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Performing atraumatic extractions

Today’s demand for esthetics has changed the way dentists perform extractions. They’re using instruments and techniques designed to preserve bone, and in the October issue of DPR, Dr. Karl Koerner outlines methods you can use in your practice to preform atraumatic extractions. He covers periotmes, luxators, mechanical leverage devices, more effective forceps and sectioning single roots lengthwise. Here, he offers more clinical solutions for atraumatic extractions.

Bone fenestration for maxillary root tips

	RELATED CONTENT    Dr. Koerner’s article, “Breaking Tradition”.

We know that some root tips are near the facial cortical plate of bone, including maxillary centrals, laterals, canines and buccal roots of upper first premolars. If, for example, a buccal root tip of an upper first premolar is fractured and attempts at retrieval are unsuccessful, the bone fenestration method (Figs. 1 and 2) may be considered. Measure radiographically how far the root is from the gumline, make a semilunar flap with an incision that will be about 5 mm from the bony window. Then drill the short distance to the root. It can be dislodged with a Heidbrink root-tip pick as depicted in the figure. Suture the flap and leave the buccal plate intact.

The buccal roots of upper first premolars are often bifurcated and either the buccal or lingual root tip can fracture. If sufficient time and care is taken for the extraction, neither one will break. However, when doing the forcep extraction, if the operator orients the forcep beaks slightly facially while applying traction this will lessen the chance of a lingual root tip fracture in favor of a buccal root tip fracture—the buccal one being easier and safer to retrieve.  

Selective proximal or interradicular bone removal instead of buccal bone loss

Sometimes a lower molar root fractures during an extraction. It is often curved, wide and in dense bone with a tenacious ligament holding it in position. Visibility and access may not be good. After failing at several more traditional attempts and not wanting to lose any buccal bone, the operator can consider what was done in Figs. 3 and 4.  A surgical highspeed (that does not blow air into the surgical field) carefully removed interradicular bone. The surgical length bur was placed to the apex of the empty socket and moved mesially toward the remaining root to excise interradicular bone. Don’t go deeper than the socket or too far buccally or lingually. Then you can use a root-tip pick or curved luxator to push the remaining root into the middle of the socket or you can use a small Cryer within the socket to bring the root coronally.

Orthodontic elastic extrusion

In the past, some dentists found out the hard way that if an orthodontic elastic is placed around a tooth and it happens to slip apically toward the gumline, that elastic will cleanly and without bleeding avulse the tooth in about six weeks (principle of the inclined plane). In this era of bisphosphonate problems, that is good to know.  Many dentists use that knowledge to intentionally extract teeth with elastics in bisphosphonate patients.

In a recent issue of the Journal of Oral and Maxillofacial Surgery (66:1157-1161, 2008), Dr. Eran Regev and associates reported their study of 10 patients—eight on IV bisphosphates and two who had been on the oral form for more than 10 years. They added a new elastic each week and occlusion was adjusted weekly as needed. Molars were treated endodontially before sectioning and elastics were placed on each root of molar teeth. No sutures or antibiotics were used. The mean time for tooth loss was 6 weeks (ranging from 2-14 weeks).

Keep an open mind

For some clinicians, these methods involve a change in mind set, a change in the way they were taught and a change in their status quo. Periodontists receive so many referrals for extractions because they are willing to use these and other atraumatic extraction methods. They also use effective bone grafting methods for socket preservation or ridge augmentation. But it’s important to remember that these techniques are well within the realm of general dentists, as well as oral and maxillofacial surgeons and periodontists.


Dr. Koerner is the Director of Oral Surgery at the Scottsdale Center for Dentistry.

Bone fenestration
Fig. 1		Fig. 2
Removing interradicular bone
Fig. 3		Fig. 4
Fig. 1  The buccal root of a maxillary first premolar is being retrieved with access through a buccal semilunar flap and bony fenestration.  Note that the incision is not too close to the bone excision. A Heidbrink root-tip pick is used to disengage the root tip from the alveolus.  Fig. 2  The root tip that was removed from the socket.  Fig. 3  During the forcep extraction, the distal root was broken and left behind in the socket. After several retrieval methods were unsuccessful, interradicular bone was removed with a “surgical” handpiece and surgical length 702 bur. Fig. 4  Schumacher small Criers (#21 and #22). The appropriate small crier was used in the socket. The pointed tip was engaged in the root and the base of the socket was used as a fulcrum to bring the root coronally.  Additionally, other instruments could have been used to push the mesial root into the middle because the bony support for it was gone.