Surgical Extraction of Maxillary Second Molar – Dental Minute with Steven T. Cutbirth, DDS
Hello: let’s talk about one of the most difficult extractions in dentistry, in my opinion, a lot harder than removing most impacted wisdom tooth teeth, and that is a complicated second molar extraction.
You can see this second molar has been undermined with decay, and so the coronal part of this tooth is probably going to come off-break off, and then we’ve got to remove the roots of the teeth, and we also want to graft the socket because we’re We want to leave the option of an implant open if we want to do that in six months, once the graft heals now. Normally, I don’t implant second molar teeth. I have the if the patient has an opposing second molar. Normally, what I’ll do is?
Have the patient wear a night guard that covers that opposing second molar because, as you know, it takes teeth 24 to 48 hours to move. So, as long as they wear that night guard every night, it’s going to keep that opposing second molar from super erupting and people do fine, with first molar occlusion.
So, the reasons I normally don’t place, an implant in the second molar reason region if the sinus is right here. Here’s the floor of the sinus, you’d like to have at least six millimeters of bone. There’s, not a problem penetrating the sinus, a millimeter or two.
When you place an implant, there’s a study in the library of dentistrymasterclasses.com, alluding to penetration of the sinus with implants, but the key is you want at least six to eight millimeters of an implant in bone.
The second reason I normally don’t implant second molars is the bone. In the maxillary, molar region is the softest bone in the mouth. The hardest bone is the lower anterior.
The second hardest is the lower posterior. The third hardest is the maxillary anterior, and the softest bone is the maxillary posterior. So, combining the sinus and often a lack of vertical bone for implant placement in the second molar region and the fact that’s the softest bone and people can do just fine with first molar occlusion. I’ve probably got maybe 15 20 percent of my practice. That does not have second molars for one reason or the other.
So for those reasons, I normally don’t imp implant, maxillary, sec or second molars in general, but the patient wanted to graft it and just have the option of an implant if he wanted it. So, when I do graft the socket of any socket of a molar tooth, I let the graft heal for six months prior to placing the implant.
You know you’ve got three to four roots, and so you can’t place the implant at the time of extraction, ideally because if you do, you want to place that implant in the friction between the roots. So, when you place it, there’s so much space around the implant. You never know for sure where that bone is going to regrow and what the final alveolar crest height will be in relation to the implant.
So i always anytime. I extract a molar tooth, a multi-rooted tooth. I graft it and let it heal for six months and then come back and place the implant. If it’s a single rooted tooth, I prefer to place the implant most of the time at the time of tooth extraction.
If we still have good facial and lingual or palatal bone plates, if the plates are lost, then we’ll probably graph the socket and come back in three to six months and place the implant one with single rooted teeth.
So let’s talk about extraction of this tooth. First, we’re going to minister topical anesthesia and anesthetize the urine. You can link to painless and profound maxillary local anesthesia in the library of dentistrymasterclasses.com.
This is an intra-ligamental injection which is very important, and then we’re going to draw the patient’s blood and make platelet-rich fibrin, which is your know, as rich in growth factor, we’re going to use that in our graph procedure, along with artificial bone.
So, this is the prf. The yellow part, and I’m not going to go into how we make that you can refer to the link, but we use this a lot in our surgical cases.
You place it on this perforated tray and then put the lid on top of it, and it squeezes the serum from the prf clots, and it goes into the tray below the perforated section of the tray.
So, this is the tooth you can see. We had an old restoration on the tooth that had broken down, and it had leaked and the whole coronal part of the tooth had been undermined with decay.
So, there was no saving of the tooth, so I’m making an intercellular incision with this 15 bard parker. Since I’m going to place a graft, I know I want the flaps to come up as, as close as possible once I’ve grafted it now. What happens if you try to extract this tooth? Is one piece, a single tooth extraction? Well, those roots go in this direction.
So if you try to do that, you’re going to have to extract it to the facial, and you’re going to lose the whole facial bony plate. So, I’m going to extract this tooth in three parts. We’ve got a powder root, a mesial buccal and a distal buccal root, so I’m going to cut between the roots and take the roots out in three parts.
Now I know this tooth is probably going to be brittle, so I’ll probably have to take each root out in parts, but you don’t take the tooth out. In one part, this is a big tooth, pretty big guy, and I know if I extract it, it’s got to be extracted to the facial, and I’m going to lose all the facial bone.
So, it’s got to be extracted or sectioned into three parts for each root powder root: mesial buccal, distal, buccal root. It’s a reflect a full thickness flap, so I’m first cutting mesial to distal right down the center of the tooth, so I’m separating the palatal from the mesial buccal and the distal buccal roots.
You want to cut all the way into the frication, be sure you cut all the way through the coronal part of the tooth into the frication, with this burr a lot of water, and this is about a number four to six long, shank round. Bur. A lot of water and just cut all the way through now, I’m going to separate the mesial buccal from the distal buccal roots.
This is tooth number two. So, it’s the upper right second molar. So, this is the mesial buccal root. This is the distal buccal root. Let me orient you – and this is the palatal root over here, so these mesial buccal and distal buccal roots are often really brittle.
So, I’m trying I want to cut all the way through the frication here on the buccal and mesial distal. I don’t want to cut through the buccal plate, though, ideally just through to the frication. So all these roots are going to be brittle, but the buccal roots will be the most brittle and a very good chance, you’ll fracture off even trying to be very careful.
The coronal part of that of the that segment, so this is just a small elevator. I’M just moving the pieces, and here comes the mesial buccal root and there’s the distal buccal rim trying to just unscrew them after I’ve luxated them a little bit.
If you don’t luxate them a little bit, they’re not going to come out well, you can see, I’ve still got. This is the paulo root, and this is the section of the mesial buccal root remaining in the coronal parts. Come has been extracted. It’s a small burnout in this case I’m not cutting bone, I’m actually cutting tooth the mesial part of the tooth. Remember when you elevate a tooth or a segment of a tooth.
You’ve got to have a space to elevate it into, you’ll, see on some of my other videos from extracting a bicuspid or a lower anterior tooth. I may cut between the tooth down to the gingival line to create a space to luxate it into if you’re trying to luxate a tooth or a root of a tooth and there’s an adjacent tooth that contacts the tooth you’re trying to extract.
You don’t have any space to lexate, so in this case I don’t want to cut the bone between the first molar and the second molar, I’m actually cutting into the tooth and into the mesial bone of the second molar, not the bone between the second molar and The adjacent first molar I want to preserve that bone, so I’m creating a space both to lexate the root into and for a purchase point for my elevator.
If you’ve got a root, that’s broken off, even with the alveolar process, you don’t have any place to place. An elevator to luxate that piece so make that little cut into the tooth of the bone.
So, you have a place to place your elevator. It’s trying to rotate that mesial buccal root. These can be very tedious. Had a dentist one time say he never extracted teeth because it was the most unpredictable part of the practice. This could be done in 15 minutes, or it might take 30 or 45 minutes or an hour, depending on how things go.
Just working trying to get a purchase point to elevate that mesial buckle root. There we go, so I’m elevating between the palo and the buccal roots and also in between the buccal roots, try to just try to get a little luxation and then once you do you’re going to unscrew the roots.
Basically, the powder root that was the powder root and once you get to the power root, you should be able to unscrew it. Just like you’re unscrewing, a maxillary central incisor, you just unscrew like say just unscrew it. You won’t go side to side you’ll, just unscrew, that powder root, I’ve still got a buccal root, tip remaining, and I’m cutting between those.
So, we’ve probably got five millimeters of bone between the frication and the maxillary sinus. So I’ve still got the root tip of the palate. I’M showing you this extraction because if you’ve got a second molar on a young person, you’ve got a good chance of getting the tooth out in one in three pieces: three complete pieces.
If it’s a bit of an older person, this gentleman was, I think, 67. Then many times those teeth become more brittle and especially if they’ve had endodontics or the tooth has been necrotic for a while non-vital, then the roots are more brittle, and it’s more of a challenge.
There’s nothing wrong by the way, once you’ve got less than a third of a root left, if you’re not going to place an implant to just sleeping that root, especially in the mandible, if you’re near the inferior alveolar nerve, just sleep, the root leave a third of The root, don’t be a hero, don’t go after it if you’re not placing an implant, and it’ll do just fine take it out to their cover it up.
Patient will never have a problem by sleeping a root. The only reason we’re taking these out is because the patient wanted the option of an implant, so I’m just what the thing to take from this as that tooth broke off, and there became just less and less of the root in the bone. You’ve got to constantly create spaces between the tooth and the bone or the tooth and the adjacent tooth to get the elevator into that space. So, you can luxate it if it’s flat with the alveolar crest.
If that part of the root is flat with the alveolar crest, you don’t have any place for a purchase point with your elevator, and so you can’t have the purchase point to elevate it, and you don’t have any space to elevate it into. So, those are the two things you’re needing a space to move it into when you’re elevating it and a space to place the elevator tip.
So, you can elevate it and these roots just kept fracturing off because they were so brittle this one. You don’t want a high-volume practice. This is taking probably at least twice as long as you thought it was going to take.
So now. We’ve extracted the parts of the tooth, and this is maxius cortical bone demineralized, and I’m mixing my platelet-rich fibrin. I’M going to mix the platelet-rich fibrin with the cortical artificial bone, and I’m going to place a couple of these pieces of prf in there and then cut it up with my scissors. And then the liquid is the serum from the bottom of the tray that I sectioned out into a 5cc syringe and I squirted that in there to wet the artificial bone and placing that into the so. This is serum, artificial bone and pieces of platelet-rich fiber.
Just filling that up, so I’m making a distal wedge back here. So, I can approximate, you can see. I’ve made a releasing incision right here, so I can approximate the flap. Now it doesn’t matter. If you have primary closure of the flap, you just want to get it as close as you can.
It really doesn’t matter if you have primary closure if you place a slab of the platelet-rich fibrin on the occlusal part of the defect. So, here’s a slab of that platelet-rich fibrin, I’m just trimming the distal part.
So, it covers the graft. The prf is kind of like working with jello. You know it moves in, so I like to cover it with a resorbable collagen membrane because it’s flat, and you can put pressure on it – it’s hard to put much pressure on a prs slab because it just it wiggles like jello.
So, here’s a resorbable collagen membrane. This is contour adapt, there’s several that are good. What I’m looking for in a resorbable membrane is, I don’t want it to have memory or the start shirt effect.
I don’t want it to keep bouncing back. I want it to adapt to the graft, so I’ve placed it over the graft, and now I’m coming back and making some small cuts where I want to trim it, and then I take it off, and I complete the cuts.
So, I’ve got the right size. The objective of this resorbable collagen membrane is to be large enough to cover the graft or any defect and also to tuck under the soft tissue flap. So, it’s secure, you don’t want to make it just fit on top of the graft.
You want to tuck it under the palatal and the facial flap. So, here it is in place – and this is 3-0 gut suture place one on the mesial one on the distal and then one in the middle on the facial.
If I have releasing incisions I’ll place, a four, oh to close, poor old gut suture to close the mesial, the releasing incision. So, here’s a trick with suturing if basically, if you’re using gut suture, and you’ve got the two ends of the suture, and you hold the needle part, I mean you’re going to wrap it one two three times and pull one.
The first of all one two three times away from you and pull then one time towards you and pull and then one time away from you and pull the three wraps. The first time will secure the suture. If you just wrap it twice, one two and pull that it may be loose, but if you wrap it three times and then one time towards you and then one time away, the three times that you do with the first pull will keep it in place.
And here’s a distal suture and whenever you suture a see how I’m taking a big bite, don’t go in right here into the edge near the incision, or it’ll pull through. You want to take a deep bite both on the facial and the palatal, one more for good measure here on the mesial, see how deep that bite is here’s the incision, and this is way down in the palate.
That’s why you have to give an intra-ligamental injection. Be sure to numb that palatal tissue, so you do not have to have primary closure because to have primary closure, I would have to make a big, releasing incision and reflect all the way down to the non-attached or the non-keratinized gingiva. So, in.
In my opinion, it’s more important to have the blood flow from the keratinized gingiva being continued to be attached to the bone. So, here it is and that’s the final suture you can see: we’ve got it nice and tight and here’s the edge of the incision here and here’s the edge on the other side and that will heal nicely, so we’ll.
Let that graft heal for six months and then come back and reevaluate see how much vertical bone we’ve attained from the graph and decide if we’d like to place a graft or not. So, that’s the dental minute, these techniques work, and they work every time. Click on the blue link in the description below and subscribe to, dentistrymasterclasses.
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