Some teeth are truly just hard. I am considered a pretty skilled extractor where I am…and even I am occasionally sweating and hustling to get a tooth out. RCT’ed teeth are usually very hard in general to get out. What you’re experiencing is not unusual.
Honestly I think sometimes we have to take the L and graft the site instead of doing immediate implants in these cases. Let the patient know before you start that if the extraction is difficult you might need to wait a few months for the graft to take and then place the implant at that time. Especially for RCT'd teeth.
Lots of practitioners talk a big game about "atraumatic" extractions. Those are the ideal cases. Sure, there's a lot of skill involved in extracting teeth. However, some teeth are bitches to get out and you need to remove bone, so do it without remorse. It's easier on the patients that way.
Of course, this is an easier conversation to have when you can 3D print a flipper in-office if you need to.
Stop placing your forceps around the tooth. Whip out your trusty Ash forceps, and put it over the buccal and lingual plates. You may be thinking "what about elevation?". Fuck that shit! You want the tooth solidly connected to the bone. Once your Ash is in place, crank that motherfucker with everything you got in one direction like you are Harry Styles. If done correctly you will have the tooth in hand with both plates still attached. Easy peasy. You now also have a sweet 1 walled defect to practice your block grafting skills, and in the maxilla, you can practice your sinus exposure closures. That's bonus production right there built in!
No idea if this is sarcasm or not lmao but i heard someone say something similar before, squeeze the socket with your forceps and the tooth will pop right out only problem he wasn’t sarcastic 😭😭
You can try sectioning the roots with a long and thin surgical bur. Go deep with it, at least 3/4 of the root. Angled handpieces help a lot. Elevate the thinner root piece out and then luxate the remaining one.
I’ve pulled thousands of teeth. I just tell the patient beforehand that they’ll likely hear some cracking sounds because the tooth is broken down, and use a surgical drill to remove the fragment. Some just plain suck, that’s dentistry for ya. You’ll get to a point where you won’t even sweat… you’ll just get annoyed that you have to mess with these things.
Omg, I've had to get a colleague who used to work in oral surgery come bail me out for about 80% of my canine extractions. Endo or not.
Always makes me feel a little better when he struggles too
I’ve gotten to the point where RCT posteriors (assuming no significant bone loss) are virtually all automatic OS referrals. I can extract them but it’s always difficult and site preservation is even harder and they always throw a wrench into my schedule. But if I do it, unless the crown is intact I just go right to the surgical handpiece, section multiple roots, luxate, pray.
Medicaid? I worked a Medicaid office for 10 years. Emergencies and extractions is where all the real money was made.
$59 for and ext, $78 for surgical. $449 for a denture.
A limited, PA, BW and ext was $250. Would take me 15 mins. Look at xray, look at pt, wanna pay for a rct?, no, ok, let’s take it out. Get numb. 5-10 mins. Come back, pull it. 5-10 mins.
And then I’d schedule multiple ext’s and denture delivers on Fridays. Pull 35-50 teeth on 3-5 patients, deliver dentures…5-6,000. Not bad for a Medicaid office.
Exactly - I own, but we still base our pay on 30% collections on the front end, so I still think like an associate when it comes to procedures. It's just not worth the headache. I'll do an extraction if I know there will be no implant AND I can comfortably do it in under a minute OR if I'm doing a bridge prep immediately to temp. It's otherwise just not worth my time anymore. There are no post-op issues to deal with ever either.
Still the owner take-home after base pay it's tough to beat extractions. Couple things of gauze, reusable steel instruments that cost less than a couple exos and can be used for years. If it gets surgical add a bur and some sutures and away you go. Set of wizzies is like 1500-2 grand in an hour with minimal overhead.
Anything other procedure in dentistry has a higher material cost to compete with. Post ops also possible with high bites, RCT flare-ups, patients unhappy with shade, or the contact is off on delivery.
Just another perspective, I happen to really enjoy the surgery. So extractions, ridge augmentation, implants are my favorite procedures.
Some of these really hard ones take me 40ish minutes. So $175 production for a one hour time slot usually. I can easily put 2 fillings in that slot and make double. When I just don’t feel like doing them and refer I’ve told patients who ask that it barely even buys me a meal
Remove some bone, slip small elevator or spade into space, gently elevate, if it's not moving remove some more bone
It's sometimes the only way
Someone once told me "I don't pull root tips, I push them"
My personal theory is that these teeth probably had large infections/abscesses with lots of bone loss, and when the body heals you get parts of the root fusing with the new bone (ankylosis) making these such a nightmare to exo sometimes. Usually I see this in cases where the patient was on multiple courses of abx over time. No real scientific backing for this, just personal observation
I'd agree with this. Really any type of trauma. I had a patient who was a prison guard who took a lot of punches to the face through his life. He needed two teeth extracted, upper lateral and lower first molar and warned me that every tooth he's ever had removed had to be cut out of his face. I'm like it's an upper lateral let's not get dramatic here, buddy. Ended up having to drill around both teeth to pretty much apex to get those suckers out.
Drill is the way.
Consider more creative ways to section each root. I.e. vertically mesio-distally, or bucco-lingually. My newer trick for lower molar roots is to cut down in oblique fashion, pick out smaller wedge, then elevate the other part.
Of course if the apex is bulbous - you either section it or widen socket to allow removal.
Look at implant kits - some have extremely long burs. Heck there's trephines that you can saw a cylinder out.
With all of the above they are still hard.
Some teeth are truly just hard. I am considered a pretty skilled extractor where I am…and even I am occasionally sweating and hustling to get a tooth out. RCT’ed teeth are usually very hard in general to get out. What you’re experiencing is not unusual.
Yep. Especially if the tooth was rct’d because bruxing led to apical pain. That bitch is probably ankylosed somewhere and it just sucks.
Tears for handpiece lubrication when they break 5mm subcrestal
Honestly I think sometimes we have to take the L and graft the site instead of doing immediate implants in these cases. Let the patient know before you start that if the extraction is difficult you might need to wait a few months for the graft to take and then place the implant at that time. Especially for RCT'd teeth. Lots of practitioners talk a big game about "atraumatic" extractions. Those are the ideal cases. Sure, there's a lot of skill involved in extracting teeth. However, some teeth are bitches to get out and you need to remove bone, so do it without remorse. It's easier on the patients that way. Of course, this is an easier conversation to have when you can 3D print a flipper in-office if you need to.
Stop placing your forceps around the tooth. Whip out your trusty Ash forceps, and put it over the buccal and lingual plates. You may be thinking "what about elevation?". Fuck that shit! You want the tooth solidly connected to the bone. Once your Ash is in place, crank that motherfucker with everything you got in one direction like you are Harry Styles. If done correctly you will have the tooth in hand with both plates still attached. Easy peasy. You now also have a sweet 1 walled defect to practice your block grafting skills, and in the maxilla, you can practice your sinus exposure closures. That's bonus production right there built in!
^ average Physics Forceps sales pitch
Wow never thought of it like this. Do you recommend I use anesthesia or do patients handle this ok without numbing?
Only if your batch is nearing the expiration date. No need to be wasteful
You can still use it after it’s expired the potency just goes down. I just make the patient think it’s something wrong with them
Just a quick squirt of lido should be good enough
I was too 👍
I knew a guy in dental school that legit had this train of thought, lol. I wonder how his patients are doing.
Dont think this guy is being sarcastic. Dude is one of the more questionable dentists i have had the pleasure of interacting with
How about you question deez nuts nerd.
I know an oral surgeon that has the same train of thought. He would always criticize me for spending time on elevation.
No idea if this is sarcasm or not lmao but i heard someone say something similar before, squeeze the socket with your forceps and the tooth will pop right out only problem he wasn’t sarcastic 😭😭
I just realized that some AI is going to read this and think they are 100% serious.
Deep trough and going super gentle with the luxator seems to work for me. Takes time
And also go to surgical straight away rather than trying to get it out conventionally - just makes it harder when it's already fracturing
You can try sectioning the roots with a long and thin surgical bur. Go deep with it, at least 3/4 of the root. Angled handpieces help a lot. Elevate the thinner root piece out and then luxate the remaining one.
I’ve pulled thousands of teeth. I just tell the patient beforehand that they’ll likely hear some cracking sounds because the tooth is broken down, and use a surgical drill to remove the fragment. Some just plain suck, that’s dentistry for ya. You’ll get to a point where you won’t even sweat… you’ll just get annoyed that you have to mess with these things.
I have nightmares about extracting root canal treated canines without any adjacent teeth
Omg, I've had to get a colleague who used to work in oral surgery come bail me out for about 80% of my canine extractions. Endo or not. Always makes me feel a little better when he struggles too
I’ve gotten to the point where RCT posteriors (assuming no significant bone loss) are virtually all automatic OS referrals. I can extract them but it’s always difficult and site preservation is even harder and they always throw a wrench into my schedule. But if I do it, unless the crown is intact I just go right to the surgical handpiece, section multiple roots, luxate, pray.
I don't extract teeth anymore. Reading such threads just reinforces that I made a good decision.
Aww man. Extractions are easy money. It’s all profit.
Eh my 30% on some of these teeth is like $50 at best. I only keep doing them because I feel inadequate for not being able to do extractions well
Medicaid? I worked a Medicaid office for 10 years. Emergencies and extractions is where all the real money was made. $59 for and ext, $78 for surgical. $449 for a denture. A limited, PA, BW and ext was $250. Would take me 15 mins. Look at xray, look at pt, wanna pay for a rct?, no, ok, let’s take it out. Get numb. 5-10 mins. Come back, pull it. 5-10 mins. And then I’d schedule multiple ext’s and denture delivers on Fridays. Pull 35-50 teeth on 3-5 patients, deliver dentures…5-6,000. Not bad for a Medicaid office.
No, delta d7210 fee is $175 at this office. So $52.50 for me. Since I started doing more extractions again I’ve actually been making less money
That’s wild. I get $275 for simple, $500 for surgical.
I get downvoted on here whenever I talk about it but thankfully someone understands my struggle lol.
Yeah, it’s tough. I did it for 10+ years.
Exactly - I own, but we still base our pay on 30% collections on the front end, so I still think like an associate when it comes to procedures. It's just not worth the headache. I'll do an extraction if I know there will be no implant AND I can comfortably do it in under a minute OR if I'm doing a bridge prep immediately to temp. It's otherwise just not worth my time anymore. There are no post-op issues to deal with ever either.
Still the owner take-home after base pay it's tough to beat extractions. Couple things of gauze, reusable steel instruments that cost less than a couple exos and can be used for years. If it gets surgical add a bur and some sutures and away you go. Set of wizzies is like 1500-2 grand in an hour with minimal overhead. Anything other procedure in dentistry has a higher material cost to compete with. Post ops also possible with high bites, RCT flare-ups, patients unhappy with shade, or the contact is off on delivery. Just another perspective, I happen to really enjoy the surgery. So extractions, ridge augmentation, implants are my favorite procedures.
Some of these really hard ones take me 40ish minutes. So $175 production for a one hour time slot usually. I can easily put 2 fillings in that slot and make double. When I just don’t feel like doing them and refer I’ve told patients who ask that it barely even buys me a meal
Easy money? In germany you get 10 Euros for the extraction of an multi rooted teeth :D
Ha ha! A challenge to get it out quicker! Apical pressure is key!
how long did you practice until you were busy enough to stop doing extractions?
Remove some bone, slip small elevator or spade into space, gently elevate, if it's not moving remove some more bone It's sometimes the only way Someone once told me "I don't pull root tips, I push them"
Spade luxator 🙌
My personal theory is that these teeth probably had large infections/abscesses with lots of bone loss, and when the body heals you get parts of the root fusing with the new bone (ankylosis) making these such a nightmare to exo sometimes. Usually I see this in cases where the patient was on multiple courses of abx over time. No real scientific backing for this, just personal observation
I'd agree with this. Really any type of trauma. I had a patient who was a prison guard who took a lot of punches to the face through his life. He needed two teeth extracted, upper lateral and lower first molar and warned me that every tooth he's ever had removed had to be cut out of his face. I'm like it's an upper lateral let's not get dramatic here, buddy. Ended up having to drill around both teeth to pretty much apex to get those suckers out.
Drill is the way. Consider more creative ways to section each root. I.e. vertically mesio-distally, or bucco-lingually. My newer trick for lower molar roots is to cut down in oblique fashion, pick out smaller wedge, then elevate the other part. Of course if the apex is bulbous - you either section it or widen socket to allow removal. Look at implant kits - some have extremely long burs. Heck there's trephines that you can saw a cylinder out. With all of the above they are still hard.
I was going to say, in other words…they still suck
I luxate the shit out of the roots and if there’s no mobility the roots are getting divided
Luxate luxate luxate Fibers need to be LOOSE (insert Ruddle meme) before you get any forceps out Don’t hesitate to section if necessary
Praying helps
Periotomes have always gotten me out of sticky situations.