Minimally Invasive Extraction With Ridge Preservation for Future Implant Placement
AMIR NOORI ESFANDIARI, DDS, FICOI
A graduate and past faculty member of the University of Southern California, Dr. Amir Noori E. is a Fellow with the International Congress of Oral Implantologists and a faculty member at the Los Angeles Institute of Clinical Dentistry. He has published numerous articles and has lectured nationally and maintains a private practice in Huntington Beach, California with an emphasis on comprehensive and implant dentistry.
When extracting a tooth that will be replaced by an implant, a clinician must consider the pathology, anatomy, and access of the tooth and choose from many available techniques and armamentarium. It is axiomatic to completely evaluate the surgical site and consider patient selection prior to deciding on an immediate or delayed implant treatment approach. In most cases, an experienced clinician will use the least invasive techniques and most efficient materials to complete an atraumatic exodontia and avoid traumatizing the surrounding tissue and bone.
A 62-year-old patient presented with a crack at the furcation of tooth No. 18 that was previously treated with a root canal and was now deemed hopeless. The patient was clinically and radiographically evaluated (Figure 1) to determine the correct treatment option, and a minimally invasive extraction with ridge preservation was planned. To ensure successful osseointegration, a staged or delayed treatment plan was chosen for this case. This will ensure a viable buccal plate and gingival tissue with ample thickness upon re-entry for osteotomy and future implant placement. A two-stage surgical technique will be used for future implant placement and restoration of the site.
After administering local anesthesia, the extraction procedure was initiated with a sequential sectioning technique of the restorative crown, coronal aspect, and roots. It is crucial to section the multi-rooted tooth past the furcation to reduce the chance of fracture. However, it is also important to avoid excessive damage to the apical one-third of the root, to avoid more complications and possibly more traumatic extraction in order to retrieve the root tips.
Root Sectioning with Patterson Carbides
In this case, initial sectioning of the crown was achieved with a Patterson Carbide FG 702 Surgical Bur (Patterson Dental). These solid carbide burs cut smoothly and efficiently to help separate the crown and roots without excessive chipping (Figures 2-3). The coronal aspect was separated with a round Patterson Carbide FG 6 Surgical Bur (Patterson Dental), which required multiple subcrestal sweeps while avoiding the buccal and lingual plates (Figure 4). A radiograph showed that the roots converge at the apical one-third. It is important to note that multiple sweeping of the #6 bur will cause unnecessary widening of the final section as it gets closer to the apex. Therefore, a narrow Patterson Carbide FG 701 Surgical Bur (Patterson Dental) was used to ensure a complete separation without damaging the narrow root tips and surrounding precious structures (Figure 5).
Prior to complete exodontia and grafting, the periodontal ligaments were incised to create lateral expansion and loosen the separated roots. An EZ-Out Periotome Kit (Tatum Surgical) was used sequentially to circumferentially incise the PDL, loosen the tooth, and create a better purchase point. Finally, a Patterson Universal Extracting Forcep #32 (Patterson Dental) was used to remove each segment without damaging the surrounding tissue.
A total of 3-mL of mineralized cortical cancellous VeraGraft Allograft (Avtec Surgical) was used to fill the socket slightly above the cementoenamel junction (Figure 6). HeliMEND Advanced Collagen Membrane (Integra LifeSciences) was used to encapsulate and immobilize the graft material in the surgical site. Two long oval pieces were cut and placed on the buccal and lingual plate, and a third small oval piece was used to add additional coverage over the socket to increase collagen thickness and protect the graft site. Finally, a UNIFY PGA suture 4-0 (AD Surgical) was used to close and secure the site (Figure 7).
Prepared for Future Implant
The patient presented 1 week later for a follow-up visit and suture removal. Note the ample bone and tissue regeneration (Figures 8-9). With proper assessment, meticulous techniques, and efficient armamentarium, clinicians can achieve the least invasive extraction and prepare the surgical site for future osteotomy and implant placement.
