Continuing Education

Course Number: 178

Extracting Teeth in
Preparation for Dental
Implants
Authored by
John Cavallaro, DDS; Gary Greenstein, DDS, MS; and
Ben Greenstein, DMD

Upon successful completion of this CE activity 2 CE credit hours may be awarded

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Extracting Teeth in Preparation
for Dental Implants
Effective Date: 10/1/2014 Expiration Date: 10/1/2017
LEARNING OBJECTIVES
After participating in this CE activity, the individual will learn:
Tooth removal techniques which employ burs as
adjunctive aids.
Clinical issues associated with tooth extractions in
preparation for dental implants.
ABOUT THE AUTHORS
Dr. Cavallaro is a clinical associate
professor, Implant Fellowship Program
and Prosthodontics, at the College of
Dental Medicine, Columbia University, in
New York City. He is in private practice,
specializing in surgical implantology and
prosthodontics in Brooklyn, NY. He can be reached via the
e-mail address docsamurai@si.rr.com.
Disclosure: Dr. Cavallaro reports no disclosures.
Dr. Gary Greenstein is a clinical
professor in the department of
periodontology at the College of Dental
Medicine, Columbia University in New
York City. He is in private practice,
specializing in surgical implantology and
periodontics in Freehold, NJ. He can be reached via e-mail
at ggperio@aol.com.
Disclosure: Dr. Gary Greenstein reports no disclosures.
Dr. Ben Greenstein is a clinical assistant
professor in the department of perio-
dontics at the College of Dental
Medicine, Rutgers University, in New
Jersey. He is in private practice,
specializing in surgical implantology and
1
Continuing Education
periodontics in Freehold, NJ. He can be reached by
e-mailing greensteinb@gmail.com.
Disclosure: Dr. Ben Greenstein reports no disclosures.
INTRODUCTION
The atraumatic removal of a tooth enhances patient comfort
and preserves bone. Traditionally, the sequence for tooth
removal after anesthesia consists of severing gingival fibers
by running a periosteal elevator in the sulcus. Then an
elevator is used to loosen the tooth, and forceps are em-
ployed to luxate it buccolingually, thereby expanding the
alveolar socket and facilitating its removal. However, a tooth
may be difficult to extract due to root length, root dilaceration,
gnarled or bulbous roots, and thickness of supporting bone,
ankylosis, or subcrestal fracture. Furthermore, if a site is to
receive an implant, a tooth must be removed atraumatically
to avoid fracturing walls of the alveolus, especially a thin
buccal plate in the aesthetic zone. This article discusses
tooth removal techniques which employ dental burs as ad-
junctive aids. In addition, various issues associated with
extractions in preparation for dental implants are addressed.
DIAGNOSIS
Prior to extracting a tooth, a medical and dental history should
be reviewed. Then a clinical oral examination is performed,
and the sulcus is assessed by walking the periodontal probe
circumferentially around the tooth to detect deep probing
depths, infraosseous defects, and bone dehiscences. The
radiograph is inspected to assess for atypical findings (eg, an
apical fenestration of bone, which manifests itself as an apical
radiolucency). These determinations are particularly
important if a site is to receive a dental implant. In this regard,
Evian et al1 delineated the following classification of extraction
sockets for immediate implant placement.
l Type I: The bony socket is intact, and the soft-tissue
form is undisturbed.
l Type II: The bony socket is intact in the coronal aspect
of the socket, but a fenestration is present in the apical
area. The soft tissue remains intact and undisturbed.
l Type III: Bone loss is present in the coronal aspect of
the socket. The soft tissue remains intact and undisturbed.
l Type IV: Bony defects exist in conjunction with soft-
 Continuing Education

Extracting Teeth in Preparation for Dental Implants

tissue deformity. Often, the severity of this defect Table 1. Thin Buccal Plate: Slightly Thicker Lingual Plate5
precludes implant placement and requires site Maxilla
development prior to implant placement. BUCCAL LINGUAL

Type I sockets after extraction require no additional 2.23 mm (Molar) 2.35

therapy (ie, bone grafting) prior to or at the time of 1.62 mm (Premolar) 2.00
implant placement. An exception to this remark is the 1.59 mm (Anterior) 1.95
possible need for hard- or soft-tissue grafting to
preserve tissue contour. The other socket categories Mandible
need to be managed at the time of extraction or BUCCAL LINGUAL

subsequently when implantation occurs. Numerous 1.98 mm (Molar) 2.51

articles have addressed these issues.2,3 1.20 mm (Premolar) 1.92
From another perspective, before extracting a 0.99 mm (Anterior) 1.24
tooth in the aesthetic zone that manifests recession,
one must consider if an implant is going to be a b
inserted to replace the extracted tooth, because a
hopeless tooth may not be a useless tooth; it can be
used via orthodontic extrusion to help correct soft-
and hard-tissue deformities.4

Dimensions of the Buccal and Lingual Plates

of Bone
In general, the buccal plate of bone is thinner than
the lingual bony plate (Table 1)5 and is more prone
to being fractured during tooth extractions. This is Figure 1a. An extra-long Figure 1b. A diamond bur is also an efficient rotary
carbide fissure bur (700XXL instrument for sectioning teeth prior to extractions
of particular concern in the aesthetic zone, [Salvin Dental Specialties]) (No. 859 [Brasseler USA]).
because a buccal bone fracture may result in is very efficient for
sectioning multirooted and
gingival recession. Furthermore, even if a labial single-rooted teeth.
plate fracture does not occur upon tooth extraction, its touching the bone. An injection administered under the
thinness renders it prone to resorption after tooth removal. periosteum raises it and can cause pain later.
With respect to mandibular block injections, the location of
Injection Techniques the mandibular foramen may differ among individuals and this
To reduce discomfort during anesthetic injections, the may influence success of block injections.6,7 Among adult
following approaches can be considered: administer nitrous cadaveric mandibles, the foramen was found above the occlusal
oxide, apply topical anesthetic, instruct the patient to take 4 plane 2.5% to 23.5% of the time.6,7 Therefore, many block
ibuprofen tablets (200 mg) an hour before the procedure, injections given at the level of occlusion will be ineffective. It is
distract the patient by shaking his or her cheek during initial advisable to inject patients at 6 to 10 mm coronal to the
tissue penetration by the needle, use a 30-gauge needle, and occclusal plane, which usually accounts for anatomical
inject anesthetic solution slowly. When administering a variations.8 To achieve anesthesia for posterior extractions,
nasopalatine injection, inject first on the buccal surface and buccal infiltration is also performed to anesthetize the long
then penetrate through the papilla to anesthetize the palatal buccal nerve. If there are symptoms of a good block injection, but
tissue, because this is a sensitive area to inject. In general, the patient is still symptomatic, infiltrate the lingual of the molar
when administering an infiltration injection, inject teeth, since there may be further innervation from C2 and C3
supraperiosteally and withdraw the needle one mm after (cutaneous coli nerve of the cervical plexus).9

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Extracting Teeth in Preparation for Dental Implants

Burs a b
There are several different burs that may be
useful during removal of teeth. In general,
long fissure burs are used to section teeth
(eg, 700L, 700XXL [Salvin Dental
Specialties]) (Figure 1a). A long slender
diamond (No. 859 [Brasseler USA]) or
700XXL can also be inserted into the
periodontal ligament (PDL) of teeth to sever
Sharpeys fibers (Figure 1b). This dramati- Figure 2a. A long, slender diamond is Figure 2b. Completed extraction (maxillary
placed into the periodontal ligament space left central incisor) demonstrating minimal soft-
cally reduces retention of the root, and this to sever the attachment of the tooth (No. 9) and hard-tissue trauma.
to the bone and create a space prior to an
technique often can be used to deliver roots extraction. The bur is inserted to
that are subcrestal and which may be difficult approximately three quarters of the root
length. Water spray must be used to avoid
to remove with an elevator. overheating periodontal tissues.

EXTRACTING TEETH
Sectioning Anterior Teeth
There are a few methods for tooth removal that can help avoid
damage to the buccal plate of bone. This is particularly
important in the aesthetic zone. Patients present with either
one of 2 extraction scenarios: a tooth with an intact crown, or
one that is broken subgingivally. If the tooth is intact, a
periotome or small elevator can be used at a 20 angle (to
avoid slippage) to facilitate extraction of the tooth. Work
around the whole tooth and release periodontal fibers to the
osseous crest. Place the instrument into the PDL and work it
apically; it is possible to reach two thirds of the root length.
However, this procedure can be time consuming and is not
always effective. Do not use forceps until there is significant
tooth mobility. If forceps are used on single-rooted teeth,
rotate the tooth and do not luxate it buccopalatally.
There are other very effective and preferred methods that
can be used to manage intact and broken teeth. Take a long,
thin diamond and sink it into the PDL of the tooth on the
mesial, distal, and palatal aspects (Figure 2). To preserve
bone, it is preferable when creating a trough mesially, distally,
and palatally to lean up against the tooth with the bur rather
than the adjacent bone. Remember that the PDL is ap-
roximately 0.25 mm10 and the bur is usually thicker than that.
This will provide room for a periotome or a small elevator to
deliver the root.
The slender diamond can also be used when the buccal
plate is so thin that it is precarious to elevate the buccal
aspect of the root. In this situation, cut mesiodistally into the
tooth, leaving the buccal plate intact and a part of the buccal
aspect of the root in place, which can be removed with a
curette.

a b c d

Figure 3a. Unrestorable maxillary
central incisor (No. 9).
Figure 3b. The buccolingual sectioning
of No. 9 has been completed.
Figure 3c. The mesial half of the root Figure 3d. View of the
(No. 9) is removed after being gently socket after removal of
elevated into the space left by the bur. the distal half of the root;
the bony walls of the
socket have not been
traumatized.

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Extracting Teeth in Preparation for Dental Implants

a b c d

Figure 4a. Nonrestorable maxillary Figure 4b. Mesiodistal sectioning of
lateral incisor (No. 7). the maxillary lateral incisor (No. 7);
note the space that is left by the
fissure bur.
When extracting a long tooth such as a canine, the bur
can be inserted into the PDL on the mesial, distal, and palatal
for a substantial distance; ie, 10 mm or more. Avoid doing this
on the buccal, because the buccal plate is thin and it may
induce recession.
After extracting a tooth, all granulomatous tissue should
be removed. Some clinicians advocate curetting socket walls
to eliminate the PDL prior to placing immediate implants.
Others use a No. 4 round bur in reverse or employ a
Neumeyer finishing bur.11 However, if there is no pathosis,
this does not need to be done.12 Sockets which are not
curetted heal; hence, the need to curette before implant
placement is questionable.
Other techniques that are used less frequently include
the following: if the crown is intact, amputate it horizontally
at the level of the free gingival margin. Drill into the pulp
chamber with a high-speed, long, thin, pointed diamond
(10-mm long, No. 859 diamond) and section the tooth
buccolingually (Figure 3). Proceed as close to the apex as
possible. Then, remove the sections by elevating the
sectioned roots toward the center. This avoids destroying the
a b
Figure 4c. The labial root of the Figure 4d. The palatal half of the
lateral incisor was gently elevated sectioned tooth has been removed;
into the space left by the fissure note the absence of trauma to the
bur and removed. soft tissue around the tooth. Alter-
nately, the palatal half could have
been removed first and then the labial
half of the root.
buccal bone. Alternately, sectioning can be done mesiodistally
(Figure 4). Then the roots are elevated into the space left by
the bur, one at a time, to avoid fracturing the buccal bone
plate. The decision to section buccolingually or mesiodistally
has advantages and disadvantages. Mesiodistal sectioning is
advantageous when the buccal plate is precariously thin and
there is good interdental space. Buccolingual sectioning is
preferable when there is adjacent root proximity or crowded
teeth. When sectioning buccolingually, caution must be
exercised not to damage the buccal plate. On the other hand,
it allows for elevating toward the center. Conversely, sectioning
mesiodistally avoids damaging the buccal bone with the bur,
but the buccal part of the root will have to be carefully elevated
in a palatal direction.
Mesiodistal Sectioning of Maxillary Premolars
This is illustrated in Figure 5.
Sectioning of Posterior Maxillary and Mandibular Teeth
Multirooted teeth such as molars should be sectioned prior
to removal to avoid bone damage that can occur when
c d

Figure 5a. Preoperative view of 2
premolar teeth (Nos. 12 and 13),
which were to be extracted.
Figure 5b. A fissure bur has been
used to section the teeth (Nos. 12
and 13) completely to the alveolar
bone in a mesiodistal direction.
Figure 5c. Each root was removed
as an individual entity, thereby
preserving circumferential bone as
well as furcation bone.
Figure 5d. Completed extraction of
premolars. Note the absence of
trauma to the soft tissue as well as
the preservation of the
interradicular bone.

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Extracting Teeth in Preparation for Dental Implants

luxating a tooth buccolingually. Further, sectioning reduces Table 2. Furcation Location Relative to the
the force that needs to be used to deliver a tooth; therefore, Cemento-Enamel Junction13
the patient is more comfortable and will not feel as much TOOTH FURCA LOCATION DISTANCE TO CEJ
pressure. Additionally, sectioning multirooted teeth affords Maxillary First Molar Buccal 4 mm
Mesial 4 to 5 mm
the opportunity to preserve the furcal bone. After an Distal 5 to 6 mm
extraction, the site should be debrided if there is
Maxillary Second Molar Buccal 6 mm
granulomatous tissue. The following techniques are Mesial and Distal > 6 mm
recommended for sectioning maxillary and mandibular Mandibular First Buccal 3 mm
molars. and Second Molar Lingual 4 mm

1. Maxillary molarsThe crown is decoronated initially

slightly coronal to the gingival margin. This facilitates
access to the individual roots during sectioning and
reduces the amount of debris if flaps are elevated after
tooth sectioning. The maxillary furcations are located 4 mm
from the cemento-enamel junction (CEJ) on the buccal and
4 to 6 mm interproximally (Table 2).13 Following detection of
the furcations, guide cuts are made on the flat occlusal
surface to correspond to their locations. This step ensures
proper alignment during sectioning. Guide cuts are
deepened and lengthened until they merge and separate
the roots (Figure 6). If there is no bone loss, and the
distance to the furcation is 4 mm from the CEJ, and the CEJ
is around 2 mm coronal the bone crest, then the furcation
is 2 mm apical to the bone crest, so cut deeply enough to
section the tooth. The palatal root is separated from the
buccal roots with a mesiodistal cut and the buccal roots are
separated with a buccopalatal cut. Proximal furcations are best
approached from the palatal aspect where wider embrasures
permit access, especially on the mesial. Furthermore, the
mesial furcation is more easily approached from the palatal,
since the furcation is normally located two thirds of the way
toward the palatal surface. The distal furcation is found midway
between the buccal and palatal aspects.
After the roots are separated, they are delivered with an
elevator. Sometimes, it is easier to use narrow-beaked forceps
to remove the roots. If a root is resistant to movement, a thin
diamond is inserted into the PDL around the root to facilitate its
removal without fracturing any bone. Try to avoid reducing the
amount of available furcal bone. In situations when the roots
approximate the floor of the maxillary sinus, it is important to
avoid direct apical pressure with instruments when removing
individual separated roots.

a b c d e

Figure 6a. Occlusal view of
decoronated maxillary molar,
tooth No. 3. It was reduced to
the level of the free gingival
margin. The white arrows
indicate locations of the
furcations of this molar tooth.
Figure 6b. A fissure bur
has been used to separate
this 3-rooted tooth into 3
separate parts. Each root
will be removed individually.
Figure 6c. First the roots are
gently elevated to determine
that they have been totally
sectioned. The distobuccal
root was delivered first.
Figure 6d. Subsequently,
gentle elevation and the
application of a universal
maxillary forceps deliver
the mesiobuccal root.
Figure 6e. The palatal root
was the last one to be
removed using a straight
elevator and forceps. Note
that the circumradicular as
well as the furcation bone is
intact. This maxillary molar
was extracted flaplessly with
minimal trauma. Sometimes
it is necessary to introduce
the fine diamond bur into the
periodontal ligament space
around an individual root to
facilitate its removal, which
was done in this instance.

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 Continuing Education

Extracting Teeth in Preparation for Dental Implants

a b c a b

Figure 7a. Occlusal view of
a mandibular molar (No. 31)
which has been sectioned
buccolingually after removal
of a PFM crown.
Figure 7b. The mesial root Figure 7c. The distal root
of this molar has been has been removed with the
removed. assistance of a slender
diamond which was placed
within the PDL space, an
elevator and lower universal
forceps. The sockets were
thoroughly debrided with a
curette.
Figure 8a. Clinical view of
a PFM crown, which is to
be cut off from a vertically
fractured maxillary central
incisor. A coarse diamond
is optimal for cutting through
porcelain.
Figure 8b. View of the tooth
after the crown has been
removed. At this point, the
tooth can be decoronated in
preparation for mesiodistal
or buccolingual sectioning,
or more likely, to use a
diamond bur within the
periodontal ligament space
on the interproximal and the
palatal aspects.

2. Mandibular molarsSimilar to maxillary molars, Teeth Restored With Crowns

mandibular molar crowns are severed horizontally, coronal
to the CEJ, approximating the free gingival margin.
Furcations are located and guide cuts are created,
deepened, and connected. The position of the furcation is
usually 3 mm from the CEJ on the buccal and 4 mm on the
lingual (Table 2).13 After the tooth is sectioned, an elevator
and forceps combination can be used to remove the roots
(Figure 7). If a root resists movement, a No. 859 bur is
inserted into the PDL and the bur is used on the proximal
surface which is not adjacent to the furcal bone, because it
may be used to support an implant.
Vertical Releasing Incisions
When performing extractions in the aesthetic zone, a
flapless protocol is preferred in order to avoid disrupting the
periosteal blood supply to the cortical bone, particularly on
the buccal aspect, which is the thinner plate of bone.
Vertical releasing incisions are sometimes needed to
provide access to extract teeth or perform guided bone
regeneration procedures to resolve bony dehiscences or
fenestrations. One approach is to create a vertical releasing
incision at the line angle, one tooth away from the lesion
site (mesially or distally) to provide access; this will help
avoid tearing an envelope flap. In general, vertical releasing
incisions heal uneventfully and rarely leave a scar within the
gingiva if primary closure is attained.
Teeth restored with crowns or part of a fixed dental
prosthesis may need to be extracted. It is prudent to sever
connections between splinted crowns and sometimes re-
move the restoration prior to tooth removal. A diamond bur
is useful to cut through porcelain, and carbide burs are
helpful to sever metal alloys (Figure 8).
Flap Versus Flapless Extractions
As indicated, a flap is used in conjunction with an extraction
for access or a bone regeneration procedure. When a flap
is elevated and a tooth is extracted, there is, on average,
1.24 mm vertical bone loss (range 0.9 to 3.6 mm) and 3.79
mm horizontal bone reduction (range 2.46 to 4.56 mm) after
6 months.14
Several investigators have suggested that tooth
removal without flap elevation and implant placement
decreased bone loss and recession in humans15 and
animal experimental studies. 16-18 However, others
reported in humans19-21 and experimental studies22-24
that with a flapless protocol, the quantity of bone loss was
similar, because tooth extraction eliminates the blood
supply to the bone from the periodontal ligament.25,26
Regardless of these contradictory data, it is the authors
judgment that if flaps are not elevated, especially in the
aesthetic zone, there is a good chance there will be less
gingival recession.

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Extracting Teeth in Preparation for Dental Implants

Treatment of Infected Sites
If a patient presents with an abscessed tooth, it is
usually not necessary to carry out incision and
drainage and place the patient on antibiotics
before extracting the tooth. Removal of the tooth
will provide drainage of the infected site. With
respect to survival rates of immediately placed
implants into fresh extraction sockets and healed
ridges, they are similar (97.3% to 99%).27,28 This
finding is also true with respect to immediate
placement of implants into infected sites29,30 or
locations with periapical lesions.31
Figure 9. Cross-sectional view from a CBCT scan demonstrating the labial positioning
of a maxillary central incisor relative to the alveolus. Buccolingual sectioning would put
PROTOCOL AFTER AN EXTRACTION the labial plate at risk, especially apically.
After a tooth is extracted, always palpate the rim
of the extraction socket to assess if there are any sharp
edges. If present, remove them with a bur or chisel. In the
mandibular posterior region, sometimes days to weeks after
an extraction, a thin lingual shelf of bone perforates the
lingual mucosa. This may protrude as a sharp point and
irritate the tongue. When this occurs, use a round bur to
smooth the bone. Anesthesia is usually not needed, since
the exposed bone is poorly innervated. Repeat this
procedure as needed during the next several weeks.
Another option is to reflect a flap to gain access to the bone,
but this is not usually necessary.
COMPLICATIONS
Perforation Into the Sinus
If a root extends into the sinus and is extracted, it may result
in a perforation into the sinus. An opening into the sinus can
be confirmed by occluding the patients nostrils and having
him or her blow gently (Valsalva maneuver). Air bubbles will
appear in the socket if there is a perforation. If the hole is
small (one to 2 mm), it can be ignored. The socket will fill with
blood, a clot will form, and it will heal uneventfully. If the
communication is a little larger, some resorbable barrier
material (eg, CollaTape) can be placed over the perforation
and it should heal without incident. If the perforation is large
(> 4 mm), several options are available. A bioresorbable
barrier can be placed over the perforation. Bone can be
placed on top of the barrier and a nonresorbable barrier (eg,
Cytoplast) can be placed over the bone graft and retained
under the flap. This avoids having to attain primary flap
closure. Another option is to perform flap advancement and
attain primary closure; this may increase patient morbidity.
Subsequently, if an oral-antral fistula develops, then it will be
necessary to freshen the periphery of the fistula and close
the fistula with flap advancement.
Sectioning a Single-Rooted or Multirooted Tooth
Sectioning single-rooted teeth either buccolingually or
mesiodistally should be cautiously performed. When
dividing a tooth mesiodistally, care should be taken not to
damage the interproximal bone or roots of adjacent teeth.
Similarly, when separating a tooth buccolingually, the
clinician must proceed with extreme vigilance near the
labial plate, which is often thin. Inadvertent fenestration of
the labial plate will result in the need for a guided bone
regeneration procedure. Further more, if teeth are
positioned to the labial relative to the alveolar housing,
buccolingual sectioning is not advisable (Figure 9).
Extreme care must be taken when sectioning mandibular
molars, especially second (and third) molars. The lingual
plate often becomes thinner in this area, especially for
lingually tipped (erupted) teeth. Injudicious use of a bur
during sectioning may result in perforation of the lingual plate
of bone and damage to vital structures (eg, lingual nerve).
Sectioning may be halted prior to complete penetration of the
lingual tooth structure and completed with a hand instrument
(elevator). Alternately, when sectioning is mostly accomp-

7

Extracting Teeth in Preparation for Dental Implants
lished, the bur can be inserted into the lingual sulcus of the
molar and dragged toward the buccal to permit the sectioning
to be completed.
Burning Bone
When a bur is used to section a tooth, and in particular when
it is inserted into the PDL, the handpiece must provide
generous irrigation to avoid burning bone. If the bone is
overheated, it will smell as if something is burning and it will
appear discolored. Erikson and Albrektsson32 reported that
bone can tolerate 44 to 47C for one minute without
impeding healing. To avoid or reduce burning of the bone
during extractions, use copious irrigation, intermittent drilling
pressures, and new burs that are sharp. If the periphery of
the socket becomes discolored, gently remove it with a
curette. It has been the authors experience that the socket
will heal uneventfully if this occurs. Importantly, since the bur
is an efficient cutting instrument, it is essential that the
operator exercise patience when navigating the bur around
the tooth.
Controlling Bleeding Problems
Bleeding after an extraction can originate from soft tissue or
bone. To control hemorrhage, inject anesthetic with
1/50,000 epinephrine and apply direct pressure. To halt
bone hemorrhaging, various techniques can be used: inject
anesthetic with epinephrine directly into a nutrient canal
and/or on gauze (twist the gauze so it fits into the socket)
and hold it in place with a periosteal elevator; burnish the
bone to try to occlude it; or place a bone graft material into
a defect, which may obtund bleeding, or use a cautery unit
(Geiger 150-S).
Rarely, post-extraction liver clots form. This is due to
incomplete fibrin clotting and manifests as a slowly
developing, red-brown mass. If a patient develops a liver
clot and is not in the office, he or she may have difficulty
controlling the bleeding. Instruct patients to wipe away the
clot with a piece of gauze and to apply pressure for 10
minutes. If the patient cannot control the bleeding, have him
or her return to the office and inject bleeding sites with
1/50,000 epinephrine, curette the oozing fibrin clot away,
and suture the area.
8
Continuing Education
Dry Socket
Symptoms of a dry socket usually commence 3 days after
an extraction and may include radiating pain.33 This
complication is due to clot necrosis. Sites prone to
manifesting a dry socket are the mandibular molars (around
3% of the time). The etiology responsible for dry sockets is
unknown. The reparative process is delayed, and is
preceded by an extensive osteoclastic activity. Therefore,
the site may lose more bone than normal. With respect to
healing, granulation tissue starts growing into the alveolus
through perforations in the lamina dura. The alveolar wound
is gradually filled in from the bottom. After the socket fills
with granulation tissue and is covered by epithelium,
healing takes its normal course.
Management of a dry socket consists of anesthetizing the
site, then irrigating the alveolus and inserting some sedative
pastes with or without a collagen carrier. Sometimes this
procedure needs to be repeated in several days.
Ecchymosis
Sometimes after an extraction, an ecchymotic area (black
and blue spot) will be seen. This is due to bleeding that
occurred under the flap or within the extraction socket. The
hemorrhage may follow the fascial planes, and the
ecchymosis may descend below the surgical site due to
gravity. Color changes related to an ecchymosis follow an
expected pattern as hemoglobin is resorbed. Initially, it
looks reddish, which reflects blood. Within several hours, it
appears black/blue or dark purple. By day 6, the color
changes to green (biliverdin). At days 8 to 9, it is yellowish-
brown (bilirubin). In 2 to 3 weeks, the discoloration is
resolved.34 Ecchymosis requires no therapy besides
reassurance for the patient.
CONCLUDING REMARKS
Utilization of burs to section and extract teeth facilitates
faster, easier, and more efficient atraumatic tooth removal,
increasing patient comfort and reducing clinician stress.
Initially, the concept of placing a thin bur into the PDL may
seem strange; however, if done with copious irrigation,
gentle pressure, and patience, it is a benign procedure.
Using burs reduces the challenge of extracting some teeth

Extracting Teeth in Preparation for Dental Implants
and makes it a more routine task.
Clinicians should at all times undertake procedures for
which they are academically and clinically trained and
experienced. If the perceived difficulty factors associated with
an extraction create unease within the mind of a practitioner,
then referral to a surgical specialist is prudent.
REFERENCES
1. Evian CI, Waasdorp JA, Ishii M, et al. Evaluating
extraction sockets in the esthetic zone for immediate
implant placement. Compend Contin Educ Dent.
2011;32:e58-e65.
2. Chen ST, Buser D. Clinical and esthetic outcomes of
implants placed in postextraction sites. Int J Oral
Maxillofac Implants. 2009;24(suppl):186-217.
3. Elian N, Cho SC, Froum S, et al. A simplified socket
classification and repair technique. Pract Proced
Aesthet Dent. 2007;19:99-104.
4. Salama H, Salama M. The role of orthodontic
extrusive remodeling in the enhancement of soft and
hard tissue profiles prior to implant placement: a
systematic approach to the management of extraction
site defects. Int J Periodontics Restorative Dent.
1993;13:312-333.
5. Katranji A, Misch K, Wang HL. Cortical bone thickness
in dentate and edentulous human cadavers. J
Periodontol. 2007;78:874-878.
6. Nicholson ML. A study of the position of the
mandibular foramen in the adult human mandible.
Anat Rec. 1985;212:110-112.
7. Mbajiorgu EF. A study of the position of the mandibular
foramen in adult black Zimbabwean mandibles. Cent
Afr J Med. 2000;46:184-190.
8. Malamed SF. Handbook of Local Anesthesia. 2nd ed.
St. Louis, MO: Mosby; 1986:183-193.
9. Cruz Rizzolo RJ, Madeira MC, Bernaba JM, et al.
Clinical significance of the supplementary innervation
of the mandibular teeth: a dissection study of the
transverse cervical (cutaneous coli) nerve.
Quintessence Int. 1988;19:167-169.
10. McLaughlin RP, Kalha AS, Schuetz W. An alternative
method of space closure: the Hycon Device. J Clin
Orthod. 2005;39:474-484.
11. Sonick M. Aesthetic management of adjacent
maxillary central incisors. Extraction, immediate
placement and immediate provisionalization. Dental
Tribune. February 2011:14-20.
12. Botticelli D, Berglundh T, Lindhe J. Hard-tissue
alterations following immediate implant placement in
9
Continuing Education
extraction sites. J Clin Periodontol. 2004;31:820-828.
13. Greenstein G, Caton J, Polson A. Trisection of
maxillary molars: a clinical technique. Compend
Contin Educ Dent. 1984;5:624-632.
14. Tan WL, Wong TL, Wong MC, et al. A systematic
review of post-extractional alveolar hard and soft
tissue dimensional changes in humans. Clin Oral
Implants Res. 2012;23(suppl 5):1-21.
15. Job S, Bhat V, Naidu EM. In vivo evaluation of crestal
bone heights following implant placement with
flapless and with-flap techniques in sites of
immediately loaded implants. Indian J Dent Res.
2008;19:320-325.
16. Fickl S, Zuhr O, Wachtel H, et al. Tissue alterations
after tooth extraction with and without surgical trauma:
a volumetric study in the beagle dog. J Clin
Periodontol. 2008;35:356-363.
17. Barros RRM, Novaes AB Jr, Papalexiou V. Buccal
bone remodeling after immediate implantation with a
flap or flapless approach: a pilot study in dogs.
Titanium. 2009;1:45-51.
18. Blanco J, Nuez V, Aracil L, et al. Ridge alterations
following immediate implant placement in the dog: flap
versus flapless surgery. J Clin Periodontol.
2008;35:640-648.
19. Mal P, Nobre M. Flap vs. flapless surgical techniques
at immediate implant function in predominantly soft
bone for rehabilitation of partial edentulism: a
prospective cohort study with follow-up of 1 year. Eur
J Oral Implantol. 2008;1:293-304.
20. Nickenig HJ, Wichmann M, Schlegel KA, et al.
Radiographic evaluation of marginal bone levels
during healing period, adjacent to parallel-screw
cylinder implants inserted in the posterior zone of the
jaws, placed with flapless surgery. Clin Oral Implants
Res. 2010;21:1386-1393.
21. De Bruyn H, Atashkadeh M, Cosyn J, et al. Clinical
outcome and bone preservation of single TiUnite
implants installed with flapless or flap surgery. Clin
Implant Dent Relat Res. 2011;13:175-183.
22. Botticelli D, Salata LA, Caneva M, et al. Flap vs.
flapless surgical approach at immediate implants: a
histomorphometric study in dogs. Clin Oral Implants
Res. 2010;21:1314-1319.
23. Arajo MG, Lindhe J. Ridge alterations following tooth
extraction with and without flap elevation: an
experimental study in the dog. Clin Oral Implants Res.
2009;20:545-549.
24. Becker W, Wikesj UM, Sennerby L, et al. Histologic
evaluation of implants following flapless and flapped

Extracting Teeth in Preparation for Dental Implants
surgery: a study in canines. J Periodontol.
2006;77:1717-1722.
25. Arajo MG, Lindhe J. Dimensional ridge alterations
following tooth extraction. An experimental study in the
dog. J Clin Periodontol. 2005;32:212-218.
26. Schropp L, Wenzel A, Kostopoulos L, et al. Bone
healing and soft tissue contour changes following
single-tooth extraction: a clinical and radiographic 12-
month prospective study. Int J Periodontics
Restorative Dent. 2003;23:313-323.
27. Lang NP, Pun L, Lau KY, et al. A systematic review on
survival and success rates of implants placed
immediately into fresh extraction sockets after at least
1 year. Clin Oral Implants Res. 2012;23(suppl 5):39-66.
28. Ortega-Martnez J, Prez-Pascual T, Mareque-Bueno
S, et al. Immediate implants following tooth extraction.
A systematic review. Med Oral Patol Oral Cir Bucal.
2012;17:e251-e261.
29. Waasdorp JA, Evian CI, Mandracchia M. Immediate
placement of implants into infected sites: a systematic
review of the literature. J Periodontol. 2010;81:801-808.
10
Continuing Education
30. Crespi R, Cappar P, Gherlone E. Immediate loading
of dental implants placed in periodontally infected and
non-infected sites: a 4-year follow-up clinical study. J
Periodontol. 2010;81:1140-1146.
31. Crespi R, Cappar P, Gherlone E. Fresh-socket
implants in periapical infected sites in humans. J
Periodontol. 2010;81:378-383.
32. Eriksson AR, Albrektsson T. Temperature threshold
levels for heat-induced bone tissue injury: a vital-
microscopic study in the rabbit. J Prosthet Dent.
1983;50:101-107.
33. Noroozi AR, Philbert RF. Modern concepts in
understanding and management of the dry socket
syndrome: comprehensive review of the literature.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2009;107:30-35.
34. Shiel WC Jr. What are symptoms and signs of a
bruise, and why does it change color?
medicinenet.com/bruises/page2.htm. Accessed May 7,
2014.
 Continuing Education

Extracting Teeth in Preparation for Dental Implants

POST EXAMINATION INFORMATION POST EXAMINATION QUESTIONS
To receive continuing education credit for participation in 1. In the classification of extraction sockets by Evian et
this educational activity you must complete the program al, in which socket type is the bony socket intact and
post examination and receive a score of 70% or better. soft-tissue form is undisturbed?
a. Type I.
Traditional Completion Option:
b. Type II.
You may fax or mail your answers with payment to Dentistry
c. Type III.
Today (see Traditional Completion Information on following
d. Type IV.
page). All information requested must be provided in order
to process the program for credit. Be sure to complete your 2. Type I sockets after extraction require no additional
Payment, Personal Certification Information, Answers, therapy prior to or at the time of implant placement.
Other socket categories need to be managed at the
and Evaluation forms. Your exam will be graded within 72
time of extraction or subsequently when implantation
hours of receipt. Upon successful completion of the post- occurs.
exam (70% or higher), a letter of completion will be mailed a. The first statement is true, the second is false.
to the address provided.
b. The first statement is false, the second is true.
Online Completion Option: c. Both statements are true.
Use this page to review the questions and mark your d. Both statements are false.
answers. Return to dentalcetoday.com and sign in. If you
3. In general, the buccal plate of bone is thinner than
have not previously purchased the program, select it from
the lingual bony plate.
the Online Courses listing and complete the online
a. True.
purchase process. Once purchased the program will be
b. False.
added to your User History page where a Take Exam link
will be provided directly across from the program title. 4. When administering a mandibular block injection, it
Select the Take Exam link, complete all the program is advisable to inject patients at ______ coronal to
questions and Submit your answers. An immediate grade the occlusal plane to account for anatomical
variations of the mandibular foramen.
report will be provided. Upon receiving a passing grade,
a. 2 to 4 mm.
complete the online evaluation form. Upon submitting
b. 4 to 6 mm.
the form, your Letter of Completion will be provided
c. 6 to 10 mm.
immediately for printing.
d. 10 to 14 mm.
General Program Information:
Online users may log in to dentalcetoday.com any time in 5. After extracting a tooth, all granulomatous tissue
should be removed. Even if there is no pathosis, the
the future to access previously purchased programs and
socket should always be curetted in order to ensure
view or print letters of completion and results. proper healing.
a. The first statement is true, the second is false.
b. The first statement is false, the second is true.
c. Both statements are true.
d. Both statements are false.

11
 Continuing Education

Extracting Teeth in Preparation for Dental Implants

6. When sectioning an anterior tooth, mesiodistal 9. When a flap is elevated and a tooth is extracted,
sectioning is advantageous when the buccal plate there is on average ____ vertical bone loss after
is precariously thin and there is good interdental 6 months.
space. Buccolingual sectioning is preferable when a. 0.74 mm.
there is adjacent root proximity or crowded teeth.
b. 1.24 mm.
a. The first statement is true, the second is false.
c. 1.88 mm.
b. The first statement is false, the second is true.
d. 2.45 mm.
c. Both statements are true.
d. Both statements are false. 10. Erikson and Albrektsson reported that bone can
tolerate _____ C for one minute without impeding
7. Furcations in maxillary molars are generally located healing.
____ from the cemento-enamel junction. a. 40 to 43.
a. 2 mm. b. 44 to 47.
b. 4 mm. c. 47 to 49.
c. 6 mm. d. 50 to 53.
d. 8 mm.

8. In maxillary molars, the mesial furcation is normally

located two thirds of the way toward the palatal
surface. The distal furcation is found midway
between the buccal and palatal aspects.
a. The first statement is true, the second is false.
b. The first statement is false, the second is true.
c. Both statements are true.
d. Both statements are false.

12
 Continuing Education

Extracting Teeth in Preparation for Dental Implants

PROGRAM COMPLETION INFORMATION PERSONAL CERTIFICATION INFORMATION:

If you wish to purchase and complete this activity
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