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“Surgical” Extractions in Preparation for IMPLANTS - Oral

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					“Surgical” Extractions
  in Preparation for
      IMPLANTS
    Howard Farran, DDS, MBA
         Dental Town

  Don’t plan on
retiring at 55.

  Probably not at
60 or 65 either.
  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
  yours is going down)
                              – Treat sleep apnea and
– Do root canals, crowns,       snoring
  and dentures                – Make mouthguards
        Dr. Jay Reznick, Oral Surgeon
    With fewer patients, many practices are trying to fill those
gaps by keeping procedures in-house that they would have
ordinarily referred.

   If you choose to refer fewer patients to your specialists and
treat them in your own practices, please make the
investment in yourself to become more proficient at those
procedures first.
Picture from the hotel.
Dental hospital.
eTriage
Teaching at
chairside while
you work.
             Plastic surgeon.




Hygienist.
Nice to have a choice.
A day of mountain climbing in Yung Ji.
The ultimate atraumatic extraction.

                       Impression for
                       immediate denture.
Dental school surgery
case.
Bad for implant, bad for bridge.
       45 y.o. female patient




                                Someone else’s extraction
My extraction.                  on the other side.
     How it works…
– Stretch then snap the periodontal
 ligaments
– Stretch (expand) bone around the root(s)
– Section the tooth
– Wedge instrument into the PDL or thin
 bur in the PDL

                    Vs.
– Drill or break away the bone to get it out
Luxators into the PDL.




       These are NOT elevators.
             2-4,000 rpm
Mechanical   $900+
             2 tips
Periotome
             Vibrating,
             Reciprocating
      Texbook of Oral
      and Maxillofacial
      Surgery, 5th ed.
      Gustav O. Kruger.




VS.
                           3 mm luxator
301                          (straight)




      Ligment space:
      0.1-0.3 mm wide.*
      (*Dr. Myer Leonard in “Essential
      Dental Handbook’. Edwab, R.
      ed., PennWell, 2003.)
 2 mm luxator with the MB
                       roo
 root of an upper 1st molar.




Luxator                        Elevator
7 mm diameter
at base. Hu-Friedy.



                      Sharpening stone
                        for Luxators.
Luxator: 3-4 mm into
PDL towards apex.
Luxat
 or
used
wron
 g.
 In
China.
Spear-point and nylon-tipped mallet.
 Watch out
 who you
“mallet” on!
 Hartzell
Periotomes
Periotome




            Dr. Dennis Tarnow:
            A periotome is time
            consuming and not
            always effective.
The Future of
 Exodontia
                          OSADA
Piezotome Blade




    SD 70Z        SD 70
               Recent email.
Hi Dr. Koerner,
My name is Dr. Eric Morrison and I have had the privilege
of taking your course several times when you have been
here in the mid-Atlantic area. I most recently heard you
several weeks ago when you were up in NJ.

After NJ, I purchased the DoWell Piezo. I must
admit, between the piezo and the luxator, you have
revolutionized the way I remove teeth. Quite frankly, it
allows me to remove teeth as your course advertises -
nearly atraumatically and certainly more
efficiently. Thank you.
Using irrigation
to remove heat.
Happy patient.
Osada Model EF-O15
Piezoelectric ultarasonic
oscillating system.

Designed with extra
cutting power for oral
surgery.
     Uses of Osada’s ENAC tips:
• Surgical extractions
   – Sever soft tissue attachments to tooth.
   – Minimally invasive bone excision.
   – Tooth sectioning.
• Perio
   – Cleaning and scaling of periodontal tissues.
   – Can add medicaments to irrigation.
• Endodontic
   – cleansing and shaping of canals.
   – Filing of canals.
   – Removal of gutta percha, silver points, posts, separated files,
     cement…
• Apicoectomy tips
   – Apical resection.
   – Retropreparation
• Implants
   – Ridge splitting     - removing an implant
   – Sinus graft procedures.
     Brands of piezos…
Piezosurgery (Mectron)     $18,000
Piezotome (Acteon/Satelec) 15,000
VarioSurg (Brasseler/NSK)   8,000
ENAC (Osada)                5,900
Piezoart (DoWell)          5,000
    “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.”
                  700XL   702




Surgical length
Regular length
Periotome bur:
FG Surg. Length: 30 mm
700 Carbide




                         30 mm
Cutting a root in half
lengthwise.
                      Luxator
Section Lengthwise.
Socket preservation case.
Main surgical suction tip:   “ Special” surgical suction tip:
3.0 inside diameter.         2.0 inside diameter.
Quality Aspirators

                                  3.0 mm (15P3A)

                            2.0 mm (03EA)


       Wire to clean it out.


(Also 1.0 mm diameter: 02BA w/wire too.)
Prior to bone graft.
What happens when you “slip”
with a Luxator or elevator?    “Slip”
                               buccal




                    Facial
                    artery
“Slip” lingual.
(Lingual artery)
Lindo Levin
Straight elevators.
Small and large.
One in the set of “Apical” forceps.
Schumacher: 1174 “birdbeak” for
lower anteriors.
Chinese
dinner.
                   19 year old girl with
                   unerupted 2nd premolar.




Dr. Karl Koerner
Straight elevator
removal caused root
fracture.
Grabbed root
  tip with
  mosquito
 hemostat.
Peet (mosquito) forcep
      for root tips.
Better yet…
Before using an elevator or
Luxator on the broken root,
first engage the Hedstrom
file and attach floss. Then
try to remove the root.
           Conventional
Size 25
           corkscrew.
Hedstrom
2nd case.




              Palatal
                root.
             Removed
            while the file
             was in the
               canal.
3rd case.
Dentist: “I’m pulling as hard as I can.”
                       4-5 mm perforation (slit) into
                          sinus at apex of socket.




½ of a Colla-Plug as
 resorbable barrier
between socket and
 sinus (compresses
    when wet).
     PTFE
(nonresorbable)
  membrane.




                  Antibiotic
                  Decongestant
                  Pain medicine
         Bone graft




Preop.




              1 mo. post-op.
                       One month
                         later…




 Painless removal of
PTFE membrane with
     an explorer.
Intra-op,
one month post-op.
Day of implant placement.
Full-arch extraction case. Surgical extraction
  of # 3.
Very nice case, everything looks very clean and
planned. That is exactly what I would do, from the
semilunar incision, to the p.o. meds. It is nice that it is
a denture case, so you probably won't have problems
with the sinus opening. ( Provo oral surgeon.)
Smoker.
Alvogel placed at 3 days
 for dry sockets.

This picture: 7 days.
Small Cryers.




      “Small”
      Cryers
                64 y.o. male


  Elevator
  Luxator
Small Cryer
Root tip pick
 Air + Water =
Possible Serious
 Complication
 Which is better? Both work.

“Surgical”                702 or 703
                             bur.
highspeed:
  no air.
Can’t find a rear-exhaust
air-turbine highspeed
(surgical) without the
45 degree head.




                            No air in the
                            water is best.
Medidenta.
 Impact-Air 45




Sabra
 “Surgical” Extractions
           with
     Dr. Karl Koerner
           and
 Dr. Gordon Christensen

Practical Clinical Courses
   www.pccdental.com



  801-226-6569
Practical Clinical Courses (PCC)
801-226-6569
Hell’s Gate.
Toilet bowl.
Other group distracted while making repairs.
     Eliminate
Tuberosity Fractures
Erupted maxillary third molar.

                If not loose after
                5 minutes…
Equivalent with a lower
erupted third molar:
Envelope flap, bone removal
   to furcation, section the
   tooth, remove in two
   halves.
                             Missing
3rd                          Premolars
Molar




        51 year old woman.
(Case submitted by an anonymous practitioner.)
             Florid Cemento-Osseous Dysplasia

Cemento-osseous dysplasia is a fairly common lesion of
the jaws originating from the elements of the periodontal
ligament.
---------------------------------------------------------------------------------------------------------------------



Most of these cases occur in Asian or African American women
in fourth or fifth decade of life and most are asymptomatic.
Since diagnosis of these conditions is based mostly on
radiographic and clinical examinations, we must recognize these
conditions to avoid misdiagnosis and mismanagement of our
patients.
shang4 he2 dou4
sinus
Natural anatomy in
some people.
    With a sinus membrane
    sighting or perforation:
Don’t poke into it !
Use the “nose blowing” test:
  – have patient pinch the nose
     and blow “softly”




• Implement sinus precautions.
Sinus precautions:

        Avoid:
   blowing the nose,
  vigorous sneezing,
   or coughing with
  the mouth closed.

Also, don’t smoke or use
        a straw.
Five day post-op. Patient careful. No apparent
communication.
Medications (for 7-10 days):

• Antibiotic
  –Example: Amoxicillin 875 mg, bid
• Oral decongestant:
  –Examples: Sudafed 120 mg
   sustained release, bid
  –Claritan D
    Gauge treatment according to the size
               of the opening:

• If 2 mm or less: no further treatment *

• If 2-5 mm:
  – figure eight suture over socket *

• If over 5 mm: get primary closure
  *place gauze over the socket for 1-2 hours

      With a chronic sinus condition, get primary closure
    regardless of size of opening.
Section cut too deep.
Required primary closure.
800-862-6657,
www.blackwellprofessional.com
?
Avoid Losing Teeth/Roots
  in the Esophagus or
      the Trachea
In stomach.
Schumacher
79AS.
In lung (right main-stem bronchus).
18 y.o. boy dead after
wisdom tooth removal.


                         2X2
                         gauze
Better (4 X 4s).
Is it malpractice to leave a root?
Pull or not ?
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.
Better ?
Upper forceps.



                 Lower forcep.




                                 Physics forcep vs.
                                    more traditional apical forcep.
“Creep” is a phenomenon whereby a material continues to
change shape over time under a constant load. In a tooth
extraction, creep may occur in bone and the periodontal
ligament.
Secret: Stabilize
with your other hand.
Lingual
 beak.
          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.
Power Elevators
      vs.
 Physic Forceps
Upper and Lower Molars
YouTube: Misch Power Elevators


 Bumper on lingual or buccal.
 Do not squeeze handles – just firm
  grip.
 Luxate predominantly to lingual if
  buccal bone thin.
 Allow time for bone to “bend”.
 Section if molars widely divergent.
Upper and Lower Molars

				
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