Extracting canines
I had a question in the past about how to extract canines without fracturing the buccal plate. Due to their bulkier buccolingual dimension, canines tend to stick out of the arch at the neck. This couple with the generally thin dimension of bone at the maxillary anterior region, extraction of maxillary canines often result in the loss of the buccal plate of bone which results in a significant defect after healing.
Today I performed a full clearance including the extraction of 2 maxillary canines and 1 mandibular canine. Despite the loss of almost 60% of bone height, the canines still provided a challenge to extract. One maxillary canine I managed to fracture a large portion of the buccal plate and the other one I didn't. Anecdotally, this is what I did differently between them:
-Fractured the buccal plate: Luxated all around the tooth, Moved to forceps once there was slight mobility. Mainly my force was towards the buccal and the extraction was quick after the buccal plate fractured.
-Didn't fracture the buccal plate: Luxated mainly mesially, distally and buccally to avoid movement of the tooth to the buccal. I couldn't gain any mobility of the tooth despite this and move to forceps. I applied apical and force to the palatal only. Once I got some mobility I forced the tooth palatally and slowly rotated. The delivery was through rotation. This took a much longer time to extract.
I will continue to experiment with these force vectors. My thoughts to avoid buccal plate fracture are:
-Keep luxating until the tooth is basically going to fall out. Even though I had spent a fair bit of time luxating I should have spent even longer.
-Avoid buccal movement with forceps and heavy luxation of the palatal. Even buccal luxation may over expand the plate to the point of fracture.
-Use a piezotome if available to loosen the tooth. Slow and steady expansion of the buccal plate will eventually loosen the tooth. Raising a flap and removing the tooth surgically often results in the same amount of bone loss because the bone is too thin to gutter.
Today I performed a full clearance including the extraction of 2 maxillary canines and 1 mandibular canine. Despite the loss of almost 60% of bone height, the canines still provided a challenge to extract. One maxillary canine I managed to fracture a large portion of the buccal plate and the other one I didn't. Anecdotally, this is what I did differently between them:
-Fractured the buccal plate: Luxated all around the tooth, Moved to forceps once there was slight mobility. Mainly my force was towards the buccal and the extraction was quick after the buccal plate fractured.
-Didn't fracture the buccal plate: Luxated mainly mesially, distally and buccally to avoid movement of the tooth to the buccal. I couldn't gain any mobility of the tooth despite this and move to forceps. I applied apical and force to the palatal only. Once I got some mobility I forced the tooth palatally and slowly rotated. The delivery was through rotation. This took a much longer time to extract.
I will continue to experiment with these force vectors. My thoughts to avoid buccal plate fracture are:
-Keep luxating until the tooth is basically going to fall out. Even though I had spent a fair bit of time luxating I should have spent even longer.
-Avoid buccal movement with forceps and heavy luxation of the palatal. Even buccal luxation may over expand the plate to the point of fracture.
-Use a piezotome if available to loosen the tooth. Slow and steady expansion of the buccal plate will eventually loosen the tooth. Raising a flap and removing the tooth surgically often results in the same amount of bone loss because the bone is too thin to gutter.
Helps to elevate against the adjacent teeth as fulcrums (since you're going to remove them anyway), so always extract the canines first!
ReplyDeleteThanks for your comment. This is certainly a very useful tip.
DeleteHowever, I find when the teeth are periodontally compromised, the incisors and premolars don't provide much of an elevation point to the canines which are generally still quite solid. Do you find the same?
So if you elevate between the teeth (which you most certainly can and should) it just ends up extracting the other teeth first. At least this is true for me. But I do agree it can provide some loosening of the canine which allows subsequent removal easier.
You could try splinting say 12-22 together with composite.
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