Educational Supplement By Jay Reznick, DMD, MD

Greetings from Howard

We are proud to bring this important information to our community. Dentaltown.com has been in the business of dentists sharing information with other dentists since 1999, and our magazine is the natural extension of that exchange. It is only fitting that this insert feature a Townie oral surgeon named Jay Reznick, DMD, MD, and quality instruments from Karl Schumacher.

Tooth extractions are as old as the dental profession. Over the years, techniques have improved and trauma is reduced through the use of periotomes, proximators and apical retention forceps. These high-tech additions to your surgical tray do not require batteries.

Join Dr. Reznick, as he guides you through two cases in his office. The photographs and text tell a detailed story of the most common oral surgery procedure performed. I’m certain you will enjoy this inside look into the inner workings of Dr. Reznick’s practice.

Finally, our free community exists due to the support of our members and commitments from our advertisers. I would like to take this opportunity to thank Karl Schumacher Dental Instruments Company, Inc., for providing the funding to bring this information to our community. Remember, when you extract your next tooth with periotomes, post the case on the message boards of Dentaltown.com.

Create a Great Day!

Howard Farran, DDS, MAGD, MBA
Founder/Publisher Dentaltown Magazine

Educational objectives

Upon completion of this course, participants should be able to achieve the following:

• Explain how atraumatic extraction techniques help preserve alveolar bone and soft tissue volume for future prosthetic, esthetic, or implant treatment.
• List the steps involved in using periotomes and Proximators™ to disrupt the periodontal ligament attachment of teeth to the socket.
• Know how and where to use the various tip configurations of periotomes and Proximators™.
• Discuss the properties of the Apical Retention Forceps, and how it differs from a standard extraction forceps.
• Discuss the differences between traditional exodontia techniques and newer techniques utilizing instruments that directly cut the periodontal ligament attachment of tooth to bone.

Abstract

The time-honored techniques of exodontia emphasize the use of forceps for most of the work of tooth removal. We are all familiar with the complications of forceps extraction, including fracture of the tooth or adjacent bone, which may then require elevation of a surgical flap and removal of bone to complete the procedure. Especially when dental implants are planned for extraction sites in the anterior “Aesthetic Zone” of the mouth, this can have detrimental effects on the final esthetic and functional result. A new design of exodontia instruments has been introduced that modifies the surgical procedure to minimize trauma to the extraction site. These instruments include periotomes and Proximators™, which loosen the tooth within the alveolus, and apical retention forceps, which grasp the root, to ease it out of the socket. These instruments are demonstrated, and typical cases are illustrated.

Dentaltown.com, Inc. is an AGD PACE Recognized Provider. This course offers 2 AGD PACE Continuing Education Credits free-of-charge.

Introduction

The practice of exodontia underwent a dramatic change in the 1970s with the introduction of the surgical handpiece. Prior to that, mallet and chisel were used to remove bone in order to get surgical exposure of impacted teeth and to section their roots to facilitate their removal. Severely decayed, ankylosed and multirooted teeth were also removed using the same technique. Today, the high-speed, high-torque surgical drill is the instrument of choice for these tasks. Other than this advance, the instruments and techniques used in the removal of teeth have remained essentially unchanged for the last century.

The latest revolution in dentistry has been the advancement of dental implants into mainstream practice. Especially when we are dealing with the anterior aesthetic zone, this has completely changed our concepts about preservation of compromised teeth, and maintenance and preservation of bone and soft tissue levels. We are now very conscious about the management of bone and gingiva around dental extraction sites, so that the natural architecture is maintained around a subsequently placed dental implant and restoration. Because of this, new instruments have been developed to facilitate the atraumatic extraction of both anterior and multirooted teeth. These instruments exploit new biomechanical concepts in the practice of exodontia.

Traditional teaching of exodontia involves utilizing dental elevators and forceps to luxate the tooth within the socket. The cardinal movements of luxation are dictated by the number and shape of the roots of the tooth to be removed, as well as the thickness of the surrounding bone. Luxation is intended to stretch and tear the fibers of the periodontal ligaments, and to expand the alveolus. Apical pressure on the tooth is also used to facilitate socket expansion. Straight dental elevators are placed perpendicular to the tooth and used to push it away or lift it occlusally within the socket. Although tooth elevation is intended to be from interproximal bone to the target tooth, it is frequently difficult to avoid contact of the elevator with the adjacent tooth, especially if there is crowding or malposition. If this tooth has an intact coronal structure, there is generally no injury. However, if the adjacent tooth has a large restoration, special care must be taken to avoid damaging the restoration or fracturing the weakened tooth structure.1 With the standard dental forceps, significant forces must sometimes be applied to the tooth to expand the socket and sever the periodontal ligament fibers. If the forceps cannot be placed far enough apically, this can lead to fracture of the tooth crown in the forceps before delivery of the intact root. If the root fracture is near or below the bony crest, a surgical bur is used to remove periradicular bone, sever the PDL, and provide a purchase point for root elevation.2 If this occurs in a site that is intended to support a dental implant, the bone volume and morphology, and gingival architecture are compromised. In the aesthetic zone, this can cause a significant cosmetic problem.

New Armamentarium: Periotomes, Proximators™ and Apical Retention Forceps

Traditional extraction techniques utilize the dental elevator as an initial instrument to slightly loosen the tooth. The primary instrument which removes the tooth is the extraction forceps.1 A new approach to exodontia emphasizes atraumatic expansion of the alveolar bone and disruption of the periodontal ligament attachment of the tooth to bone as the primary focus. The forceps is then used to gently lift the root out of the expanded socket. For removal of multi-rooted teeth, the crown and roots are sectioned using a surgical handpiece by the standard technique. Once the roots have been separated, they can be removed by the atraumatic techniques described here.

In 1999, a new type of instrument, called the periotome, was introduced. This instrument is designed to sever the periodontal ligament attachment of the tooth to the alveolar bone.4 It is advanced down the PDL space around the entire circumference of the tooth, as apically as possible. Periotomes are available in a variety of designs. The periotome No. 1 [Fig. 1] combines a straight ligament-cutting blade on one end with a socket expander at the other end.a The periotome No. 2 [Fig. 2], combines two ligament-cutting blades contra-angled to access mesial and distal regions of a root. The periotome blade is a thin (0.5mm) end-cutting instrument. The entire cutting action takes place at the sharpened, rounded end of the blade. The periotome blade is positioned along the long axis of the root, between the root and the alveolar bone. Apical pressure is applied to the periotome blade, which is angled toward the root apex, in conjunction with a gentle rocking motion [Fig. 3]. This allows the tip of the periotome blade to be reinserted more apically with each subsequent pass, severing the periodontal ligament attachment of the tooth as completely as possible.

A prying motion, as is done with elevators, should never be used in a direction perpendicular to the root. Prying motions can lead to fracture of the instrument. Only the leading edge of the periotome blade is used to cut the periodontal ligament fibers. In other words, the blade does not cut laterally. Rather, the blade is inserted and rocked in an axis that is parallel to the PDL space. Severing of the PDL attachment should be done at every aspect that access will allow. It is useful to return for a second, deeper application in each area to eliminate more apical attachments. Some minimal compression of the surrounding bone results from the insertion of the periotome blade. Additional expansion of the socket can be accomplished with the “socket expander” blade of the periotome.

Although a periotome is often sufficient to relieve the periodontal ligamental attachment of a relatively straight root, root curvature or dense bone may limit the degree to which the periotome will enter the PDL space. In this case, a refinement of the periotome, the Proximator will be helpful.a Proximators, [Fig. 4] are used where the root anatomy dictates that some expansion of the socket will be necessary to facilitate tooth delivery. There are four patterns of Proximators. The tip of the Spade Proximator easily enters the PDL space to loosen the fibers, as well as aiding in the retraction of the sulcus [Fig. 5]. The retraction aids in identifying the periodontal gap for application of the other Proximators. These other tip designs are available in either a 2.5mm or 5mm width. The Straight Proximator can be used on all aspects of the anterior teeth, as well as the labial aspect of premolars and molars. The narrow tip is able to advance subgingivally to the very apex of the root structure, severing the PDL fibers, but will not cause a root fracture. The tip of the Mesial Proximator can advance in the mesial aspect of any posterior tooth, effectively severing a significant portion of the periodontal fibers quickly. The angulation of the Mesial Proximator allows it to also be used on the buccal aspect of a molar to sever the fibers apical to the furcation. The Distal Proximator tip can advance into the distal aspect of any posterior tooth [Fig. 6], or on the palatal side of a maxillary molar, superior to the furcation. These instruments can be placed into the interproximal spaces to create mesiodistal expansion of the socket. This avoids excessive expansion of the thin labial plate where it is at a high risk for fracture, as in the case of anterior dentition. Proximators can be used to create space for the application of a forceps to what remains of the tooth structure in severely broken-down teeth. Multirooted teeth are sectioned with a surgical handpiece to create individual roots, which can be luxated with the Proximators. Socket expansion with the Proximator is accomplished by luxation of the root with a slight wheel-and-axle motion [Fig. 7]. This expansion eliminates the mechanical retentive factor created by the root curvature. As the Proximator tip is advanced toward the root apex, periodontal ligament attachment is disrupted, and progressive displacement of the root causes occlusal movement of the tooth. The tooth prepared in this way is easily removed from the socket with a forceps using gentle traction. In some cases, use of the Proximators mobilizes the tooth to such an extent that it can be removed with only a hemostat [Fig. 8].

Traditional extraction techniques utilize forceps pressure applied in an apical and buccolingual direction, despite the fact that the tooth is removed in an occlusal direction1. A new generation of extraction forceps, called Apical Retention Forceps, have recently become available.5 These forceps provide a deeper grip around the tooth and root, improve access around crowded teeth, and improve visibilitya [Fig. 9]. They are designed to make deep, continuous progress into the PDL space, with minimal displacement of the buccal plate, and achieve multiple contacts with the root structure. Modifications to the forceps design – such as thinner, sharpened beaks, a parallel gouge, a tapered insertion profile, and longitudinally cut serrations [Fig. 10] facilitate a more apical placement on the root structure and greater conformity to the true shape of the tooth, which improves grip with less damage to surrounding tissues.6,7

Case Reports

Case 1: A 49-year-old woman with a history of fracture of tooth #10 was seen for consultation regarding extraction and tooth replacement with a dental implant supported crown. The tooth had been treated endodontically 10 years prior, and the crown had come loose approximately one year before presentation. Her medical history was significant only for well-controlled asthma. There was also history of an abscess development one month before. Clinically, there was swelling of the buccal alveolar mucosa and vestibule, without fluctuance or drainage. The crown, post and core were easily removed with finger pressure, leaving a carious root below the gingival margin. Radiographically, there was a 3mm round radiolucency at the apex of root #10, which had an endodontic filling to the apex. There was about 2mm of crestal bone loss on the mesial and distal of the root [Fig. 11]. The history and clinical exam were consistent with fracture of the root of tooth #10. Extraction was planned. Because of the history of long-term infection, immediate implant placement was contraindicated. The patient was started on cephalexin 500 mg four times per day, and chlorhexidine gluconate 0.12% oral rinseb twice per day, beginning two days before surgery, and continued for seven days postoperatively.

Because this site was planned for an implant-supported prosthesis, and was in the aesthetic zone, atraumatic extraction of the tooth was desired, in order to maintain the bone and gingival height and contour. Tooth #10 was extracted using a flapless technique and periotome. The procedure was begun with the straight periotome, which was directed into the space between the root and alveolar bone.a The tip of the periotome was advanced circumferentially around the root, using a rock ing motion parallel to the root surface to advance it toward the apex. This was followed by the large periotome to expand the alveolus [Figure 12]. This made the root mobile enough that it was removed with only a curved hemostat [Fig. 13]. The socket was then thoroughly debrided with curettes and irrigated under direct visualization with surgical telescopes and fiberoptic headlight, removing a significant amount of granulation tissue. A bony defect of the buccal plate was noted approximately 8mm apical to the bony crest. The site was grafted with approximately 0.5 cc of allogenic cancellous bone particlesc, and a Collataped barrier was placed to contain the graft8 [Fig. 14]. Four months later, the ridge was clinically and radiographically ready for implant placement [Fig. 15]. A Narrow Platform (3.5mm) 13mm Replace.

Select dental implante was placed using a flapless technique. The implant was uncovered six months after placement [Fig. 16]. A fixture-level impression was taken and healing abutment placed. Two weeks later, a custom titanium abutment and acrylic temporary crown were delivered. The final prosthesis was placed one month later. At four month follow-up, there was good soft tissue morphology, with preservation of the interdental papillae [Fig. 17]. Radiographically, there was good integration, with minimal crestal bone loss [Fig. 18].

Case 2: A healthy 22-year-old college senior was referred by her dentist for extraction and replacement of teeth numbers 8 and 9. Both teeth had been traumatized 10 years previously and subsequently became necrotic, requiring endodontic treatment [Fig. 19]. Recently, both teeth had fractured supragingivally, and the temporary restorations were non-retentive. Clinically, the gingiva facial to these teeth was mildly inflammed. They were not tender or mobile. Radiographs demonstrated periapical pathology at both root apices. The root of tooth #9 had external resorption [Fig. 20]. The treatment options for tooth replacement were discussed with the patient. She was very concerned about the esthetic results of treatment. It was her preference to avoid a removable prosthetic appliance during the implant integration period. Placement of dental implants at the time of tooth extraction was the treatment of choice to help optimize alveolar bone and gingival anatomy. She was told that if the bone quality was poor or infected bone could not be completely debrided, that the site would be grafted, and implants placed at a later date. She was also informed that abutments and provisional restorations would be placed only if there was adequate stability of the implants at the time of placement.

The patient was begun on a chlorhexidine gluconate 0.12% oral rinse twice daily, beginning two days before surgery, and continued for 10 days post-operatively. An intravenous dose of 1.0g cephazolin was given before the induction of intravenous sedation. Teeth numbers 8 and 9 were extracted using Proximators to sever the periodontal ligament around both teeth and to expand the alveolar bone on the palatal and interproximal aspects of the roots [Fig. 21]. The teeth were then removed with Apical Retention Forceps with light occlusal force. The sockets were debrided and irrigated thoroughly under direct visualization. They were then prepared using the standard drilling sequence for Replace Select Tapered 4.3 x 13mm dental implantse [Fig. 22]. Both implant fixtures were placed so that the top of the implant was 3mm apical to the gingival margin. Because both implants were well stabilized in the alveolar bone, temporary abutments (0.5mm collar RP Easy Abutmentse) were placed on both fixtures, and tightened to 20Ncm [Fig. 23]. Temporary acrylic crowns were fabricated at surgery by her general dentist, and adjusted so that they were out of occlusion and were not contacted in excursive movements of the mandible. The patient was seen in follow-up one week following surgery. There was excellent soft tissue contour and health around the temporary crowns [Fig. 24]. The patient had no complaint of tenderness or pain.

Conclusion

Recently introduced extraction instruments have allowed a modification of the classical exodontia technique, resulting in greater preservation of the hard and soft tissues, as required by the introduction of dental implants into the aesthetic zone. This article has reviewed a new surgical protocol focused on occlusal movement during the removal of teeth, following disruption of the periodontal ligament attachment and expansion of the alveolus. Also, the recently introduced instrumentation used in these procedures was introduced and discussed.

The goal of preserving an alveolar ridge that will have a dental implant placed should be considered before performing a dental extraction at that site. Then, choosing the best technique to accomplish this task is essential. With the introduction of periotomes, Karl Schumacher Proximators, and Apical Retention Forceps, an atraumatic extraction of the diseased teeth can now be achieved, resulting in more predictable ridge maintenance. This facilitates more predictable and aesthetic implant and prosthetic reconstruction.

References 1. Peterson LJ, Ellis E III, Hupp JR, Tucker MR, eds. Contemporary Oral and Maxillofacial Surgery. 3rd ed. Philadelphia, Pa: Mosby Year Book, Inc; 1998. 2. Kohn MW, Chase DC, Marciani RD. Surgical misadventures. Dent Clin North Am. 1973;17:533. 3. Quayle AA. Atraumatic removal of teeth and root fragments in dental implantology. Int J Oral Maxillofac Implants. 1990;5:293-296. 4. Thomson PJ. Minimizing trauma in dental extractions: the use of the periotome. Br Dent J. 1992;172:179. 5. Clinical Research Associates. Use of apical retention forceps. CRA Newsletter. April 2001;25:4. 6. Assael LA. The effect of design on performance in surgical practice: improving instrumentation. J Oral Max Surg. 2004;62:397-398. 7. Malden N. Surgical forceps techniques. Dent Update. 2001;28:41-44. 8. Reznick JB: Options in Ridge Preservation Grafting. Dentaltown Magazine July 2004.

Dr. Jay Reznick received his undergraduate Biology degree from the University of California-Berkeley, Dental degree from Tufts University in Boston, and his M.D. degree from the University of Southern California (USC). He did his internship in general surgery at Huntington Memorial Hospital in Pasadena, California, and trained in oral and maxillofacial surgery at Los Angeles County – USC Medical Center. He is an assistant clinical professor at USC and is a diplomate of the American Board of Oral and Maxillofacial Surgery. He can be reached through e-mail at jreznick@scofsg.com. Disclosure: Dr. Reznick declares having received an honorarium from Karl Schumacher Dental Instruments Company, Inc., for this course. Answer the Post-test Questions Online – for FREE CE Credits After reading the preceding article, go to www.dentaltown.com. Then, click on ONLINE CE in the navigation column on the right side of the page. Then, click on the VIEW ALL COURSES button. Choose the title of the course you have read and click on it. Then, click the TAKE COURSE button. After the Web cast has loaded (you also may view the course in the Web cast format), scroll down and tick “I wish to claim my CE credits.” Then, simply follow the prompts. Please note: If you are not already registered on www.dentaltown.com, you will be prompted to do so. Registration is fast, easy and of course, free.