Surgical Extractions: When To Pick Up The Handpiece

This is part 1 of a two part article 
How long should a surgical tooth extraction TAKE?

How many of us have labored over a tooth for an hour or more only to send the case down to the oral surgeon to finish?   Or if we did finally get it out, we have now wrecked our schedule and lost the trust of our patient? (So much so that the patient decides to just “wait till it hurts” to get the next extraction.)
And to add insult to injury, that night or the next morning the patient calls in pain saying that the meds aren’t working, and can I get something stronger?

It’s embarrassing. It’s demoralizing. It makes us question ourselves and our abilities.  Worse yet, it creates doubt in the minds of our patients and staff.

The other day, I was having a conversation with my staff about efficiency.  Actually, they were asking me if I had ever been slow when doing dentistry.  

And specifically, they were asking about extractions.

Now most of them have worked for other docs, so I commented to them: “I only know how I do extractions. What differences have you noticed in how I do extractions vs. how other docs that you’ve worked for do them?”

After a little discussion the consensus was that I pick up the handpiece faster than most other docs.  And of course, their next question was “Why?”

My answer, a little tongue in cheek, was “Because I don’t want to work any harder than necessary”.  And that is only a little tongue in cheek!

We were all taught about “laying a flap and sectioning teeth” in dental school.  But unless we were in a clinic whose patients needed a lot of extractions, we may not have gotten a lot of experience with this.

So, when and how is that decision made?  

Is it after 30 minutes of elevation and luxation with the forceps? Sooner? Later?

Does flapping and sectioning complicate and prolong the procedure?

Do we really need to do all that for a single tooth extraction?

Doesn’t this increase the amount of post op pain?

Well, for starters, most of the time, the decision to section the tooth can be made before the procedure is ever started.  It starts with an evaluation of the radiographs and the tooth

• Are the roots significantly divergent? (This is most maxillary and not a few mandibular molars)
• Do the roots have significant dilacerations?
• Is there an absence of infection that might have softened up the bone?
• Is the crown so compromised that placing forceps on it is likely to crush it or is there no crown at all?
• Are the roots surrounding the sinus?
• Does the tooth have previous RCT?

Once in the mouth, how long do you work on a tooth before deciding to pull out the handpiece? 

What exactly do experienced dentists do to move through this efficiently and effectively? 

What follows is my process.

Prepare the patient

The whole point here is to remove the tooth efficiently AND to build trust with the patient. So, I always start by pointing out to the patient that because of the condition of the tooth, we will be sectioning and taking the tooth out in at least three pieces. That it’s not an oops, it’s our plan.  This way when the handpiece starts spinning, they aren’t thinking that there is a problem.

Remove the crown to no more than 2 mm above the bone

Once we’ve entered the realm of sectioning and removing roots individually, that extra tooth structure will actually get in the way.  The sectioned area is only a couple of millimeters wide and once things start moving the sectioned pieces of the crown will start running into each other and get in the way of a successful extraction. So, I remove it right from the beginning.

A surgical handpiece with a surgical bur is a necessity

For reasons I will enumerate as we go on, this will make life infinitely easier.

And let’s face it, the cheap Chinese knock offs go for $35-$45 on eBay.  We buy three at a time.  When one dies, throw it away.  In my office, these will typically last a year or more.  So, expense is no longer an excuse.

A small sharp elevator or luxator is also a “must have”

Sectioning and removing teeth in this manner requires being able to get an instrument between the root and bone.  This is extremely difficult to do without a sharp instrument. You could cut a groove next to the root with a bur and use a dull instrument but that’s another step, more trauma and could endanger the adjacent tooth.  So, getting and maintaining some sharp instruments is crucial.

Section the tooth AND remove bone

Sectioning the tooth is only half the job.  Unless you are trying to immediately place an implant and need to keep the interseptal bone for stability, removing some interseptal bone makes this process faster and easier.  

How much bone?  About two thirds of the way to the apex.
This is why that surgical handpiece is needed! Doing this with a standard handpiece and a surgical bur is much more difficult, and you run the risk of introducing an air embolism.  Just spend the $35.

 

Why 2/3 of the way to the apex? If the tooth is simply sectioned, the bone will still need to be expanded from around the root in order to remove it.  During this process it is fairly easy to fracture bits of root and end up trying to dig out root tips, deep in the socket, from very stable roots that can barely be seen.  By removing the interseptal bone, now the root simply need to be “pushed” into the space to loosen and remove them.

To avoid perforating the buccal or lingual plates with the bur, the tip of the bur is angled slightly toward the center of the mandible or maxilla during the sectioning and bone removal.  Since roots taper as they approach the apex, generally there are no worries about not having removed enough bone buccal-lingually as removal progresses towards the apex.

Alternatively however, if the roots are more divergent, the tip of the bur may need to be pointed more mesiodistally in order to remove a wider section of interseptal bone to allow for movement of the root.  

In maxillary cases, it is important to be cognizant of the location of the sinus when sectioning in order to avoid it.

If you’re worried about removing bone “unnecessarily” don’t be.   As long as the buccal and lingual plates have been maintained, everything will heal up without a defect.  If you are doing socket preservation (which you should be) it’s even less of a deal.

“Push” the root into the space

Using your instrument of choice, place the blade between the bone and the root. 

Rotate slightly to “wiggle” the blade and work it towards the apex.  This will have the effect of pushing the root into the space where it can be removed.  The instrument can also be worked over to the other three “sides” of the root.  However, I usually avoid the buccal, if possible, to maintain the thin buccal plate.

 Stay tuned for part two next week!