Space Around Coronal Half: Graft or Not?

Dear Dr. P, I would have definitely grafted, any space more then 2mm between bone and implant should be grafted. Especially on tooth #9 where resorption can create a esthetic failure for you. Another bit of advice, atraumatic extraction in the anterior is key to esthetic success of the case. I would never "troughed" around #9 and this probably a reason why you had such a gap. Any bone you removed could have been helpful in you case especially around tooth # 9. In this day and age with technology like Piezo you could have done a piezotome extraction removing little to no bone. Look into the technology, it is changing the way people practice. Hope thats helpful

what are you going to do now?

Dear Dr. P, Troughing around a tooth today is almost never ever needed if you divide and conquer correclty and have the proper instruments. Whenever i take out a tooth I start with periotomes from Karl Schumacher to release the attachment. I then use my luxator to tease the tooth out and most of them time do not even use a forcep. Troughing around the bone is just contraindicated IMHO if you will place an implant. As for an immediate implant the success and especially esthetic success is based on Thickness of buccal plate. You definitely do not want to compromise that with troughing. When placing an immediate you want to try not to engage the buccal plate for fear of resorption. THere is a concept called "Jumping Bone" in regards to immediate placement and space between implant and plate, if you have 1-2 mm there is no need to graft because it will fill in with bone. if you have more you should probably graft it and cover the implant and let it heal and come back in 4 months fro uncovery. I feal that by covering the implant in that situation I decrease the likelihood of losing my graft to the enviroment. All in all, purchase some periotomes and Original Luxators they are AMAZING! good Luck Dr. Jonathan Abenaim DMD www.jonathandentalspa.com

Dear Dr. P, Another option to the Periotomes, Luxators and Piezo is the "Easy X-Trac Kit" sold by Schein that can 'pluck' a root out of the socket. A screw is secured into the canal space and then pulled strongly with a leverage instrument. I have had very good success with it on dozens of root-tip extractions so far. Jim James C Cope, DDS

Dear Dr. p as you know #9 is in a very critical area ( esthetic zone)so to prevent of any esthetic failure it seems logical using bone graft and membrane and leave it for 4-5 month and after that try for supra structure.and now a days trouging is not recommended for extracting tooth ,espcially when you are going to replace it immediatly after extraction. good luck Dr. s-yaghobee periodontist

If the tooth would not budge, you might have had to use a handipiece on it. On anteriors, I refrain from touching with a drill. But, if you did and were left with a space over 2mm, for whatever reason, you should have grafted immediately, with a membrane if you couldnt get primary closure.

First use periotome whenever possible. The finest one that I have ever used is made by PDT. The Piezo unit is also nice but it does remove some bone. If it was impossible to remove with periotomes then I would use burs internally and infracture the root or I would use the Bendex extractor. I would absolutely graft around the implant whenever I could if the gap is greater than 1mm. Boticelli et al 2003 at IADR but then get only 70% fill in gaps less than 2mm(Int J of Oral Maxillofacial Implants 2003)

Dr. P, I do not really like periotomes, so I do all of my atraumatic extractions with a 15c blade. I simply work the blade down the PDL space on the mesial, distal, and palatal. I work the buccal as little as possible to avoid fracturing the buccal plate. This usually proves to be enough to remove the tooth. If the tooth does not want to come out, I will use a bur to section the tooth and collapse it in on itself. This should be done so the tooth collapses in a mesial/distal manner. Again, this is to avoid any pressure towards the buccal plate. When the tooth is out, there is virtually no trauma to the bone. Once the tooth is removed, assess the buccal plate for thickness and continuity. Scribe a groove in the palatal aspect of the extraction site to guide your twist drills. Without this, your drills will want to take the path of least resistance and fall into the wide open socket. The implant will be engaged apically and lingually. My personal criteria for grafting is 1.5mm. If the HDD is greater than 1.5mm, I will graft. Hope this helps.

I agree that a blade is nice and when I use a blade instead of a periotome I use a microblade like a # 64.It has a rounded edge. The PDT periotome has a serrated cutting edge on the sides so it causes the least amount of damage of any periotome

I have to agree with Kimsey, the best way now to atraumatically extract is the piezo (periotome insert), the fact that it removes some bone is actually good (in fact excellent!)as it promotes bleeding and angiogenesis, just look at the technique of bartee, palti and horowits, they all use a bur whenever blood is poor in the extraction area, to remove some bone and have some bleeding. As quoted by kimsey (boticelli) is the person to read in these respect, but also Kimsey can be quoted, he published a nice paper at the academy of osseointegration last year on clinical innovations, and he suggested using a special condenser made of titanium, on the extraction site whenever immediately placing the implants to fill in the space,the nicer part of the presentation by kimsey was the literature review. I suggest you look at it! personally, I prefer to always graft and fill in the space, it makes me feel comfortable with the case.

I have great luck using my Waterlase. With the correct tip I can eliminate the ligament down along way and often the tooth is quite easy to remove. The laser also can sterilize the socket when any residual infection from an old root canal might be present.

Dr. P, You should clarify your trough technique. Did you extract the tooth first and then trough for some reason around the extraction site? Or did you actually remove the buccal and palatal bone prior to the removal of the tooth? If you removed bone and shortened the alveolar height in the vertical dimension, then you are surely going to have esthetic issues with gingival recession and asymmetry.

I agree with Dr Holtzclaw. The 15 blade is great. I actual will lightly tap the handle with a malet to engage the ligament and then wiggle the handle back and forth and work it around the tooth. I tried to remove a tooth with the Piezo and got horrific results. The bone died around the socket and I lost the implant. I took Dr. Vertelacci's course and found that he cuts into the tooth than touch the bone. The Piezo is a great tool but it has its place. Be careful with this device.

A spinoff or Dr Kinecht's use of the mallet on the #15 blade would be to look into the periotome made by ACE surgical. Different sized blades insert into the collet front and the whole thing can be tapped in with a mallet. Zoll mfg makes a very thin elevator in sizes 1s and 2s which all in combination makes for atraumatic extractions.You need to take your time and have patience with it though.

I am confused regarding torque of implant to 35 ncm when placing the implant? I will always place the implant to the lingal, engaging the palatal bone and actually place graft materil against the buccal plate prior to screwing in the implant. I use cortical cancellous graft material. This fills the gap perfectly on the facial of the implant. I will cover with a membrane only if i feel it is necessary. I decide whether to place an immediate restoration or cover it based upon the stability at placement. Never would I torque an implant into place.

Why are we talking about extractions. That wasn't the question! The toothroot and the dental implant never have the same sizes. So we should talk about the jumping-gap instead of how to extract a tooth. What I have understand is that if there is a jumping gap of 1 mm or less teh prognosis is good for bonecells growing towards the implant and give you a stable result. Every gap byond the 1 mm should be graft to get a good result. Personally I would graft any gap to make it easier for the bonecells---> guided regeneration. We have the technics, so why not using them. Succes with your cases. P.s. Whit the waterlaser you still get a jumping gap allthough you have a better bone regeneration because there is no smearlayer to be broken down first

Do not use continuous pressure with the Piezo you MUST have irrigation hitting the tip as it will get hot. It works very nice but like many instruments we use it can be abused with terrible results.

Talking about piezo I use it all the time and it works great! This is the deal: IF YOU APPLY TOO MUCH PRESSURE ON THE HAND PIECE YOU WILL BURN THE BONE AND HAVE A NECROSIS, IT DID HAPPENED TO ME IN THE BEGGINING! IT HAS NEVER HAPPENED AGAIN EVER SINCE. I have been using piezo from the very beggining, it is incredible for atraumatic extractions, the BEST instrument for that purpose, but keep in mind that as you go deeper, the irrigation wont reach the area where the active work is being done and you will risk overheating the bone. Keep in mind that your piezo tip will go deeper with no force than your periotome ever will, so, it is your responsability to develop a good technique with this instrument. Just like with any other instrument, you do the job, you control the instrument, the instrument is just a facilitating tool.

I use the same 15 no blade and mallet technic that Dr Knecht mentioned and in all cases except one got splendid results. A fortnight ago had a lower left premolar and molar who wouldn't respond to all osteotomes put together. Finally had to do troughing and lost 3 mm bone. Planning to do a graft. Osteotomes are good and make life easy. But they are not panacea no matter which make or technic. Once in a while the dentist WILL have to take of some buccal bone and then pull out the tooth and then put a graft. We are not counting those teeth with very curved roots, ankylosis, hypercementosis and situated in unusual locations and angulations.