Chapter 9- FIG. 9.42 & 9.

44

Extract the distal root, together with the crown in a bucco-lingual manner, and once it is out, you can
user your Cryer elevator to engage in the little interseptal bone and rotate in a CLOCKWISE manner so
that the teeth will go UP. The Cryer elevator is a PAIRED INSTRUMENT. So, you can also use it in a
COUNTERCLOCKWISE manner. Doc has not performed this, because complicated daw compared sa
other technique na I-section og bur nimo ang ngipon.

Fig. 9.45
Now, for the MAXILLARY MOLAR, since it is TRI-ROOTED, the book shows to have made a flap, remove
the BUCCAL BONE until the furcation is seen. They have used a STRAIGHT-FISSURE BUR to have
separated the two BUCCAL ROOTS from the rest of the tooth. We still have the PALATAL ROOT attached
to the crown, so, remove the crown with the palatal root using a FORCEP with the direction tilted MORE
BUCCALLY. If you move PALATALLY, there is a high chance that it will break, leaving the root fragment
attached in the palatal area. So, BUCCO-LIGUAL MOVEMENT BUT MORE ON THE BUCCAL SIDE. Once it is
removed, try removing the two buccal roots, ONE PIECE AT A TIME. So using a straight elevator, using
the wheel-and-axel technique or use a Cryer elevator in a CLOCKWISE DIRECTION (refer to the arrows on
Fig. 9.45 para sayon ang life) to bring the roots out. So as we can see, dili ra usa ka movement ang
pwede ma follow, kung unsa nga movement ang ma allow sa inyo instrument which is easier for you,
then that’s what you should follow. Sa Cryer Elevator is a PAIRED INSTRUMENT. So kung asa ang working
tip nya, adto mo rotate and elevator.

Fig. 9.46
If it is already a root fragment, and there is no crown, you can directly make an incision, separating the
two buccal roots with each other, and you know that there is only one palatal root, they you cake an
INVERTED-Y. Retrieve each root one piece at a time. So, a total of THREE roots. By doing a WEDGE
TECHNIQUE, katong i-insert APICALLY then tuyokon. But be very careful that only enough or little APICAL
FORCE is applied. Remember, MOLAR and i-extarct, if the is a direct communication with the MAXILLARY
SINUS, it might go in into the sinus. That is why IT IS COMPLICATED.

How to extract a maxillary molar by sectioning it:

Fig. 9.45

IN THE BOOK:

So in extracting a MAXILLARY MOLAR, we have to section both BUCCAL ROOTS, so that we can remove
the whole crown together with the PALATAL ROOT using a forcep in a BUCCO-LIGUAL MANNER BUT
MOSTLY ON THE BUCCAL SIDE para you can take it out.

WHAT DOC RIVERA NORMALLY DO: (WALA SA BOOK)

Doc usually makes a INTERVERD-Y Cut, separating the two buccal roots and the palatal root. In the book,
this technique is only used if THERE IS NO MORE CROWN. But even if there is a still a coronal structure,
we can still do the same principle by separating the two buccal roots from each other and the palatal
root. We just have to make sure that it is deep enough to reach the furcation area and break it using a
STRAIGHT ELEVATOR. Ideally, the luxator. We can use the 301 or 304. We can insert it in between the
cuts we’ve made (katong INVERTED-Y) AND TWIST, so that we can have THREE SEAPRATE PIECES
(ROOTS) of one tooth that will be coming out one piece at a time.

*the technique doc used is pwede nato ma gamit in our practice puhon, but for exam purposes, FOLLOW
WHAT IS WRITTEN IN THE BOOK!

If we’ve noticed in the book, all the procedures are done with a FLAP REFLECTED AND A BONE
REMOVED, to gain access of the furcation of each tooth. Another modification we can do is to try
sectioning the teeth without making a flap and removing a bone. What doc means, WITHPUR
REFLECTING A FLAP, get your FISSURED BUR (In the book, make a flap, remove bone mesio-distally until
the furcation is seen and section it.) and section it a little bit above the gums so that you won’t be
traumatizing the gums. So run your bur towards the lingual until you only reach the part you leave 1mm
of tooth structure intact para ma break. After going to that direction, just keep your bur inside the tooth,
ayaw gawas para di ma cut ang gums og bone. And continuously go DOWN until such time you’ve
reached the furcation. So that would still the purpose of extracting the tooth one piece at a time, but
without reflecting the soft tissues and the removal of bone.

Another option, you can reflect a flap, but you won’t be cutting ½ or 2/3s of the bone, but it is enough to
use the ROUND SUGICAL BUR AND AS RECOMMENED IN THE BOOK, USE SIZE 8 (so dako gyud siya).
Doc personally prefers to use the SIZE 4 because the smaller the diameter, the smaller the cut. So sa
bone, use the round bur to go down (sa bone ha kilid para kung asa ma sulod and elevator para ma
luxate ang ngipon), make a ditch with the exactly same size or diameter sa bur or if it is too small or too
shallow, you can extend up to 2mm. so para naa tay, canal, which sreves as a purchase point na ma
sulod nato ang elevator. So we can have an area we can use as a fulcrum to loosen tha attachment of
the tooth. We can use it for MULTI-ROOTED or SINGLE ROOTED TEETH. It is conservative because you
won’t be removing ½ or 2/3s of the bone to expose the furcation. So naa ra nimo ang final decision on
what technique to use.

Retained Parts: ROOT FRAGMENTS

Fig. 9.47
So ang root nga retained, we can extract it using ROOT TIP PICKS. Root tip picks is a very fine instrument.
They come in three kinds, one facing the RIGHT, the other facing the LEFT, and STRAIGHT. THIS CAN BE
DONE, OR IT IS EASY IF THE TOOTH IS ALREADY MOBILE BEFORE IT BROKE. Refer to the pic on where to
insert and what direction kay gi tudlo2 ra ni doc gamit iyang lapis hehe. So if I follow ra to nato, ma
tang2 ra ang tooth all by itself (refer sa pic).

Fig. 9.48 and 9.49

Below the level of the bone, this is complicated. So, if we will follow the directions in the book, we will
be cutting the bone, extending ½ or 2/3s of the total length of the tooth and use the elevator pushing it
to the side (again, refer sa pic para sa mga arrows) para ma tang2 rag iya ang tooth.
Fig. 9.50

Another possible option, if the tooth is very hard to retrieve and you need to retrieve it, so when you
can’t see it, or ming adapt well gyud sya og mayo sa bone when you broke it, make an estimation as to
where the APEX OF THE ROOT is, make a hole, and you can insert and instrument – a STRAIGHT
ELEVATOR OR CRANE PICK with applied force to push out the tooth out of the socket.

Considerations in Leaving Root Fragments Inside the Socket:

1. If it is small in size. Maximum of 4-5 mm in length only.

2. If It is not infected. Because if it is infected or associated with a cystic lesion, it can cause
problems – swelling, inflammation, abscess formation, or maybe cellulitis.
3. It should be deeply embedded that even in the course of resorption, it will not get exposed and
it will not cause trauma to the gums of the pxn who is wearing denture. Once a root fragment is
not deeply embedded in the socket, once the tooth resorbs, the root fragment becomes
exposed to the outer surface causing tissue impingement and inflammation. So mag balik2 ra
ang problema.

Multiple extractions:

So to make extraction go faster, with using local infiltration in the maxilla the effect of the anesthesia
goes away faster because of the porosity of the maxilla and there is rich blood supply so dali sya ma
clear sa system and it becomes painful with just a short amount of time compared to the mandible
where the pxn will be comfortable for at least 3-4 hours completely covered with anesthesia.

After anesthesia, we can reflect or incise the gums and try to extract the adjacent teeth para ma human
na. in doc’s case, if we try to reflect more gums, there will be continuous blood loss in the area where
you are working (maxilla sand gipa kita ni doc) if you are not fast enough. And it will be painful again, kay
dali ra ma wala ang effect sa anes sa maxilla, so mag balik na sd kag anes again. So kang doc, she will
LOOSEN AND EXTRACT one teeth at a time and she would only anesthetize the teeth adjacent to one
another that she could finish in time nga wala kayo pain and she could proceed somewhere adjacent to
it to continue reflecting the tissues out of the way before i-ibot.
Sequence:

 Extract the MAXILLARY TEETH FIRST BEFORE THE MANDIBULAR TEETH.

- Why? As we continue to luxate the tooth some parts might chip off, calcular deposits might
also chip off and all other substances might chip off when manipulating the tissues in the maxilla
and the can possibly fall on the sockets in the mandibular if the mandibular teeth are worked on
first. And if you are not careful and you did not irrigate the bone chips in the sockets, it can lead
to bone infection.
- Disadvantage: Some of the blood might be dripping into the lower dentition as you are trying
to extract that teeth in that area. Even tough it can hinder your vision in extracting the teeth in
the mandibular area, it is a small price to pay compared to the infection it can result if we
extract the mandibular dentition first before the maxillary dentition.
 Start form the MOST POSTERIOR, the teeth anterior to it, LEAVING THE FIRST MOLAR, and
then move on to the second premolar, then first premolar, LEAVING THE CANINE, then onto
the later and central incisors.
- Why? The FIRST MOLAR AND CANINE are the most stable teeth in the mouth. So, we are
removing them last w/out their adjacent teeth so that you can have room for expansion when
you remove those teeth.
- Between the two, REMOVE THE MAXILLARY FIRST MOLAR FIRST and then onto the
MAXILLARY CANINE.
- The first molar is stable because of its TRI-ROOTED nature and its roots are bigger compared
to the roots of the second and third molar.

Where to place the knot in when making a suture:

 Place it LABIALLY OR LINGUALLY. Disadvantage of placing it lingually , it might be uncomfortable

for some pxns because it will interfere with the tongue.
 Do not place the knot ON TOP or OCCLUSALLY. It will add weight to the area where it is
positioned. So, instead of healing in the normal position, it will go down. And if sufficient tissue
was not allocated when inserting the needle, because of the added weight or pressure, it can
tear the tissue or dehisce and longer healing period.

If all the principles are followed, there is less likely to be a complication. As long as you do not violate
the primary principles, you can always make your own technique comfortable and exclusive for you.