3/2/2015

Howard Farran, DDS, MBA

Surgical Extractions Dental Town

(Nearly no bone removal, timely surgery.) Don’t plan on

retiring at 55.

Probably not at
60 or 65 either.

ADA News
Nov. 2014.

ADA n Answer to ‘how to do better’:

– Lower expenses – Pull teeth, even easier
– Increase marketing wisdom teeth
• Have a good website – Join insurance plans
and be “search engine – Use 3D CBCT
optimized” – Don’t do gold
• have a Facebook page (overhead too high)
– Add new products and – Place single root-form
implants
services
– Do simple ortho,
– Freeze wages (after all, Invasalign
68.7 yours is going down)
– Treat sleep apnea and
– Do root canals, crowns, snoring
and dentures – Make mouth guards

Basics that are still valid!

Extractions
• Sever gingival fibers attached to the root
• Luxate the tooth - stretch and snap PDL fibers
– Place fingers of opposite hand on adjacent teeth to detect any unwanted
mobilization

Stretch ligament.
Expand bone.

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Weekend pain.
The basics are still valid:
Saw dentist for an
• Use firm and deliberate movements with “sustained” “emergency” extraction.
pressure (8-10 seconds in each direction)
• Luxate tooth as much as possible BEFORE sectioning.
• Don’t take too long for an extraction
• Avoid excessive force
• Section teeth as needed
• Be aware of major nerves, blood vessels, and the
maxillary sinus during the procedure

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.

The “standard” from the past.

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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
practice.

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

• For moderate to severe pain: 400 to 600 mg
ibuprofen with 500 mg acetaminophen every 6
hours for 24 hours. Then 400 mg ibuprofen
with 500 mg acetaminophen after the first day.
• It is important to avoid daily doses of more
than 3000 mg acetaminophen or 2400 mg
ibuprofen.

• In addition, they cited a study by Daniels

et al comparing various combinations of
ibuprofen, codeine, and acetaminophen
for treating the pain of third molar
extractions.

• Not only did the patients receiving the

ibuprofen/acetaminophen combination
experience less pain than those receiving
codeine and acetaminophen but they
also had fewer adverse reactions such
as nausea, vomiting, headache, and
dizziness.

45 minute
Age 27 surgery

• Previous research has shown that

combining analgesics that work
differently provides more pain
relief than a single analgesic can
provide on its own.
Wife: age 27
Husband: Emergency room physician
600 mg ibuprofen with 500 mg acetaminophen every 6 hours for 24 hours.
Then 400 mg ibuprofen with 500 mg acetaminophen after the first day.
Oxycodone (without acetaminophen) 5 mg X 12, 1 q4-6 h in case of
“breakout” pain
Zofran 8 mg X 12, 1 tab tid in case of nausea.
Dexamethasone 8 mg IV or IM pre-op, 1.5 mg qid starting the next day for 10
doses (for swelling but also cuts pain in half).

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One side: very conservative.

Two sides of “minimally

traumatic” extractions

(both with no buccal bone removal)

Silverstein LG, Kurtzman D, and Shatz, PC

Principles of hard tissue Regeneration
and implant Therapy.
AEGIS Publications, LLC, Newtown, PA 2010.

Two sides of “minimally Two sides of “minimally

traumatic” extractions (both with no buccal bone removal) traumatic” extractions (both with no buccal bone removal)
• Section teeth just as seems • Section all multi-rooted
VS.
• Soft tissue elevation: VS. • Soft tissue elevation: #12 necessary teeth to remove roots
periosteal elevator blade and periotome individually
• Bisect the papillae (between • Bisect the papillae with a
buccal and lingual) with just blade
the periosteal elevator

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.

Two sides of “minimally

traumatic” extractions (both with no buccal bone removal)

• Luxate with an elevator • Luxate with a periotome

and a regular forcep down the PDL then rotate
• Use buccal/lingual luxati,then
traction
VS.
tooth out with a thin-
beaked forcep Flaps and Sutures
• Avoide buccal/lingual
luxation, only use rotation
and traction

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Surgeon’s knot summary.

2 throws one way
1 throw the opposite way
1 throw the same way as how you started
(optional)

Clockwise twice around.

Counter-clockwise once around.

Hupp J, et al. Contemporary oral Hupp J, et al. Contemporary oral

and maxillofacial surgery., 5th ed. and maxillofacial surgery., 5th ed.
Mosby. St. Louis, MO. 2008. Mosby. St. Louis, MO. 2008.
Clockwise once around.

Triangular flap:
• One release on side of a papilla
• Envelope flap can be converted to
a triangular flap
• Sutures as needed: 3 mm apart AND to
stabilize papillae
• Bone removal not appropriate any more

Hupp J, et al. Contemporary oral

and maxillofacial surgery., 5th ed.
Mosby. St. Louis, MO. 2008.

‘Triangular flap’
Angled release one
tooth away from the one
worked on.

Triangular flap.

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Hupp J, et al. Contemporary oral

and maxillofacial surgery., 5th ed.
Mosby. St. Louis, MO. 2008.

Simple horizontal mattress.

(instead of two interrupteds)

Hupp J, et al. Contemporary oral

and maxillofacial surgery., 5th ed.
Mosby. St. Louis, MO. 2008.

8 mm

Horizontal
Mattress

Silverstein, LH, et al.

Suturing for optimal
soft-tissue management.
J Imp Dentistry. 35(2):82.
2009.

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Suture Material Burs For Oral Surgery

• Plain gut: tensile strength lasts 24-48 hours. Need minimum of 5 #10 round #703 #702 #700 (or 701)
days. Usually too short.
• Chromic gut tensile strength lasts 5 days. Resorbs in 7-10.
• Polyglactin (Vicryl) absorbable but works like a non-absorbable.
Tensile strength for 14 days gone in 21-28.
• Non-absorbables: Silk, PTFE, polyester…
have good tensile strength.
• 3rd molar impactions • 3rd molar impactions • Routine extractions • “Periotome” or “skinny” bur
• Bulk buccal bone removal • Troughing, section cuts, • FG or straight • Routine extractions
• Needle: 3/8 circle most common. • FG or straight • FG or straight •
•
FG: 19,25,30 mm
(30 mm FG from Sabra
•
•
Down PDL at expense of root
FG or straight
Dental) • FG: 19,25,30 mm
• (30 mm FG from Salvin)

For FG, recommend at least surgical length (25 mm).

“Another 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.”

One hour attempt by a dentist - and still not out. Cavallaro JS, Greenstein G and Tarnow DP.
Removed in 2 minutes with better methods. Clinical pearls for surgical implant dentistry,
Part 3. Dentistry Today. Oct. 2010.

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Inter-radicular bone removal instead

of buccal bone removal.
Prior to bone graft.

Starting today:
Access to an additional surgical
instrument worth hundreds of
dollars.

No extra charge.

8,000 rpm 60,000 rpm

Dental slowspeed.
About 8,000 rpm.

Not for enamel.

8,000 rpm Good enough for
85,000 rpm bone and roots.

Can drill bone with both

Stryker and regular straight
handpiece.

Both require irrigation.

Monoject syringe (12cc)
commonly used.

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More length
than a highspeed
when needed.

+
Increased

= effectiveness
and
production.

“Down three-quarters of the root length.”

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.

Quality Aspirators

3.0 mm (15P3A)

2.0 mm (03EA)

Main surgical suction tip: “ Special” surgical suction tip: Wire to clean it out.
3.0 inside diameter. 2.0 inside diameter.

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

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Case Report

Gold bridge cut twice through contacts. Exostoses cuts made with a
700 carbide.

Decay Exostosis
#29 non-restorable
decay Exostosis
Bridge cut (twice)
Extraction of #29 Exostosis
2 implants (29,30)
Facial bone graft

Luxator mesial/distal – didn’t work.

Skinny bur distal/mesial then Luxator – didn’t work.
Root tip pick – didn’t work

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2 mm luxator with the MB

roo
root of an upper 1st molar.

Luxator Elevator

Which is better?

“Surgical”
highspeed:
no air.

Hupp J, et al. Contemporary oral

and maxillofacial surgery., 5th ed.
Mosby. St. Louis, MO. 2008.

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Can’t find a rear-exhaust

air-turbine highspeed
(surgical) without the
45 degree head.

Air + Water =
No air in the Possible Serious
Complication
water is best.

 Immediate air
emphysema
 Infraorbital area to
anterior neck
(subcutaneous)
 Also to mediastinum and
carotid sheath
 Hard to breath
 Treatment
 Steroids, oral antibiotics,
pain meds (no
decompression)

Stanton, DC & Yepes, JF. Subcutaneous

cervicofacial emphysema and
pneumo-mediastinum: A rare
complication after a crown
preparation. Gen Dent. Mar/Apr,
2005.

Common
practice.

Another alternative. Keeps together

instruments often used for an extraction.

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Readily available
sterile 18 X 26 inch latex-
free, plastic-lined, towel
for placing under
instruments or as a sterile
bib for patients.

Where do you put

your sterile instruments?

The Most Effective Instruments Periosteal Elevator – Forceps

for Surgery: Basic
Periosteal elevator
Straight elevator Molt
Surgical scissors Periosteal Apical
Needle holder
Forceps
Retractor (Seldin or Minn.)
Apical forceps (2)
Surgical spoon curette
Scalpel handle (flat or round)
Bite block (child) Apical Traditional
Suction tip

Upper forceps.

Lower forcep.

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My evaluation for CR:

 Good  Challenges
– Generally, they do work. – Need to be careful in the
mental nerve area.
– They conserve bone by pushing
the tooth coronally enough to – Harder for 2nd molars because
snap the ligament. of the cheek.
– It is a faster extraction. – Steep learning curve,
especially not to squeeze.
– Patients are impressed by the
ease and quickness. – Need to section lower molars.
– Gauze in undercuts
– Fairly expensive.

Schumacher Gold crown

79AS. in stomach.

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In lung (right main-stem bronchus).

Aspirated denture a year
ago. Didn’t know it.
Had a cough. Developed
headaches from a brain
abscess.

One in the set of “Apical” forceps.

Schumacher: 1174 “birdbeak” for
crowded teeth.

Chinese
dinner.

Some of the best instruments: Small Cryers.

Supplemental

Root tip pics (2) Tissue pickups

Small Cryers (2) (for bone grafting)
Very effective.
Periotomes Curved Kelly Hemostat
Luxators Peet Forcep
Cogswell B elevator Bone file (2X)
Other special Ronguer (Blumenthal 30°)
elevators Other forceps
“Small”
Cryers Not as effective.

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What happens when you “slip”

with a Luxator or elevator? Slipped
to buccal

Facial Prevents slipping.

artery

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Piezotome Blade

SD 70Z SD 70

J. Oral Maxillofac Surg.

Volume 72, Issue 11,
November 2014,
Pages 2126–2133.

Pull or not ?
Is it malpractice to leave a root?

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Not malpractice if..

1. The root is small (5 mm or less)
not loose, and not infected.
2. You feel that it is in the best
interest of the patient to leave it.
3. The patient is informed.
4. The occurrence is recorded in the
patient’s chart.
5. An x-ray is taken for
documentation.
6. Follow-up is scheduled.

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