Exodontia is a procedure routinely provided in many general dental practices, but some clinicians are more discretionary than others when it comes to case selection. For some patients, a single extraction may be needed, but for other patients multiple extractions might be required to eliminate dental disease. The curriculum of most dental schools includes exodontia, however, many dental students do not get thorough instruction in the complexities of multiple simultaneous extractions and associated procedures, such as how to groom the alveolar bone after removing several teeth in a row (alveoloplasty), how to appropriately debride the gingival soft tissue, and how to close the surgical wound to enhance wound healing and minimize post-surgical complications. There are distinct differences in the approaches to single extractions versus multiple extractions that will be discussed and recommended in this brief article. As these recommendations are applied, enhanced patient comfort and improved patient outcomes can be realized.
To the right is a one-month post-op photograph of a 60 year old man who had all of his remaining mandibular teeth removed in preparation for a denture. (See Fig. 1). He had just been through the worst month of his life. Although his teeth were removed, no alveoloplasty was done. Gingival papillae shrunk down allowing interseptal bone to become exposed. Sensitive nerve endings throbbed like multiple dry sockets giving him constant and prolonged pain. He could not wear his new denture, he could not eat, and even had a difficult time talking. Unfortunately his dentist didn’t do anything to provide relief. Because of financial reasons the patient didn’t seek help elsewhere during this painful period. How could this have been prevented?
Figure 2: Maxillary erupted third molar in a 25 year old woman. Roots are long with fused, bulbous buccal roots and a flared palatal root. Radiographically, the root appeared conical. Removal of thin buccal bone was necessary to avoid a tuberosity fracture. Note the width of the apical portion compared to the width of the cervical area.
Figure 3: Examples of 3mm and 5mm straight Luxators™ to be pushed vertically (approximately 4mm deep) into the periodontal ligament space of a single root.
Figure 4
Figure 5: Radiograph of a 55 year old man. On the lower right (see arrow), teeth were extracted one year previously but longstanding pathology was not removed by the clinician. As a result, healing did not include bone filling into the defect.
Figure 6: The swollen and diseased papillae in this case will likely need to be excised post-extraction or, in anticipation of that, could be cut at their base before extractions.
Figure 7 A and B: A. Postoperative radiograph of two molar extractions and high interseptal bone that was not lowered and smoothed after the extractions. B. One week postop. This patient endured severe pain for a week due to lack of alveoloplasty. At the one-week postop visit, the patient was anesthetized, the bone was trimmed down and smoothed, and the interproximal area was sutured. Following this procedure, the patient healed uneventfully.
Figure 8: Bone sharpness status being evaluated by feeling through soft tissue. If needed, the flap can be reflected back and appropriate smoothing can be performed with a bone file (minor smoothing), a rongeur, or a bone bur such as a Komet H73 OS.HP .055 (5.5 mm football) or H73 OS.HP .040 (4.0 mm).
Figure 9 A and B: A. Preoperative picture. B. Same patient having had multiple extractions followed by closure with a continuouslock suture. An immediate denture was subsequently inserted. Proper suturing technique is to insert (and exit) the needle 3 mm from the edge of soft tissue wound margin or at the base of a papilla (which would also be at least 3 mm from the edge of soft tissue).
Let us review the steps necessary to perform exodontia in a situation like this according to current standards of care:
1. Minimally Traumatic Extractions
2. Removal of Pathology
3. Appropriate Alveoloplasty
4. Closure
Step One:
Minimally Traumatic Extractions
If at all possible, teeth should always be removed with minimal bone loss and with particular emphasis on retaining the buccal plate. One exception would be bone reduction buccal to erupted maxillary third molars if they are suspected to have a root configuration that prevents withdrawal and could predispose a tuberosity fracture. (See Fig. 2). Another exception would include bone removal in conjunction with impacted teeth.
Many extraction techniques exist that can contribute to the successful luxation and extraction of teeth without buccal bone loss. Among them are using elevators, appropriate forceps, sectioning of multi-rooted teeth, Luxators™ placed vertically into the periodontal ligament space mesially and distally (See Fig. 3), and use of the surgical burs such as 700 or 701 crosscut fissure burs (sometimes referred to as a periotome burs). 1,2 (See Fig. 4). There are also piezo blades, Powertome™ blades, and devices for anchoring a drill into a root followed by pulling on that drill, such as the Sapian™, X-tract™, and the Messinger/Benex™ systems. Other approaches include the use of Proximators™, Physics Forceps™, or sectioning a single root lengthwise to name a few.
Step Two:
Removal of Pathology
To allow rapid and successful healing, all pathology associated with the tooth or teeth in question should be removed. This includes using a long-shank surgical spoon curette (such as a Lucas 86) to debride periapical abscesses and periodontal infections. A rongeur is effective at “plucking” out more extensive granulomatous periodontal disease.
Long-standing infections in bone may contain fibrotic tissue that resists elimination through the body’s normal healing processes thus leaving behind osseous cavitations and defects that could remain indefinitely. (See Fig. 5) These cavitations and defects can make it difficult for future implant placement. Healthy papillae should be carefully reflected to prevent being crushed or torn during the extraction, but diseased papillae can be carefully excised along with other unhealthy pericoronal soft tissue remnants. (See Fig. 6)
Step three:
Appropriate Alveoloplasty
With teeth that are closely approximated, the post-extraction alveoloplasty may begin with incising from socket to socket across the interseptal crests. When elevating the full-thickness mucoperiosteum, the operator should be careful not to reflect past the mucogingival line as subsequent wound closure could lead to a more shallow mucobuccal fold than was originally anticipated.
Next, sharp edges of bone should be smoothed using a rongeur, a bone file, or a bone bur. These edges are generally 1) interseptal (See Fig. 7) and/ or 2) labial/incisal or buccal/occlusal. There may also be other locations of sharpness. If not removed, these sharp areas can easily poke through the overlying soft tissue in the days or weeks following the extractions and cause acute pain. One way to assess the successful completion of bone smoothing is to feel the ridge of the bone with your finger through the soft tissue to detect any protruding bone. (See Fig. 8). According to dental codes published by the American Dental Association3 even the most routine extractions includes removal of tooth structure, minor smoothing of the alveolar socket bone, and closure of the surgical site – all as indicated.
Simultaneous to smoothing the bone, other pre-prosthetic procedures may need to be considered, such as exostoses removal, canine eminence reduction, fibrous tuberosity reduction, frenectomy, or epulis removal. Some procedures such as vestibuloplasy and alveolar ridge augmentation for dentures are not as common as they used to be because of implants.
Occasionally alveolar ridge recontouring can interrupt the flow of minor blood vessels in the alveolus creating brisk bleeding (allowing blood to spurt out) from the bone. Bleeding may be stopped by using an instrument such as a periosteal elevator to crush or burnish bone from around the bleeding orifice into the center. Additionally, one may use direct or indirect pressure, bone wax, bone graft material compressed into the bleeding site, or coagulation products such as Surgicel™ and hemostatic gauze to help occlude the flow.
Following the alveoloplasty, copious irrigation is of paramount importance. Failure to carefully debride the entire surgical site of loose particles, including in sockets and under soft tissue flaps, can result in a prolonged post-surgical course including inflammation or infection. A properly executed alveoloplasty should result in a smoother ridge more conducive to normal healing. Following any extraction, manual digital compression of the socket (also part of the alveoplasty) is usually needed to bring expanded bone back to its original position in the alveolus.
Step four: Closure
Remaining papillae may be sutured straight across from each other or may be interdigitated for better closure of the sockets. Suturing the wound can be completed with interrupted, horizontal mattress, continuous, or continuous-lock sutures (See Fig. 9B). Continuous-type sutures are quick to place and avoid so many knots but without a denture to protect them they can easily break down as the patient tries to chew. A combination of interrupted sutures and continuous sutures may provide the most secure wound closure.
Conclusion:
Without proper training, some dentists may feel that removing multiple teeth at one time is not much different from single extractions. In reality, those two situations are quite different. Not understanding this can lead to patient pain and dissatisfaction with treatment. The purpose of this short treatise is to help colleagues understand the differences between single tooth exodontia and multiple tooth exodontia, and to be better prepared to address both situations. The procedures themselves are not that difficult but proper attention must be given to the details. It is a matter of awareness and developing the resolve to follow necessary steps that leads to more favorable outcomes.
References:
1. Cavallaro JS, Greenstein G and Tarnow DP. Clinical pearls for surgical implant dentistry, part 3. Dentistry Today. Oct. 2010. (Peer reviewed article for CE credit)
2. Cavallaro J, Greenstein G, & Greenstein B. Extracting teeth in preparation for dental implants. Dent Today. Oct. 2014. (Peer reviewed article for CE credit).
3. Codes on Dental Procedures and Nomenclature (CDT Codes). American Dental Association. 2016.
Dr. Koerner has presented hundreds of oral surgery presentations to general dentists at dental meetings in the U.S. and abroad. He has written over 25 surgery articles in dental literature and authored or co-authored four texts. His videos are available through Dr. Gordon Christensen’s Practical Clinical Courses. He is a general dentist with a practice in which he does only oral surgery. He is adjunct professor in oral surgery at Roseman University of Health Sciences College of Dental Medicine. He lives in Bountiful, UT. karlrkoerner@comcast.net.
Dr. L. Kris Munk is an Associate Professor and Director of the Oral and Maxillofacial Surgery Clinic at Roseman University of Health Sciences College of Dental Medicine located in South Jordan, Utah. He completed his undergraduate dental education at Creighton University in Omaha, Nebraska, followed by a General Practice Residency and an Oral and Maxillofacial Surgery Residency at Denver Health Medical Center in Denver, Colorado. He was the former Site Director of the Idaho Advanced General Dentistry Residency at Idaho State University. Dr. Munk has a Master’s Degree in Organization Development and Leadership and was in private practice in Idaho Falls, Idaho for twenty-five years before accepting his current full-time appointment at Roseman University.
