Extraction of Teeth and the Impact on Site Preservation: Open Discussion
The extraction of teeth prior to implant installation has received a great deal of attention in recent years because of the impact on site preservation. The goal is to extract natural teeth and produce minimal negative impact on the existing bony architecture to prepare the site for implant installation. One of the new techniques to accomplish this is the use of piezoelectric handpieces to extract the teeth. Also new kinds of extraction forceps have been developed that minimize bone destruction during the extraction process. Other devices have been developed. But there are times when bone destruction is unavoidable due to the complexity of the extraction process. What techniques do you use for minimizing bone destruction during complex surgical extractions?
14 Comments on Extraction of Teeth and the Impact on Site Preservation: Open Discussion
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Robert A. Horowitz DDS
1/3/2012
This is a subject that is impossible to discuss without knowing the surgical skills of the operator and the size of the defect. There are numerous articles describing graft and/or barrier techniques. The more volume of bone that is missing requires more operator skill, more grafts and barriers, often using graft enhancers (BMP, PDGF, PRF or CaSO4 for example). Also, the more bone that is missing at the time of extraction, the greater the likelihood that there will be the need of a secondary bone and/or tissue grafting procedure. Additionally, if the tooth/implant is in the aesthetic zone, that adds another entire layer of complexity to the case. The greater the risk, the more advantageous it is for the restorative dentist to send the patient to a surgical specialist to set up the foundation for ideal prosthetic results.
Dr G J Berne
1/3/2012
The question appears to be based on complex surgical extractions, but I would comment that frequently more bone is lost with "simple extractions" than with surgical extractions. The reason is that with simple extractions one tends to remove the tooth as a whole, whereas with surgical removals the tooth is frequently split and some bone is conservatively removed and roots are frequently split to enable relatively atraumatic removal. It is not a major problem to remove bone in close proximity to the roots to enable easier removal, but what is a major problem is loss of buccal cortical plate during removal. A 4-walled socket will usually heal uneventfully with relatively little loss of bone and without the need for augmentation material. Loss of one of the walls presents a much more uncertain future for healing without bone loss. So the aim should always be to avoid fracturing or destroying the cortical plate.Any technique which enables one to achieve this outcome should be worthwhile investigating.
Lawrence D Singer, DMD
1/3/2012
Difficult extractions require a surgical approach. Typically forceps elevators and picks do not work on more difficult situations. What armamentarium are we left with? Osteotomes are great although the patient may get a bit freaked out if not sedated. Piezo tips can work as well. As much as I has to admit it, the Biolase works very well. I hate to admit it because they are so damned expensive to buy run and maintain. THey are really good for toughing around a tooth root. I have asked them to make longer tips, but right now 14mm is the max. With patience, you can trough all the way around a tooth root and not have destruction of the plate. Tit also works to obliterate the root itself as you get to the apical tips. The new laser is better than the MD, but hard to justify the investment if used only for surgical purposes. THey are also great for removing implants by troughing around them with minimal peripheral damage.
peter fairbairn
1/4/2012
Firstly try and encourage your referring surgeons to let you do the extractions no matter how easy ( as Dr Berne states) , always split multi-rooted teeth and use periotomes and rotational forces on anteriors . I worked in a Mission type clinic in Africa where I removed 160-200 teeth a day for 6 months with no available hand-pieces which was a great experience , and possibly taught me a fair amount.
But when implant treatments are planned always take twice as long and tell the patient as such , here there is no race.
Then assess the socket extensively for defects etc and wether there is sufficient bone to attain primary stability for an implant if not socket grafting will be needed as the bone loss will have been extensive , yes I know it will heal by itself but the bone dimensions will be lost.
Easygraft ( now part of Sunstar group )is my choice here as closure will not be attained and this material will not be lost from the socket .
If PS is attainable then I leave for two to three weeks for soft tissue closure and place the implants and peri-implant graft the site .
Peter
John Manuel, DDS
1/4/2012
While all of the above are excellent, one might consider that he/she can reduce the volume of graft by simultaneous placement of an implant capable of providing circulation and integration in the middle of a clot. I.e., one that can integrate without needing intimate bone contact.
Such an immediate implant will also allow some membrane support by supporting a granular graft and/or using a healing abutment configured thusly.
The finned Bicon implants work will in these situations.
John
Baker vinci
1/4/2012
I'm sure some one said this before I did, but as a resident I suggested "keeping the surgery within the tooth", at all cost. There will be times when some bone must be sacrificed, but nothing beats absolute knowledge of nerve position and rotating cold steel, assuming it is being cooled. The sharp bur is not terribly expensive. Periotomes lever against bone and I have heard plenty of reports of fractured buccal plates. Nothing will trump the experienced surgeon, in this scenario. I also agree with placing the implant at the same time. The crestal bone will never be as high as it is at extraction. This also can almost obviate the graft, in certain cases. I have been given some of these new devices to use , only to give them back. A laser for extraction? Mini- me, quit humping the laser!( Austin powers). Bv
Baker vinci
1/5/2012
Peter , my mission work was in Memphis , Tn, Dallas , Tx. , New Orleans/Baton Rouge, La. and Buris La. . Everyone knows the devastation our state has taken and our "mission work", will last forever. Those scenarios absolutely augment your acumen, but do you really think it is a fair statement to suggest , that at least in general, the omfs should be more qualified in the atraumatic removal of the failed tooth . I challenge the statement, simply because, I believe that lay people use this site to gain insight, before embarking on this type of surgery. I also did a cleft palate mission abroad and the restorative dentist there wouldn't let me remove any teeth either. You know historically, before we became ORAL AND MAXILLOFACIAL SURGEONS, we were simply exodontist, that did some occasional plastic surgery. The name in my opinion ,is a hair pretentious and impractical. Most office managers and patients, can't even pronounce the damn thing. Please don't take the "outlandish" statement ,too hard . Bv
Baker vinci
1/4/2012
The surgical tray for the seasoned omfs needs nothing more than the # 9 periosteal elevator, the medium straight , the small pointed and the root tip pick. A sharp cross cut fissure and a small round bur , can take any tooth, if you are patient enough. Having the luxury of the sleeping patient, is paramount. In our part of the world, you would be hard pressed to convince anyone that the surgeon should refer to the restorative guy to remove a tooth for an implant case. That maybe the single most outlandish thing I've read, since participating on this forum. I have restorative guys call my office, to make sure I'm in , before they start extraction cases. At least twice a week , I treat the incompletely removed tooth. Let us be perfectly clear about this. I am not complaining; I rather enjoy this part of what we do. Bv
peter fairbairn
1/5/2012
Hi BV , sorry you got me wrong there I meant Dentist as in GDPs , of course the OMS are the specialists in this field .
Just a terminology issue my apologies ! Must have been speed writing between patients and I agree it is complete non-sense in that form but meant to read General dentists ........
I also agree the use of periotomes must be to sever the ligament and not too much elevation especially on a buccal plate else it could be damaged.
Regards
Peter
Dr. Vipul G Shukla DDS
1/5/2012
Best way to minimise excessive bone loss during surgical extractions is to plan a procedure in detail before embarking on it.
Using periotomes for even simple extractions is a proven method.
Use cow horn forceps for lower molars no matter how simple they look on the PA Xray.
Section where there are large restos or endo treated.
And yes, luxate, luxate, luxate. Figure of 8 movement for multi-rooted teeth and anteriors as well.
Have a wide array of elevators and root picks for those endo treated vertical fractures where the patient was constantly warned to get a crown and he did not listen then tried opening crab legs with his teeth on Christmas eve. Ouch!
IMO, once the handpiece is picked up, living bone goes to hell in a handbasket. Minimise bone drilling to a trough on mesio-buccal angle for an elevator purchase, if more is removed, then consider socket preservation grafting at same aptt.
Happy 2012 everyone!
Baker vinci
1/8/2012
So once the handpiece is picked up , it's down the crapper? Well I beg to differ. The spinning bur, wether it be the 701 or small round, with copious irrigation, will take every difficult tooth, without touching bone. Go watch a good omfs, or a rest. guy with the same philosophy . Cow horns eat buccal and lingual plates ,if used as designed and figure of 8 movements on the partially ankylosed tooth , No thanks. I do agree with the apical pressure and pediatric forceps on simple teeth. Again just another preference. Bv
Dr. Claiborne
1/10/2012
Now that we have figured out the best way to the remove the tooth......just curious how everyone out there decides to preserve the socket. I have tried almost all techniques, collaplug, socket seal w/ CTG, CaSO4, etc. Just curious how most doctors are treating the MOLAR 4 or 5-walled extraction site. In these cases I am not advancing a flap for primary closure. Most of the time I get good results when placing a collaplug with mattress sutures. Occassionally I will get a patient that some wash out occurs. Are most doctors advancing flaps for primary closure or using some sort of "plug" technique? Always interested to hear other peoples techniques and opinions.
Baker vinci
1/17/2012
Dr. Claiborne, I do not think primary closure, is at all necessary for the single or double tooth extraction and preservation graft. In my hands I lift the buccal and palatal/linqual flaps just enough to allow my resorbable membrane to rest passively, with no tacks or fixation device. I graft with autogenous almost exclusively, sometimes mixed with demin. or min. bone . I think " the jury is still sitting in a sequestered hotel " on that issue. I remove the gortex sutures at two weeks , wether it is a graft around an implant or not. This has worked well for me for two decades. I've said it before, in the right patient, all that is needed is a membrane. My concerns with primary closure in these scenarios, is you are disrupting the nutrient supply and effectively moving your attached tissue too coronally. Primary closure is a must in big cases, but, in my opinion, regardless of the type of closure you are attempting, it must be passive( with no tension ). Some of these "larger" cases should be grafted trans neck, subsequently leaving the vascular supply almost uninterrupted . I hope this answers your question. Again, this is just an opinion, based on some strong retrospective data. Bv
Jerome Smith DDS
2/19/2012
Well stated--I completely agree with everything you've posted. Us Louisiana dentists must think alike!
