TRANSCRIPT:

Okay, so this is a patient that was referred to me by his general dentist. He had a crown that had broken off with part of the tooth inside, and they went over restorative options, and the patient elected to get the tooth pulled out and an implant placed. The tooth was temporarily patched up with some flowable, and they cemented the crown back on. It kept popping off, and so what he actually did was he superglued the tooth on himself.

And so what I'm going to show you right now is the atraumatic extraction of the tooth and the immediate placement technique. Alright, so here you see me trying to remove some of that residue. That's actually superglue that the patient used to hold this temporary crown in place, and so I'm just kind of trying to separate the tissue from the superglue, and what I'd like to do is just remove some of the PDL attachment.

And so now what I'm using is a periotome. I have a little periotome with interchangeable tips, and what I'm doing is I'm going around the tooth, just around the circumference of the tooth, and tapping on it with a mallet. This could be a little disorienting for patients, so what I do is you've got to tell them we're going to have a little bit of light tapping. Don't worry. Nothing's wrong. We're just kind of tapping gently around your tooth. Usually, they're okay with it.

I'm being really gentle on that buckle aspect because I don't want to damage any of the buckle bone there. So I'm just taking that little periotome all the way around the entire tooth. The key to this step is just being patient. I'm not trying to rush anything. That's the key to having atraumatic extraction, not trying to rush anything, and just taking your time to really cover every millimeter around that tooth. If there's even just like one area, one spot where it's holding on, it might hang up your whole extraction. It might delay you and make you try to rush it.

So I just carefully inch my way around the entire circumference of the tooth. In the areas of the embrasure, I actually angle the periotome a little bit differently. I angle it like almost like a 45 or even 90-degree angle to the long axis of the tooth just so I can reach that interceptal bone. Now I'm coming from the lingual. For these maxillary anterior teeth, it's a little bit easier to get the lingual of the tooth also, so it makes it a lot easier.

I feel like this palatal area of bone is really where the tooth grabs on really tight, so I make sure to go all along the palatal as well. At this point, I'm just going back over, making sure that there was no area at the circumference where I left out any tapping.

So I'm actually showing you exactly how long it took me. I'm not cutting part of the surgical time out. So this is, at least for me, this is realistically how long these things take. You've really got to take your time, and even if you feel like you've already tapped every single inch of that circumference, I just like going over it a little bit again and again to make sure that I'm not reaching for the forceps too soon or even reaching for the elevators too soon.

How many times have you just reached for the elevator on a tooth like this and then the crown just cracks in half? Now, finally, I'm reaching for the elevator on this tooth, and I feel like I can't really stick my elevator in there too effectively. That elevator's a little bit too fat, and that super glue really took up a lot of space there, and it's not going to let me work.

So what I do is I take my high speed with a chamfer burr, more like a 856 burr or something, and I just open up the interproximals. I do that so that I have a better grip for my elevators and also a better grip for my forceps.

And so now you can see that those embrasures are nice and square. I can put my elevator into the embrasure actually and use that to effectively start levering the tooth out. Oh, and there goes the crown. And I go in and see if I can try to wiggle that with some forceps, and it looks like it's not quite budging yet.

I just stuck my throat pack back there. I want to make sure the patient doesn't aspirate. And I'm going to use those forceps again, being careful not to apply any buckle pressure. It still wasn't giving. I mean, I probably could have tried to force it, but definitely not something you want to do for these cases.

So I'm just going to use the elevators just a little bit more, apply just a little bit more pressure, and just gently let that tooth give way on its own. In these cases, you also want to balance any trauma that you might apply on the adjacent tooth. Like, for example, right here, I want to be careful that I'm not going to pop off the adjacent crown. Just be really aware of that and just be really careful and really gentle.

I'm just applying side-to-side motion here. And you can already start seeing that that tooth's got some mobility on it now.

I can see little bubbles and little bits of blood kind of coming up from the tooth socket. And I'm going to go back in with my periotome, as if I didn't use that enough already. But I'm just going to use that just to wedge that last little root tip out. So I'm making sure to angle the periotome towards the root of the tooth. You want to make sure this follows the extraction socket and that you're not creating some defect in the bone.

Some people like to use a high-speed for this and just kind of cutting the bone around the tooth also. That works well. I like to use, like, a fine-tip burr for that. In this particular case, I felt like I could get the tooth out without doing that. When you do that, you are sacrificing a little bit of bone and you are spraying a lot of air and water into the tissues. So when I can, I try not to do that.

So like I said, this is in real time, so if this is seeming like it's taking a while, well, it's true, it takes a while, but taking your time with these cases really pays off. All right, so now I'm ready to use the forceps again, but I want to make sure that my forceps... I put my forceps to really good use, so I'm going to go ahead and make those notches again. So I'm making the interproximals flat and I'm making the facial and the lingual flat. The forceps only work if you have something to grab onto, and so if it's tapered, you're not going to grab onto anything very effectively, so I'm making undercuts all around the tooth. I'm just making sure the forceps have something to grip onto.

Now I'm going back with these forceps and I'm just wiggling the tooth, measly, distally, and I rotate it a little bit, and you can see that right there, finally it gave way. And now it's out. All right, so now that the tooth is out, I'm going to start by making my pilot drill, and I start my pilot drill with that little extender. You can see that I have my lance pilot drill on an extender because I don't want to hit the adjacent teeth. And where I'm making my initial pilot incision, I'm making it in the lingual wall of the tooth, so the palatal wall.

Now I'm going in with my Lindeman pilot drill, and I'm working on that same site. It's really easy in immediate extraction sites for your drills to slip and for you to actually slip out of the intended implant preparation, so I use the Lindeman just to kind of make my osteotomy a little bit more pronounced before I jump in with my 2-millimeter pilot drill.

So now you see me here with my 2-millimeter pilot drill, and I'm going back into the hole that I made with the lance and the Lindeman pilot drills. And so I'm making sure to do this with sterile saline irrigation, and I'm just carefully going in and out, just minding my angle. The angle is super important. Now I'm going to go ahead and put the paralleling pin into the osteotomy, and I'm going to look at it from a head-on angle. I'm going to look at it from a side-to-side angle, just making sure that it's exactly where I want it to be. This part really is critical because you don't want the implant to be angled in such a way that it's going to be sticking out through the buckle and mess with your emergence profile.

Here I'm showing that the implant preparation is actually not directly into the extraction socket. It's a little bit palatal, so you can actually see a distinct palatal preparation. Now I'm going back with my 2-millimeter pilot drill just to make my implant preparation just a little bit deeper and a little bit more pronounced because, remember, I just checked it with the little paralleling pin to make sure that it was in the angle and in the position that I wanted it. Now I have the confidence to go back with my 2-millimeter pilot drill to take it to depth.

With immediate implants, you're actually making them a little bit deeper than you would for a healed-site implant. For an immediate implant, you've got to engage a little bit deeper just to be able to achieve primary stability. For this implant site, I'm actually placing a 13-millimeter implant, and so I'm actually drilling to where the gingiva are at, are showing that I'm 16-millimeter deep. My 16-millimeter mark is right at the gums.

Now this is an occlusal view of the preparation after I've used my 2-millimeter drill. Finally, I'm at my last drill, and notice how I don't run my drills at full speed. I actually just, like, feather the rheostat to make it run faster or slower, depending on what region of the mouth I'm in. So now you can see I'm using a drill tap. I actually use the drill tap on a hand driver. It's that straight hand driver, and I use that to make threads for me. Because remember, I don't want my implant to slip into the extraction site. I want it to follow the path that I created. I want it to follow my implant preparation. So I stick this implant tap to carve the threads all the way down so my implant follows the desired path.

Now I'm just taking the sterile saline irrigation, going into the socket, and flushing it out. Now I'm ready to place my implant. This is a Zimmer implant, and I'm inserting it with that same hand driver that I used for the tap. It's a straight hand driver.

It almost looks like a screwdriver. And this is the best way to be able to get the most control of my implant insertion. I'm just doing it real slow, making sure I go to depth, and making sure that I'm following the same angle. You've got to be really careful with that part right here because it's really easy to have your implant slip, and all of a sudden it's in a different angle than you intended.

Now that my implant is to depth, I'm going to use my little driver to unscrew the implant transfer, or the impression coping. It basically comes with an impression coping. So I'm unscrewing that, and I'm going to remove it. And now I see that my implant's almost at the desired depth.

I make sure to look at my implant, like the circumference of bone around my implant, to see if there's anywhere where the bone is not fully encircling the implant. And so now what I do is I continue to insert the implant a little bit deeper, just to make sure that I have bony walls covering all the implant platforms.

So this is a picture of what the implant looks like inserted. Notice that it is slightly more lingual, slightly more engaging. It's engaging the palatal wall, and so you have a gap on the buccal wall. And so what I'm going to do to fill that gap is just to stick in my particulate bone. I'm using cortical cancellous bone, mineralized. I like to use a spoon or like a curette to stick it in there because the space is pretty thin. And so you can use like a thinner instrument. A curette works well. Sometimes I'll even use my extraction elevators to push the bone in there. And so I spend actually a really long time pushing bone inside just to make sure that I get bone all the way down to the deepest parts of that extraction socket. To do that, it actually takes a pretty long time. You got to work at this for a little while.

Now finally, this is a shot of the implant in position with the bone graft placed around it. I actually used a skinnier healing abutment just to kind of cover the implant while I was packing bone. And then after I'm done packing the bone, I carefully remove that healing abutment and then I swap it out. I placed a fat healing abutment on it afterwards. That fatter healing abutment helps me with better emergence profile. And it also helps hold more bone in place.

I also use my finger, so like my index finger on my thumb, and I kind of squeeze the tissue around it just to kind of help approximate it a little bit better. That tissue is going to heal rather quickly and it's going to hold a lot of that graft in place. I tell my patients to wear their flipper overnight and then they can take it out the next day and clean it out. And that helps act as a band-aid for the clot to stay in place.

So this is what the tissue looks like after two weeks of healing. It's looking like perfectly healthy tissue. You can see that the buckle aspect of the tooth didn't have much recession. It doesn't look like there's much trauma. It was a very atraumatic procedure, and I'd say it turned out very well.

Lesson Summary

In this text, the author describes a dental procedure involving the extraction of a broken tooth and immediate placement of an implant. The patient had used superglue to temporarily hold the broken crown in place.

The dentist began by gently loosening the tooth using a periotome, followed by elevators to further loosen it. Once the tooth was sufficiently loosened, it was removed using forceps.

After the tooth extraction, the dentist prepared the implant site by using a pilot drill. The implant was then inserted into the site using a hand driver.

To ensure correct placement of the implant, the dentist checked that it was surrounded by bone and added particulate bone if there were any gaps.

Following the insertion of the implant, a healing abutment was placed. The tissue surrounding the implant was squeezed to aid in healing, and a flipper was worn overnight to support the clot.

After a two-week healing period, the tissue appeared healthy with minimal recession or trauma.

Overall, the dentist took their time and exercised caution throughout the procedure to ensure successful results.