Minimally Traumatic Extractions for the GP

You're listening to the Phil Klein Dental Podcast One of the most common procedures we do as dentists is remove teeth. And for most of us, it's a fairly routine procedure that we've done over and over, pretty much the same way since we graduated dental school. But with more research on the topic of tooth extraction and the extraction site itself and how it all relates to implants, minimizing the trauma to the surgical site is of utmost importance. To tell us more about this is Dr. Isaac Tawil. Dr. Tawil received his diplomat from the International Academy of Dental Implantology, as well as his fellowships with the International Congress of Oral Implantology and the Advanced Dental Implant Academy. He is the founder of Advanced Implant Education and is a partner in TBS Instruments and Universal Shapers, LLC. He is a graduate of NYU Dental School and practices in Brooklyn, New York. Dr. Tawil, it's a pleasure to have you on the show. Thank you for having me. So what's the difference between the terminology atraumatic extraction versus minimally traumatic extraction? It's funny because you go to all these symposiums and lectures and you hear the words atraumatic extraction. And I can't imagine trying to portray to my patient that I'm about to rip a part of appendage out of their mouth and tell them that there's no trauma that's going to be occurring. Obviously, atraumatic means without trauma. There's always going to be trauma whenever we do anything surgically. And certainly when we're moving a tooth, we're going to be causing a cascade of effects that's going to occur. So the term atraumatic attraction to me should be wiped from the dictionary completely, at least from the dental terminology. There's things that could be atraumatic in dentistry. The filling maybe might not be traumatic if it's a bonded filling and you're not anesthetizing the patient. But as soon as we do anything to the patient to cause any type of inflammation, obviously that's a cascade effect. happening from trauma. So we prefer the term minimally traumatic extractions. We want to extract a tooth with a minimal amount of force with as little trauma to the surrounding tissues so that the patient can have a better overall experience. We're going to get back to Dr. Tawil in a second, but first, thanks to GC America, we're now able to incorporate all the advantages of glass ionomer into a beautifully aesthetic, strong, long-lasting restoration. That's a great reason to try GC Fuji Automix LC. You'll love the convenient automix delivery system and ergonomic dispenser. which allows precise placement into the preparation. And GC Fuji Automix LC is bioactive, allowing for a high rechargeable fluoride release, which is ideal for high caries risk patients. And because it forms a chemical bond to tooth structure, even in the presence of saliva, there's no need for etchant and adhesive bonding. This saves steps and is ideal for challenging patients where access and isolation are difficult. And the small filler particles in the material allow for superb polishability and excellent aesthetics. So when you're thinking glass ionomer for your clinical cases, think GC America, a world leader in dental materials. To learn more, visit gc.dental. All right, so let's talk about the importance of minimally traumatic extraction. Why is it crucial that we... these procedures in a way where we induce minimal trauma to the area, the surgical area where we're delivering that tooth. Why is that more important and crucial today than in the past? So let's take it back, you know, 30, 40, 50 years where when we first learned to take out teeth, the most likely thing that we were going to do was either going to be a removal of prosthetic or maybe a fixed prosthetic. And one of the things we actually were taught to do in dental school, at least my father always taught me this when we were younger, was as soon as you take out the tooth, crush the buckle plate. Flatten it out so that there's no sharp edges. Smooth it down because that denture that's going to go over it or that bridge that's going to go over it, you want to be able to make a pontic over it, kind of have a nice smooth surface. Today, that's the exact opposite of approach. Our ultimate goal, if the patient can have implants, if there's no medical considerations that we have to worry about, if there's adequate bone, the goal should be to take it out with as little amount of force as possible, as little amount of stress to the surrounding tissues, especially the buccal plate. There's a very famous phrase that was coined by Dr. David Garber from South Africa, who's in the Team Atlanta group with Dr. Salama. the world famous Dr. Ronald Goldstein, father of modern restorative dentistry. All of that in his years, he came up with this wonderful term saying the bone sets the tone, but the tissue is the issue. Sometimes you hear it in the reverse. The tissue is the issue and the bone sets the tone. And it's never been more true. than ever before because we know that in order for implants to survive, we need a very nice amount of bone. And we don't want that to start to degrade as soon as we extract the tooth. So we want to perform procedures such as socket preservations, such as soft tissue preservations. Sometimes we do even grafting on the soft tissue as well because we want to enhance that area. But if we start out by kind of taking out these teeth with a violent amount of force and we we created a hissence or a fenestration now the procedure goes from a simple procedure of a socket preservation or even trying to get an immediate implant and it goes into a procedure where now we have to rebuild we have to do bone augmentation not preservation so our goal should be to try to preserve and sometimes even enhance the tissue that is present in front of us. And in order for us to do that, it has to start from square one, which is take out the tooth with the minimal amount of trauma so that the patient can receive an implant either same day, next month, next three months, six months, whatever the plan or treatment plan may be. That's our overall goal. And I think as a whole in dentistry, there's so many different... ways to take out teeth. You see all these different tools that come out with over the years. Some of the tools don't actually help you preserve the plate. They help you remove the tooth, but not actually preserve that area. And they can actually lead to more problems than good. So what you're trying to say here to keep it minimally traumatic is that we obviously need to understand the technique that will lead us to a minimally traumatic procedure and also have the right tools, the right instruments to do this. So talk about the tools, the techniques that enable a GP to perform a minimally traumatic extraction. Sometimes it can be something as simple as a specific type of an elevator. The first thing that we always like to do is separate the soft tissue from the actual tooth itself. Because if you just pick up a forcep, even if the tooth is loose, you might actually, let's say you have a class two, class three mobile tooth and you think you could just pull it right out. When you put the force on the tooth, a lot of times if you don't separate the tissue, that tissue will come with it. And now you've just ruined all that tissue that was there and you're trying to re-stitch it up. And that's never minimally traumatic at that point. That becomes more of a traumatic situation. And usually you end up losing bone. So if we can use different tools, like a periosteal elevator or the newer developments of things called peritomes, which are very fine instruments, some of them have serrations, some of them are very sharp, more like a blade, and we just go right around in the sulcus of the tooth to separate the actual crown and cementum of the tooth from the surrounding soft tissue. The next step after that could be the use of an elevator, but elevators are kind of big and bulky and they don't give you the dexterity. that some of the newer instruments can give you. One such instrument is a approximator. or Luxator or with the company that I am a partner in, TBS, we make these devices called Elvatomes. We actually just came out with a new Elvatome that has a kind of a twisted steel. And the reason that we did this twisted steel is to give you the ability to hold it in a pen-like fashion. So when you go over to the tooth, we go over to it with a very sharp spade blade. We find a purchase point, a spot that we can locate in between the tooth and the bone itself. We don't like to put pressure on the neighboring teeth. A lot of times you'll see in older lectures where they use this wheel and axle lever action type of a motion where you go with an elevator, grip it with your palm of your hand and turn and press, and you inevitably end up putting pressure on the adjacent teeth. If there's a crown on the adjacent tooth, it might crack. If there's a filling, it might pop out. But even still, why would we want to put neighboring pressure on neighboring teeth? It doesn't make sense. So I'm the fan of trying to displace the tooth out of the socket, just like a rock. If you drop in a cup of water, we'll displace the water and the water will come out of the glass. If it's a full glass, the same thing should be done when we think about extractions. We can hold these albatomes or approximators or whatever you'd like to use. And we hold them in a pen like grip. We go find a purchase point in a pen like grip. And then once we have a good anchorage spot, a good purchase point, we can then, take our hands and turn it over into a palm grip style fashion. And then we can put apical pressure to follow the contour down the root. And with a slight twisting action, what you'll find is the tooth will start to eject itself out of the socket. We do this from the mesial, distal, palatal, lingual, but never from the buckle because putting pressure on that thin buckle plate could cause that to break. And then we're looking again at an augmentation procedure. In a second, Dr. Towel is going to be addressing piezoelectric surgery. But first, are you looking for an air-driven handpiece that rivals the power and torque of electric? Well, I have good news. It's finally here. It's called the TMAC-Z, and it's from NSK, a company we all know and trust as a world leader in dental handpieces. In addition to being lightweight and ergonomic, this revolutionary air-driven handpiece delivers unprecedented 44 watts of power, allowing it to cut through tough zirconia smoothly and quickly. In fact, the TMAC-Z reduces overall cutting time by 30%. That means less chair time, reducing the burden on you and your patient. Take a test drive of the TMAC-Z air-driven handpiece from NSK. For a free 10-day trial, go to nskdental.com and find your local rep to inquire. Experience the power and excitement of the TMAX Z series. Another really nice tool that has been developed over many years ago is piezoelectric surgery. One company that developed it, Tommaso Varsolati, with his Mectron piezosurgical unit, created a really nice device that we can go around into the periodontal ligament with these extraction tips and separate the tooth from the surrounding bone very lightly without any heat. And then from there, we can go in with either an elevator, elvatome, or forceps. One other really nice tool that's been developed more recently is gone away from the traditional forceps. At our company, at TBS, what we developed was a spring-loaded forcep. Imagine a Ranjur, but in a forcep-style fashion. And what that gives us the ability to do is to have light finger pressure on our wrists so that when we then go ahead and grab onto the crown of the tooth, we can use just our back three fingers. We can use our... pinky finger, our ring finger, and our thumb to hold the back part of the handle of the actual forcep because it starts in an open fashion because it's a spring. The second important part is taking your index finger and putting it on the front where the beak is, closer to the beak where that hinge is. That hinge is where the spring is located. Now that gives us the ability to be able to put our finger on it and actually be able to push apically as well. So when we squeeze lightly with our back fingers and take our index finger and push down on that hinge, we're able to provide apical pressure so that the tooth won't slip and we won't have to do too much rotational movement to be able to deliver the tooth. So we're starting with the peritone, then an elvatome or a piezo-surgical instrument, and then using a forcep. that's going to be able to deliver the tooth. Now we're talking about having minimal trauma to the area in 99% of the cases. Obviously, there's going to be those cases where the tooth just keeps cracking and breaking. It's all decayed and it's ankylose. Those are going to exist. But if we use the proper surgical tools, 99% of extractions can be minimally traumatic and not have to end up in these bigger, larger augmentation type of cases. Yeah. So once the teeth are delivered, So they're out of the mouth. You're looking at the socket. Tell us about the granulation tissue. There's new instrumentation that allows you to remove granulation tissue. Yeah, because in the old days, yeah, we used to use these smooth instruments that would go inside the socket. And I'm not sure it would actually remove the granulation tissue in the most effective way. So tell us what are some of the latest developments in that area. So the newer developments are of the curettes are much sharper than they used to be. And more recently, they've added serrations. Now, you have to be careful with serrations. You don't want big serrations because that won't scoop out the entire area. So we either like really sharp instruments, but sharp instruments dull very quickly. You have to keep resharpening. Ask any hygienist that's trying to clean calculus off of teeth and during a scaling and root planting. They have to constantly sharpen their instruments. So unless you're planning on buying new sharpened curettes every few months, if you're doing a lot of surgery, then the serrated curettes are the way to go. What we've thought about and what most of the companies are doing now is creating micro serrations so they don't have big gaps between them. So we're able to actually get the same type of a scoop to be able to clean out that granulation tissue in the same methodology as a super sharp curette would do. The other nice trick that no one ever talks about is that it's much easier to take somebody and to push them with your hands and push them away from you. If you're trying to pull someone and you take them with two hands and you pull them, they're able to fight back and they don't move very easily. So a great little trick, one of the best tricks that I teach all my attendees, is to actually take the curette that you're using. And if it's being stubborn, this granulation tissue is not coming out easily and you see you're struggling for a couple of minutes to get it out, just simply start at the coronal aspect of the extraction site and push with the curettes down into the apical portion. I know that sounds weird. Actually take the material and push it deeper into the socket. But when you do that, you're pushing it away. You have more force and the tissue doesn't fight you. Once you've released all of it, then you can go in that opposite motion and scoop it out going from the apical to the coronal aspect to just scoop it out right of that socket. And we can do that as long as there's no opening into a sinus or opening into a nerve. That's the main thing. So as long as we have a... or bottom to our traction circuit. We can push that tissue down. It takes only about 30 seconds or so. Then take the instrument in the opposite direction and pull the tissue out. One last very nice device that has been come out over the last bunch of years have been these degranulation burrs. You can actually take a burr at very low speed, 50, 100 RPM. You don't even need to use water. And we can go as long as there's no vital. uh structures in the area and we can have a a light debridement with the burr and that will clean up most of the granulation tissue usually when you take out the burr you'll see them the granulations issue at the tip of your drill and just go one more time with the curettes to clean it out rinse it out with some saline and now you're ready for either putting in a some type of a plug a prf material or a bone graft with a membrane or no membrane whatever your preference may be so as gps and specialists how can we use technology to help us kind of foresee what we're getting into and evaluate our approach to make sure we can ensure minimally traumatic extractions? That's a very important question. Over the last couple of decades and change, we've developed wonderful technology called cone beam computerized tomography, which is an amazing technology. When this first came out, we could say that medical grade CTs were finer. than our cone beam units, but the cone beam had less radiation. I just went to a conference this weekend and someone repeated that quote. And I literally burst out laughing in the audience. And I said, that's it. I'm sorry, I have to interrupt, but that's completely not true. And I can tell you this because my wife recently had a brain tumor and it was removed. When we went to go and get the procedure done, the CT scan was not as clear as the cone beam that I took in my office. cone beam CT to help them use their navigational equipment to avoid the carotid artery. That's how accurate and clear these machines are. So we can utilize cone beam technology. And if we utilize in the right manner, there's a very nice article that Dr. Gans wrote many years ago about the lip lift technique. What we do is we take a cotton roll, we stick it underneath the lip in the vestibule in between the teeth, the gingiva and the lip. It helps to create a little dark space around that area. So when we take this scan, the CBCT, once we get the reconstruction of that scan, we can actually see the tissue and the buccal plate. So now we know exactly where that root is at and how much bone there is before trying to remove this tooth. We can also see amazing technology of the root canal system and see if it's... the ligament is totally gone or if there's something remaining, where the granulation tissue is at, what location we should be focusing on. And more importantly than that, we now have the ability to see on a multi-rooted tooth how the tooth looks and presents itself. So if it's a... barely mobile tooth that has root canal and has an infection, we can simply then say, well, I'm going to section this tooth. And that's pretty much what I like to do with all my molars that are divergent, not convergent roots. I like to section them. I'll take a handpiece, let's say a nice long surgical burr, like a 701 surgical burr, and we'll split, let's say an upper molar, which should have three roots into three different individual roots. It's a lot easier to remove one tooth than that has one root than a tooth that has three roots that's anchoring into the bone, especially when they're divergent roots or if they dilacerate a little bit where they curve a little bit at the end. So instead of fighting the tooth, you want to figure out what's the best way to approach to remove the tooth. Just like if we got in our car and we wanted to get the best straightest way to get to a location without traffic, without issues, we would put on Google Maps. Even if you know the direction, you put on Google Maps so you can avoid the traffic. You can get around those nasty lights that are are having issues. If there's construction, it's going to warn you. And if you're using something like Waze, it'll tell you where the police cameras are so you don't get a ticket. That's the idea behind Combine. It's giving you all that technology to make your life simpler. So you can jump into that extraction, remove that tooth easily, quickly. And most of my patients, when I take out the tooth, they don't know that I've taken it out already. I don't mention anything. And then I clean up and I'm already putting in the graft. And they look at me and I'm pretty much done with the procedure. I'm about to stitch. And they say, the tooth is out already. I say, no, not only is the tooth out, you already have bone graft and we're about to suture. That's how the technique should be. The patient should not be experiencing pain from all the pressure because now you don't have three roots fighting each other. And they should be a nice, minimally traumatic extraction. And the procedure should go smoothly so that your post-op will go smoothly. And then the patient will give you. a lot of referrals because they think that you're a superhero being able to extract teeth. Yeah. And I'd like to say to the audience that Dr. Tawil does have some YouTube videos that you can look up that shows some of the instruments he's developed with the company that he works with, TBS. Again, you can look up Tawil, T-A-W-I-L. You could even do a search for minimally traumatic extraction, and those YouTube videos will show up right away. So those are good to look at as a reference. And in closing, I'll say, Dr. Tawil, the technology also helps the GP. make the decision that this tooth is possibly too complex for them to get involved with, and it's time to refer out. Now, you're, of course... Correct. That's the other part. Yeah, you're an oral surgeon, you're kind of an implantologist, but for many general dentists, cutting the tooth into three pieces on these divergent roots is really something a dentist... Could do as a GP if they're trained and they're used to doing it, but it might be something they want to refer out, especially if it's up near the sinus. Absolutely. Never be afraid to pump the case. Never be afraid to pump the case. You want to keep that patient. It's not about moving that tooth. It's about keeping that patient. And also, we also do have the webinars on your learning center. on extraction site management too. Yes. So the audience can go there as well then. Thanks for reminding me about that. VivaLearning.com. That's VivaLearning.com. Look up in the search field, Tawil, T-A-W-I-L, and you'll see all of Dr. Tawil's webinars, podcasts, et cetera. And he does show videos and so forth about minimally traumatic extractions, which are so important today. Thank you very much, Dr. Tawil. We'll talk to you on a future podcast. My pleasure. Thanks for having me. If you're enjoying this podcast please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.