Partial bony impaction (mesioangular). Flap with distal and buccal releasing incisions, follicle removal, root retrieval.

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1 Surgical Extractions: Faster, Easier, and Less Stressful 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. Surgical extraction, root tip removal, socket bone graft with barrier membrane, cross and interrupted sutures. Multiple extractions (4) with alveoplasty, root retrieval, continuouslock suturing. Dr. Karl Koerner 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. Originally developed for an ADA Meeting with my denture lab technician, Gerry Bryant in Logan, UT (he now lives in St. George, UT) Excisional biopsy. Frenectomy. Case Report 85 y.o. lady Tooth #30 How much time for the procedure? Cannot use an elevator on the distal. An elevator won t work very well on the mesial. Surgical Extraction Step-by-step instructions from Dr. Karl Koerner for the clinician performing the case. 1

2 Soft tissue reflection scalpel in sulcus periosteal elevator in sulcus enough room to slip in forcep beaks down to bone (Most likely cowhorn.) Crown part breaks off. Section cut. How deep is the section cut? How wide M-D? How wide B-L? 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) 2

3 Inter-radicular bone removal - if necessary and Instead of buccal bone removal. Then Luxator at 10 mm again. Mini-Cryer Fulcrumed against bone, not soft tissue Cryer point into root Mesial root. Mesial root Tried to remove distal root with: The same mini-cryer within the socket Luxator from the distal of the distal root DIDN 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. Roots out, BUT buccal plate fractured in the process. See video clip below. Bone was attached to the periosteum so the root was kept and not removed. Then Mini-Cryer from within the socket, and Luxator in the PDL on the distal of the distal root THEN SUCCESS! 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

4 Cavallaro J, Greenstein G, & Greenstein B. Extracting teeth in preparation for dental implants. Dent Today (Peer reviewed article for CE credit). Oct Pp Authors suggest: Bur into the PDL -- up to three-quarters of the root length. Elevator Luxator 3 mm luxator with the MB root of an upper 1 st molar. roo Luxator Elevator Straight (for anterior) Straight 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. 4

5 Oral surgeons pride themselves in taking out teeth quickly. When rules change that you can t remove facial bone to 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 into the 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 Luxator to depth (white lines) - turn clockwise and counterclockwise (sustained pressure) - for a few minutes Only on mesial and distal.. Be careful. Which handpiece is easier to cut apically along the tooth toward the apex? RPMs don t matter. 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 ,000 rpm GP Slowspeed straight 5-8,000 rpm ,000 rpm OMS handpiece + = Another way. 5

6 Which is better? Surgical highspeed: no air. Lower 1 st molar extraction. Gen Dent. Tooth sectioning with regular highspeed handpiece. May-June, 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. Sinus and orbit level. 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 closure regardless of size of opening. Hupp J, et al. Contemporary oral and maxillofacial surgery., 5 th ed. Mosby. St. Louis, MO

7 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 Five day post-op. Patient careful. No apparent communication. 7

8 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., 5 th ed. Mosby. St. Louis, MO Cut through periosteum into the fat. A. Baumann, et al. Closure of oroantral communications with Bichat s buccal fat pad. J Oral Maxilofac Surg. 67: , Pictures compliments of Dr. 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. 8

9 X Suture. The X is on top of the soft tissue allowing for better hemostasis. Advantages: Fast and easy. Horizontal Mattress. Easy to place. Advantages: Can sometimes act in place of two interrupted sutures, especially for a smaller socket. Buccal Examples of using a horizontal mattress for exodontia. Cocero, N, et al. Bleeding rate during oral surgery Of oral anticoagulant therapy patients with associated systemic pathologic entities: A prospective study of more than 500 extractions. J Oral Maxiiolfac Surg. 72: , 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. Hypocalcification at mid-root. Pre-Hedstrom 9

10 Peet forcep (mosquito hemostat). 5 mm perforation (slit) into sinus at apex of socket. ½ of a Colla-Plug as resorbable barrier between socket and sinus (compresses when wet). The other half. PTFE (nonresorbable) membrane. Bone graft Preop. Antibiotic Decongestant Pain medicine 1 mo. post-op. 10

11 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. Immediate post-extraction. Bone Grafting for Socket Preservation Dr. Karl R. Koerner Facial bone loss several months after a routine extraction. Does your dental extraction socket need a bone graft: A decision matrix. February 25, 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). Twothirds 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 Bone loss from extraction trauma. (excessive force) 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: Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Perio 1998;69:

12 Socket healing: About 4 days: The blood clot is replaced with granulation tissue 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. Commonly the thickness of facial bone. In a favorable situation, an implant can be placed in about four months. 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 12

13 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. General Dentist-Friendly Socket Grafting Retzepi M and Donos N. Guided bone regeneration: Biological principle and therapeutic applications. Clin Oral Implants Res. 2010:21(6): Greenstein, et al. Utilization of d-ptfe barriers for post-extraction bone regeneration in preparation for dental implants. Compendium 2015:36(7), pp July/August. Which materials are easier to use? It depends on your capabilities. What is periosteal 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 mm) Laminar bone BioXclude (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 in Don t need periosteal release. anterior with thin Can remain open the width of the socket. phenotype cases 4 week removal. Could be as long as 6. Needs to be sealed Assures the presence of keratinized tissue. 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, PTFE more predictable. 2 week post-op. 1 month post-op. 13

14 No periosteal release rather, 3-tooth wide envelope flap. Most common sutures: PGA PTFE Nylon One month post-op. Osteoid 14