In this clinical case, techniques will be illustrated that can make crown removal, extractions, and grafting a more simple, predictable, and efficient procedure for the dentist, regardless of overall extraction and grafting experience, or confidence with such procedures. In the first part, Dr. Kosinski provided background and discussed removal of the crown using the WAMkey system (Golden Dental Solutions).
Step 2
Timothy Kosinski, DDS.
The second step of the treatment was to perform an atraumatic extraction. Atraumatic means less damage to the bone surrounding the root and less pressure on the root of the tooth, allowing removal of even fractured or damaged roots. It also means that there is less negative experience for patients, as they do not feel the forces and trauma of conventional techniques. Finally, being able to remove even the most difficult teeth with no hand, forearm, bicep, or shoulder strength is a positive experience for the dentist.
In this case, the tooth was sectioned, where the beak of the Physics Forceps (Golden Dental Solutions) could easily engage each root of the tooth treated as if it were the extraction of two bicuspids. With the forceps, I find that maxillary molars never have to be sectioned, but in the case of divergent mandibular molars, it can make the extraction process easier to section the tooth (figure 1).
Figure 1: Using a surgical bur, the lower molar divergent roots are sectioned into two roots, where now the tooth can be extracted as two individual roots using the Physics Forceps. All images courtesy of Dr. Timothy Kosinski.
The Physics Forceps are a modified first-class lever consisting of two components. Tension is applied with the beak, or flattened end of the instrument, onto the palatal aspect of the tooth. The second part of the instrument, referred to as the bumper, is placed onto the facial aspect of the tooth as deep in the vestibule as possible. The bumper acts as a fulcum, and the working end of the instrument is the beak that engages the root of the tooth 1 mm to 3 mm subgingivally. The handles are held firmly but never squeezed (figure 2).
Figure 2: The Physics Forceps instrument handles are never squeezed but held lightly in your hands, so the instrument is really a lingual elevator rather than a forcep. The handles should be held very lightly, allowing the instrument to do the work. No strength or arm pressure is required. Little pressure is placed on the bumper or fulcrum point.
They allow for tension to be created onto the palatal aspect of the root, creating a physiologic release of enzyme that breaks down the periodontal ligaments (PDL). Once the PDL is destroyed, the tooth is simply elevated up and out of the socket. The instrument is not intended to deliver the tooth from the socket; rather a tooth delivery instrument is used to remove the tooth from the socket site, leaving a socket with all four walls intact (figures 3-8).
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A more popular technique is to use allograft material (bone from the same species — human) or an alloplastic material (a synthetic such as tricalcium phosphate), which have both proved to be predictable. Xenografts are made from another species, such as cow bone. In general, all these materials require the use of a membrane to protect the graft from invagination of epithelial cells.
At a minimum, simple socket grafting following an atraumatic extraction has become an integral part of general dental treatment and should be offered to patients to prevent bone resorption. Following extraction of a nonrestorable tooth, the remaining socket heals from the apex toward the crest. When nothing is placed into the socket at the time of the extraction, the soft-tissue infiltration at the crest often results in facial and crestal bone loss. This will often impede ideal implant placement in the future or will require more invasive grafting procedures in the future, which is a secondary surgery for the patient that could have been prevented.
In this case, I demonstrate a simple technique that can be used when all walls are intact using a product called Osteogen Plugs (Golden Dental Solutions) (figures 10-13). Osteogen is a highly crystalline osteoconductive bioactive resorbable calcium apatite bone graft that is physicochemically similar to human bone. The bioactive and resorbable crystal clusters control migration of connective tissue and form a strong bond with newly growing bone. Its hydropilic 3D matrix leads to immediate absorption of blood flow, which is important for the initiation of bone formation, early angiogenesis, and bone bridging even across large defects. The Osteogen material is a low-density bone graft and, thus, will be radiolucent on the day of placement (figure 14).
user/images/content_images/nws_rad/2016_06_01_10_51_35_678_2016_06_02_Kosinski2_image10.jpg Figure 10: An Osteogen Plug is cut in half, approximating the contour of the socket site and placed into each root. The plug is lightly condensed into the socket site and inserted dry. No membrane is used with this product.
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