A Modern Approach to Exodontia, Part 2: Helping to Ensure Successful Implant Outcomes

In the previous article in this series, “A Modern Approach to Exodontia, Part 1: Helping to Ensure Successful Implant Outcomes” (Dentistry Today, January 2018), we discussed the importance of patient selection for safe and predictable outcomes. In the second, and final, installment of this article, the procedural steps and recommended armamentarium for easy and bone-preserving exodontia that will best prepare the patient for implant placement are presented.

THE 5-WALL SOCKET
The primary goal in successful tooth removal is to retain 5 walls of bone around the tooth, if they have not been lost previously due to pathology. These walls include the mesial, distal, buccal, and lingual (or palatal) and the apical floor (Figure 1).

THE CURRENT AND RELEVANT ARMAMENTARIUM
No matter how skillful you are, you can break a root. Periotomes are concave. The goal is to engage the blade of the instrument in the remaining root to establish a fulcrum to leverage the root away from the buccal plate. You need to be equipped with high-end magnification and lighting because you will fail without them. Additionally, you should employ a high-speed drill designed with “reverse exhaust” to avoid a rare, but possible, episode called an air emboli.

To understand the why of recommended instrumentation, we need a quick review of the attachment phenomena of a tooth. The tooth is suspended in the socket by a periodontal ligament (PDL), which has the ability to compress, literally changing the shape and size of the socket. When pressure is exerted on the PDL, chemical changes occur that result in the release of Sharpey fibers, loosening the tooth.¹ As implant therapy becomes the mainstay of dental rehabilitation, the need to minimize socket trauma and expansion becomes paramount. Clearly, the days of “rocking” a tooth from side to side until it loosened have become obsolete.

DIFFERENT TEETH REQUIRE DIFFERENT TECHNIQUES
Successful removal requires some understanding of the various anatomy of different teeth. In all cases that are not periodontally involved, the atraumatic extraction embraces sectioning, troughing, and the use of a myriad of elevators that result in retaining a 5-wall socket.

Maxillary and mandibular incisors: These are the easiest group of teeth to remove. In most cases, the use of longitudinal and rotational forces will result in a successful extraction. There are numerous variations that can complicate the process.

Figure 1. The 5-wall socket.	Figure 2. Severing attachment fibers with a 15C scalpel blade. (Note: The blade should rest on bone.)
Figure 3. A #859.36.010 bur (Brasseler USA) is used for trenching in “tight corners” found in anterior teeth.	Figure 4. Troughing a lateral incisor.
Figure 5. A good array of elevators.	Figure 6. Periotome: leverage away from the buccal.
Figure 7. The cuspid was “cut down” for access.	Figure 8. Partial extraction therapy is a relatively novel approach that leaves a portion of the buccal root, minimizing the resorption of the labial bone and soft tissue. (Note: This technique is not for clinicians with abbreviated experience in tooth removal.)

Teeth adjacent to delicate crowns and bridges: Imagine removing the maxillary central in a 2-year-old rehabilitation that resulted in full-coverage restorations on all of the anterior teeth. The first step in any tooth removal is to sever the attached fibers to prevent tear and trauma.² There are 13 fibers that attach from bone to tooth.² Simply use a 15C blade (or a molt 2/4) to free the fibers both buccally and palatally (Figure 2). Then use a thin diamond bur (#859.36.010 bur [Brasseler USA]) to hug the root (Figure 3). Advance the bur from buccal to palatal, slowly to the depth of the diamond (12.0 mm). Be mindful of your angulation so you do not nick the adjacent crown and bridge, and hug the root following the natural angulation (Figure 4). Insert the thinnest periotome available. A periotome is a longer and thinner version of a dental elevator.2 One of the remarkable advances in modern tooth removal is the myriad of periotome designs now available. The author strongly recommends including this array of elevators (Figure 5). With the flat side of the periotome firmly up against the root exerting apical pressure, turn the periotome buccal to palatal; then slightly reverse this movement as the root begins to move (Figure 6). Always exercise major movement away from the buccal. When engaging the side (I call it the blade) of the elevator, the clinician will be able to force the root toward or away from the buccal plate. Force should always be toward the palatal or lingual wall of bone. Allow 15 to 20 seconds of force at a time. Only proceed to a forcep when there is clear mobility of the remaining tooth. The most common mistake in tooth removal is made at this juncture. Do not hesitate to go back with a thin diamond and trough further apically or use a differently shaped periotome to loosen the tooth further. Taking an extra minute or 2 of preparation can save you from a broken root tip that would only complicate the process.

Maxillary and mandibular cuspids: These may represent the most challenging teeth to extract. Long roots and a thin buccal plate create the problem. Here is the protocol:

1. Cut the tooth down to the gingiva (Figure 7). This will allow further apical troughing. Sink the #801 bur (Brasseler USA) on both the mesial and distal.
2. Use a thin periotome to engage the trough. Engage the blade of the periotome so the force is away from, not toward, the buccal plate. It will be common to employ the micro elevators in the process. This is a critical teaching principle. The tooth will move easier toward the buccal (because the bone is thinner). It can be tempting to the clinician to just continue and get the tooth out, but that will result in a lost buccal plate and the procedure will no longer be an atraumatic extraction! If you get movement, continue this action until the tooth is clearly loose, and then remove it with a forcep.
3. Sectioning: An experienced clinician will recognize an exceptionally thin plate and a pronounced labial root. The approach to these teeth is often to section them from the incisal toward the root apex. Then first remove the lingual aspect of the root, followed by tedious removal of the buccal aspect. There is a relatively novel approach that leaves a portion of the buccal root, called partial extraction therapy (PET) (Figure 8). This minimizes the resorption of the labial bone and soft tissue and is not for clinicians with abbreviated experience in tooth removal.³

Maxillary premolars and molars: It should be expected that sectioning multi-rooted teeth serves the purpose of reducing trauma to the surrounding bone as well as lessening the chance of chasing a broken root. The approach for multi-rooted teeth is as follows (Figures 9 to 12):

1. Remove the clinical crown to the roots
2. Section pre-molars buccal/palatal
3. Section molars mesial/distal/palatal
4. Trough on each side of the remaining roots
5. Elevate (and expand sockets with root elevators)

Mandibular premolars: These teeth fall under the heading of easier extractions and are removed using longitudinal and apical forces. Occasionally, there will be a multi-rooted premolar, and, in that case, the clinician should follow the molar guidelines.

Mandibular molars: According to Misch,⁴ bone density in the mandible is described as D2 or D3. In my opinion, it is best to prepare for tooth removal in this region as if it is D2, which is a thick layer of compact bone surrounded by a core of dense trabecular bone.⁴ One would surmise that their multi-rooted anatomy in D2 bone make these teeth more challenging than their maxillary counterparts; however, ease of access plays a huge role in assisting even the novice dentist in removal. The 5 steps outlined for maxillary molar removal should be followed for these teeth as well.

Maxillary and mandibular third molars: It is the author’s opinion that most clinicians would be well served to refer third molars to the oral surgeon. Although all extractions can result in serious postoperative complications, the percentages simply soar when we operate just one tooth posterior. There are abundant anatomical challenges prevalent in the maxillary and mandibular third molar region. It will take only one paresthesia or serious bleeding episode to erase all the satisfaction of the collective successes that you may have previously had.

1. To flap or not to flap: A good rule of thumb is to always begin without a flap. If you break a root, or if your vision is too compromised to succeed, then proceed to laying a flap. It is beyond the scope of this article to address all the types of flaps one could employ, but a simple, full-thickness sulcular flap, one tooth mesial and distal from the tooth being extracted, is an easy go-to skill to hone.
2. Common complications: Broken root tips, sinus tears, and/or prolonged bleeding are complications that can occur. Unequivocally, the best way to prevent any of these is through careful patient/case selection, especially in the beginning of your training/experience. In all cases, it is the responsibility of the clinician to make prudent surgical decisions. If you are in a complication that you cannot resolve in 30 minutes, the best patient-management protocol is to refer the patient to a specialist.
3. A root tip you simply cannot remove: Using the techniques outlined, most teeth should be removed within 20 minutes at most. As a rule of reason, if you are 30 minutes into the procedure with little movement, then strongly consider aborting the procedure. Simply place a suture, if needed, or have the patient bite on gauze, and follow the instructions as if you were successful. Explain truthfully that you feel they will be better served if you stop here and refer them to the local oral surgeon. This is not easy, but it’s the right thing to do. The patient will be much better off than if your ego kept them in the chair for hours.

CLOSING COMMENTS
Clinicians who have been practicing for more than a few years do not need convincing that it has become extremely challenging to maintain the success they once held earlier in their careers. Toxic insurance reimbursements, corporate care, and a myriad of other factors have contributed to these current circumstances. Fortunately, there are many ways to thrive without giving up. It is the author’s opinion that the easiest and greatest skill set to add is oral sedation, knowing that there are many successful clinicians with their own sedation protocol, including yours truly. (You may request this information from the author via the email address at the end of this article.) If, in fact, you take this road, then the masterful removal of teeth will be a skill you will also have to know. Many of these patients will have their extracted teeth replaced with implants, which is yet another skill to learn and one that requires a significant lifetime commitment to training—something that I advocate for the GP. When done right, the end result will be a rapidly expanding patient base that will become your most powerful source of referrals and appreciation.

References

1. Brand RW, Isselhard DE, Satin E. Supporting structures. In: Brand RW, Isselhard DE, Satin E. Anatomy of Orofacial Structures: A Comprehensive Approach. 7th ed. St. Louis, MO: Mosby; 2003:83.
2. Misch CE, Suzuki JB. Tooth extraction, socket grafting, and barrier membrane bone regeneration. In: Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby; 2008:870-872.
3. Gluckman H, Salama M, Du Toit J. Partial extraction therapies (PET) part 1: maintaining alveolar ridge contour at pontic and immediate implant sites. Int J Periodontics Restorative Dent. 2016;36:681-687.
4. Misch CE. Bone density: a key determinant for treatment planning. In: Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby; 2008:139.

Dr. Rasner earned his DMD degree at the University of Pennsylvania. He has completed the Misch International Implant Institute curriculum and the Pikos Institute continuum. Dr. Rasner has been teaching for 19 years. His courses, “Atraumatic Extractions for the GP” and “The Bulletproof Guide to Implant Success,” have been popular at ADA and AGD component society meetings as well as the national ADA meeting. His newest course, “Hands-on Atraumatic Extractions for the GP,” features 2 days of live-patient experience in his office. He has authored 3 books and more than 50 industry and journal publications. He can be reached via email at drrasner@aol.com.

Disclosure: Dr. Rasner reports no disclosures.

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