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Avoiding Surgical Extraction Problems- A Case Review

May 5, 2022 10:51 am Published by

Surgical Extraction Problems. So Many are Avoidable.


When removing upper 1st premolars, the buccal plate is commonly obliterated. Example in pic 1. it can be rationalized, but it is 95% avoidable. This case shows a younger clinician being talked through a case.
buccal plate

#1: Obliteration of the Buccal Plate

First, is there an indication of bifurcation on the x-ray? Sometimes hard to tell. About 60% have two roots. Use a blade, PE, elevator, forcep. Insidiously, the tooth may loosen up – but the double-root divergence prevents its release. Wrong choices can send you digging for root tips and bone loss.

Case report: Upper 1st Premolar Extraction

#2: finger on the buccal to support bone and help evaluate forcep pressure.

Upper 1st premolar was luxated to Class III mobility but would not come out. Here is when excessive force can rear its ugly head (as it can with first molars, canines, and tuberosities) for regretful outcomes. Younger clinician with finger on the buccal during the procedure – supported bone and helped evaluate forcep pressure. Pic 2. With this case, the clinician was advised to section off the crown slightly coronal to the gumline.

Sectioning the Tooth

#3: Cut M-D into furcation

Then cut M-D into the furcation, shown in pic 3. The M-D bur cut was with a 701 (because it is smaller than a molar) — cut 6 mm deep by the initial clinician and another 4-5 mm by the senior dentist (young clinician too timid) since the furcation usually happens in the apical portion (1/2 to 2/3 down the root). Luxator placed in the cut to fracture into B-L halves. The lingual half would not come until the buccal half was removed first. Why? The lingual root wanted to curve to the buccal on the way out. Transient lack of irrigation (a few seconds when the bag ran dry) caused some burning of the tooth by the bur shank – more serious and definitely to be avoided with bone.

#4: All pieces removed and accounted for.

Broken Roots

Pic 4. If a buccal root tip breaks, removal through an apical buccal window (like an apico access) is a good option. If a lingual root breaks, interradicular bone removal and implosion of the root to the buccal is a good option. Every case is an opportunity to learn and improve. Example of discussions at KCSI courses – things to do, not to do, how to be more careful, and not loose buccal plate… We mentor for success using either a straight or surgical highspeed.

Ready to Master Surgical Extractions?

Are you ready to get better, faster, more predictable with surgical extractions, and adeptly handling situations like these?  Sign up for KCSI’s next Continuum 1: Hands On Surgical Extraction course.  Upcoming courses are scheduled for May 13-14 or July 15-16.  See all upcoming courses here:

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This post was written by Dena Rathbun

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