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Surgical Extractions- Class is in Session With Dr. Koerner

April 15, 2021 12:45 pm Published by
Dr. Koerner drops a few pearls of wisdom about removing the dreaded upper first molar in this Quickie Case Report.  KCSI covers this, and much more in the upcoming  Continuum 1: Hands-On Surgical Extractions Course. 
Extraction problems. So many are avoidable.  Continuing education in surgical extractions with KCSI helps dentists get faster, more efficient and more confident with surgical extractions.
obliteration of the buccal plate

Photo 1: Obliteration of the buccal plate

Preserve the Buccal Plate

When removing upper 1st premolars, the buccal plate is commonly obliterated. See example in photo 1.  It can be rationalized, but it is 95% avoidable. The case demonstrated here  involves a younger clinician being talked through an extraction case.
Things to Consider and Evaluate With Upper Premolar Extraction
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 or 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.

Photo 2: Finger on the buccal during the procedure supported bone and helped evaluate forcep pressure.

Case Report: Surgical Removal of Upper 1st Molar
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. The younger clinician, with finger on the buccal during the procedure,  supported bone and helped evaluate forcep pressure. (Photo 2).

Photo 3: Section off the crown slightly coronal to the gumline. Then cut M-D into the furcation.

 

Sectioning the Tooth

With this case, the clinician was advised to section off the crown slightly coronal to the gumline. (Photo 3), then cut M-D into the furcation. 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, 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. (Photo 4)

Photo 4: 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.

 

Strategies for Broken Root Tips

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. quickie case report is just a small fraction of the instruction and discussion that takes place during KCSI courses.  Participants learn about  things to do, not to do, how to be more careful, and not loose buccal plate and more.   We mentor for success using either a straight or surgical highspeed.
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