-6 mm: Gelfoam, figure 8 suture, sinus

precautions.• Over 6 mm: tension-free primary closure.

Lam D and Laskin D. Oral and maxillofacial surgery review: A study guide. Quintessence Publishing.2015.

Five day post-op. Patient careful. No apparent

communication.

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• 2 mm sinus exposure.• 2 Colla-Plugs, cross horizontal mattress and

interrupted sutures.• Precautions and medications.

Hupp J, et al. Contemporary oral and maxillofacial surgery., 5th ed. Mosby. St. Louis, MO. 2008.

Cut through periosteum into the

fat.

Cut through periosteum into the

fat.

A. Baumann, et al. Closure of oroantralcommunications with Bichat’s buccal fat pad.J Oral Maxilofac Surg. 67:1460-1466, 2009.

Pictures compliments ofDr. Charles Miller, DDS, MD

Suturing for Routine Exodontia

Dr. Karl Koerner

Sutures

• For exodontia: Chromic gut, silk (need 5-day tensile strength)

• For bone grafts: PGA, PTFE, nylon (no silk, want 14 day tensile strength for 2-week removal)

• Type of needle: usually 3.8 circle, reverse cutting (C-6 or FS-2 - which are the same)

• Size of suture material: 4.0 common, some like 3.0 more than 4.0 for exodontia.

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“X” Suture.The X is on top of the soft tissueallowing for better hemostasis.

Advantages:Fast and easy.

Buccal

Horizontal Mattress.Easy to place.

Advantages:Can sometimes act in place of twointerrupted sutures, especially fora smaller socket.

Cocero, N, et al. Bleeding rate during oral surgeryOf oral anticoagulant therapy patients with associatedsystemic pathologic entities: A prospective study of more than 500 extractions. J Oral Maxiiolfac Surg.72:858-867, 2014.

Examples of using a horizontal mattress for exodontia.

Cross Horizontal Mattress.Can rest on a hemostatic agent OR on a membrane.

Advantages:Helps keep a product added to the socket in place. May need interrupteds on mesial and distal.

Sinus closure

with bone grafting.

Hypo-calcification atmid-root.

Pre-Hedstrom

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Peet forcep (mosquitohemostat).

½ of a Colla-Plug as resorbable barrier

between socket and sinus (compresses

when wet).

½ of a Colla-Plug as resorbable barrier

between socket and sinus (compresses

when wet).

5 mm perforation (slit) into sinus at apex of socket.

5 mm perforation (slit) into sinus at apex of socket.

The other half.

PTFE (nonresorbable)

membrane.

PTFE (nonresorbable)

membrane.

AntibioticDecongestantPain medicine

Bone graftBone graft

Preop.

1 mo. post-op.

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One month later…

One month later…

Painless removal of PTFE membrane with an

explorer. Bone graft now stable. Will epithelialize

in about two weeks.Implant can be placed in

3. 5 months.

Painless removal of PTFE membrane with an

explorer. Bone graft now stable. Will epithelialize

in about two weeks.Implant can be placed in

3. 5 months.Immediatepost-extraction.

Bone Grafting

for

Socket

Preservation

Dr. Karl R. Koerner

Facial bone loss several months after a routine extraction.

Bone loss from extraction trauma. (excessive force)

Does your dental extraction socket need a bone graft: A decision matrix . February 25, 2015. By Scott

Froum, DDS,

One highly quoted study suggests that 50% of

horizontal ridge loss can occur after tooth extraction

with an average of up to 6.1 mm (Figure 1). Two-

thirds of this loss of bone volume occurred within the

first three months. (3) Loss of vertical ridge height can

also occur and usually takes place along the buccal

aspect of the ridge to a lesser degree than horizontal

ridge loss. (4) References

3. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue

contour changes following single tooth extraction: A clinical and radiographic 12-

month prospective study. IJPRD 2003; 23:313-323.4 Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Perio 1998;69:1044-1049.

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Socket healing:

• About 4 days: The blood clot is replaced with granulation tissue.

• 21-28 days: Granulation tissue is converted to connective tissue.Osteoblasts initiate bone formation by secreting osteoid as several

specific proteins.o Osteoid (fibers and ground substance) is a precursor to bone.o Osteoid tissue organizes and mineralized to become woven bone.o Osteoid doesn’t need a protective membrane.

• About three months: the socket is filled with woven bone.

• About four months: Mineralizes to become lamellar bone.

• For the next year: Lamellar bone continues to mineralize.

In a favorable situation, an implant can be placed in aboutfour months.

Commonly the thickness of facial bone.

Commonly the thickness of facial bone.

How long does it take a bone graft to not need

protection any more…

to not need a barrier membrane any more…

to become “osteoid”?

Minimum 3-4 weeks.

Types of bone grafting materials:Autogenous (from the patient)

Allograft (from another person). Advantage: rapid turnover ≈ 4

months.Mineralized (cortical, cancellous, or mixed)* Osteoconductive.Demineralized (may have osteoinductive capability due to bone

morphogenic proteins)Mixed mineralized and demineralized. Has advantages of both.* cortical bone alone will take longer to turnover. ≈ 6 months

Xenograft (from a species other than human). Bovine. Usually takes longer. ≈ 6 months

Alloplast (synthetic). HA, TCP, bioactive glass, or polymer. Usually take longer. > 6 months

Where to use which bone graft:

• For future implant.• Want to do the implant ASAP.

1. Demineralized Allograft blend of demineralized + mineralized

2. DBM (demineralized bone matrix)

3. Mineralized allograft cancellous, cortical OR blend of cancelous/cortical

4. Tricalcium phosphate (TCP)Blend of TCP and other products

• For pontic site.• Peri-implantitis repair.• Not going back in.

• Bovine bone• Resorbable HA

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Why a barrier membrane?

• Prevent epithelium and connective tissue from migrating into the grafted site,

• Facilitating repopulation of the bone graft with progenitor cells from adjacent bone.

Retzepi M and Donos N. Guided bone regeneration: Biological principle and therapeutic applications. Clin Oral Implants Res. 2010:21(6):567-576.

Greenstein, et al. Utilization of d-PTFE barriers for post-extraction bone regeneration in preparation for dental implants. Compendium 2015:36(7), pp.465-472. July/August.

General Dentist-FriendlySocket Grafting

Which materials are easier to use? It depends on your

capabilities.

What isperiosteal release.

Types of bone barrier membrane materials:

Resorbable

Usually tucked under periosteum on buccal and lingual More predictable if have primary closure Many types can be successful without primary closure, especially

if only open 3-4 mm.

Bovine collagen (some stronger than others)Porcine collagen (Ossix Plus, Vitala)Allograft collagen• pericardium (stronger than normal collagen)• fascia collagen (thicker 0.8 - 1.0 mm)Laminar boneBioXclude (amnion/chorion)Polyglycolic acid (Epiguide)

Non-resorbable

e-PTFE. Effective but can become infected after about 4-6 weeks if exposed.

d-PTFE. Advantages: Disadvantages:Need not be submerged. Needs to be removed.Don’t need primary closure. Can blunt papillae inDon’t need periosteal release. anterior with thinCan remain open the width of the socket. phenotype cases4 week removal. Could be as long as 6. Needs to be sealed Assures the presence of keratinized tissue.

2 week post-op.

1 month post-op.

PTFE (Teflon) membrane

If nearly closed (within 3-4 mm)can use collagen membrane.

(Unless can cover with provisional, then can be open more.)

If open more than that, PTFEmore predictable.

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One month post-op.

No periosteal release – rather, 3-tooth wideenvelope flap.

Most commonsutures:

• PGA• PTFE• Nylon

Osteoid