No Ferrule? No problem! Dr Peter Raftery, Endodontist, discusses the contemporary use of the ‘Surgical Extrusion Technique’ to make hopeless teeth restorable. Crazy, I know, so take a listen because the science makes sense!
All the way back in Episode 9 with Dr Aws Alani (Restorability with a Restorative Specialist) we briefly mentioned this technique in passing…which led to a cascade in events and Dr Raftery reached out to me with enthusiasm because I called out to the audience if they knew anyone using this technique! I love that!
Essentially you are (gently!) extracting a tooth and then intentionally re-implanting the tooth, except this time you are going to be a little greedy and ‘grab’ some ferrule. Then, a customary Root Canal Treatment 2 weeks afterwards, and you have yourself a restorable tooth. As someone who loves saving teeth, this is just fantastic. We know the science works because we DO re-implant dirty, grotty avulsed incisors of 12 year olds with some decent success rates.
Protrusive Dental Pearl: have you used Viscostat clear? It is my preferred astringent and will not interfere with bonding
- How to restore teeth which appear to be restoratively hopeless aka no Ferrule
- Compared to SCL or Ortho extrusion – could this be more cost effective and less invasive?
- Surgical Extrusion technique – either with humble luxator or a posh Benex device
I will have to add the resources later – right now I am running late for work!
Click below for full episode transcript:Opening Snippet: So yeah odds of it still being there 12 years later still 93% and that was with forceps removal so i'd argue that the Benex only stands to last longer...
Jaz’s Introduction: Okay, so you have your patient they’ve come in, they’ve fractured their upper premolar at gingival level. Kaput. There is no ferrule like you can maybe get your perioprobe inside and feel maybe a millimeter subgingival but there’s hardly any tooth structure left. What are you gonna do right? Because most of the times it’s going to be for the bin right? Like it’s hopeless, let’s extract it. Now if you want to get really extravagant you could arrange for orthodontic exclusion which takes time and it’s costly or you can do surgical crown lengthening also incur a fee but also involves surgery obviously and it will also mean that the patient will have potentially black triangles and the gingival zenith of that tooth will now no longer be the same as the adjacent tooth so again that all takes time and money and effort so a lot of times people say let’s just take it out and stick an implant in, a bridge in, whatever. Now what if i told you there was one more way this way i was exposed to it on on social media actually in about 2017 and in 2018. I attended a bard lecture about the surgical extrusion technique and it was interesting It was Italian chap Dr Bachiani talking about this technique and it was the first time i’ve seen it presented in a scientific way and then if you remember in 2019 i did a lecture or a podcast with Dr Aws Alani restorative consultant it was restorability with the restorative consultant and i discussed a technique whereby you can partially extrude, surgically a tooth and then gain ferrule and restore it and i said in the podcast hey i don’t know if anyone’s doing this technique in the UK please get in touch if you are and fast forward a year someone’s doing it in the UK and they’ve done a lot of cases and he got in touch so Dr Peter Raftery is joining us for this episode Protruserati welcome this episode on the surgical extraction technique aka the partial exodontia technique and this is going to blow your mind if you’ve never been exposed to this you’re going to think whoa how is this even possible? It’s basically taking that aforementioned broken down tooth and extruding it surgically so be it with a luxator or with something called a benex device and now you let nature heal it maybe with a splint okay like one of those wire splints not the kind of splints i bang on about all the time and then a few weeks later you go back in to do a root canal and by now the tooth has fully healed which is amazing like biology is amazing right? And now you have a ferrule and you can now restore this tooth which was otherwise unrestorable. So today with Dr Peter Raftery, who’s an endodontist based in Portsmouth we’re going to be talking about this technique. He’ll walk us through the all the stages of this technique, case selection, things that can go wrong, what advice he would give to a person doing it for the first time and we also take a look a little bit at the evidence space as well for this because i think this has a place in general dentistry and now we know that implants are not the panacea we once thought they were therefore i think this technique could be pretty worthwhile even if for the odd case here and there maybe for us upper second premolar as your first case that you want to just surgically extrude it and give this tooth a second breath of life. Sp i’m going to dive into the interview and before i do obviously i owe you a Protrusive Dental pearl. What do you guys dip your retraction cord in or what do you use to get hemostasis? I’ve used a lot of things in the past like ferric sulfate, expasyl that kind of stuff but you know what my favorite still and this isn’t sponsored or anything this is just me sharing for those who don’t know about ViscoStat Clear is 25% aluminium chloride and what i love about it is the hemostasis that it achieves without that horrible brown nasty residue which you can sometimes get with ferric sulfate and also did you know that ferric sulfate can interfere with bonding. So any time i’m doing like anterior crowns and i’m using retraction with cords, i’m always gonna be using ViscoStat Clear in fact anterior posterior i’m just using ViscoStat Clear everywhere i ordered this big tub of it and my nurse knows that it’s the only astringent i guess i will use so a big shout out to ViscoStat Clear which has just been brilliant and i’ve really enjoyed using it no more horrible brown mess. So i hope you enjoyed that material selection pearl of ViscoStat Clear. Let’s dive into the episode so we can learn more about this surgical extrusion technique aka partial exodontia technique.
Main interview: Dr Peter Raftery, welcome to The Protrusive Dental podcast, how are you? – Very well, thanks. Excited to be on thanks for the, thanks for making it happen. – No. Thank you because what we’re talking about today is something really cool and at the moment i would say it’s very much niche, it’s very much eyebrow raising. Some people maybe an implant dentist might say what’s the point you know and basically what it is and there’s so many different names for it but before we get into the beautiful part of the sort of discussion where we talk about the technique and you know what it’s all about is just tell us, set the scene for us a little bit, Peter, where are you based? What do you do? What’s a normal week for you Yes so endodontist. It’s been trained endodontist maybe 10 years now. You sort of forget after about three or four don’t you? But i am down in Hampshire, where is the majority of my week is my endo practice in haven’t and i’m a day a week in Central Portsmouth you know one town over like a micro dental school i think it’s it’s called Portsmouth dental academy and it’s primarily involved with training nurses, hygienists and therapists but my involvement is with King’s College London, so that’s the biggest dental school i believe maybe in europe and i assume that the massive final year 160 of them. They can’t all get a dental chair maybe at the same time. So Portsmouth is called their outreach one of two places that final year kings college london undergrads come down and i’ll supervise those final years primarily in endo with a bit of uh everything so that’s my one day week and that’s how i got to hear about your podcast actually. So it’s whilst endo can be a little bit blinkered you know single not quite single-handed practice i’ve got i’ve got an associate but you know you are at the cold face and you’re a little bit head down whereas i love my thursdays in that i have colleagues and we can you know chew the fat and stuff like that and over lockdown, everyone turned to podcasts didn’t they? Everyone tends to research them out and listening to them clearly you’ve been producing them and a colleague David Brown, he said to me, Peter, the thing you’ve been banging on about was mentioned in a podcast i was listening to last night so i then look it up and i don’t know a few days later i was instagramming you and you know four months later maybe we found a date that could fit so. You’re a very busy guy. You’re very difficult to get hold of, Peter. How many kids have you got? One of them they’ll be wandering any minute now like bbc style but yeah down here absolutely married to gp four kids Four kids amazing. Fantastic, well i’ll set the scene for those listening in a moment. You quite touched me because you had been told about that episode and it was something we sort of mentioned in passing in towards the end of the episode and the episode was restorability with the restorative consultant was it Was Alani and i’d mentioned this to him and i forget whether he was very familiar with this technique or not to be honest with you but i mentioned it to him because in 2018 January I went to a lecture at the BARD, the british academy of aesthetic dentistry and there was a chap i’ll read his name. It was a Doctor Ricardo Betchiani and i probably said that horribly wrong but that was one of the first times i’d seen a scientific presentation on the technique so pretty much two years ago now I saw a scientific presentation but the first time i ever saw it was on facebook and i was gobsmacked right? But then after seeing the scientific literature and then now seeing your cases on social media, it makes so much sense but before we dive into the nitty-gritty. Can you just tell us what the different names for this technique are and what essentially is it? Yes, so i know it as benex and we’ll call it benex Benex is a…what’s the word portmanteau i think of the guy’s name. The belgian i believe that it may be let’s say invented it and extrusion or extraction because it’s a method or a device for extruding or extracting teeth and I have my endo practice and we’re just an endo practice. So i don’t have all the other specialties nearby and the reason i mention that is if i did i would maybe say it doesn’t look savable but you know what next door is the prosthodontist guy or the oral surgeon guy or whatever but so i do feel this real, i do feel a duty maybe? Even more than most to try and avoid saying i can’t help to the patient or the dentist okay and one of the style of case would be the old-school post and core crown that has no ferrule and the white bit has fallen out and so it’s flush at gum level right? The dentine is flush at gum level and yes a restorability and avoiding saying i can’t help were a big deal and i heard it was at a british endo society meeting that the distributors of the benex device had a stall and kind of sowed the seed and i attended a course maybe a year and a half ago now with a professor from oral surgery from Birmingham Dental school Thomas Diedrich. Dietrich, german guy and he.. it was great and there were endodontists on it and there were implant dentists on it. The endodontists are interested i guess in extruding let’s stick with those decoronated teeth, extruding the tooth to hey presto, get ferrule. So now it’s not unrestorable and the implant dentists on the course were most interested in the most most most atraumatic of extractions to minimize i suppose the need for bone grafting or delayed what’s the word placement while they wait for the bone i don’t know what i’m talking about now when it comes but i suppose delayed placement of implant because they’ve lost the bone or something or that kind of thing. Atraumatic extraction for those guys and for me it’s extruding teeth Well sometimes to understand a new technique we have to look at potentially new technique is different you know it depends on what the origin of it was and we’ll get into that but sometimes to appreciate a new or a different way of doing things, we have to look at the alternative. So the alternatives of a tooth let’s say an upper first premolar okay common tooth to have fractured at gingival level maybe you’ve got half a millimeter of ferrule pallatally and measly and then the rest is maybe equigingival and you can maybe in the sulcus feel an extra millimeter but for a lot of people that’s unrestorable so extraction and maybe for an implant. For some people if you wanted to, you can do surgical crown lengthening right? You can cut some gum away, cut some bone away and hey presto you now have some ferrule and i guess the other way i mean those are the real two ways i can think of to make..Oh orthodontic extrusion, so using orthodontics to extrude a tooth but what you’re talking about is surgically extruding tooth. Now you mentioned the benex device but interestingly the lecture i went to in 2018 the guy was just using a laxator right? Which has his risks we can we can talk about hazardous risks So imagine just luxating a tooth until it’s just loose and you can almost just pull it out but instead you then suture it and you tack it to the adjacent teeth and you let biology do the work, the root canal happens and for you i want to find out from you exactly when to do the root canal it’d be nice to hear the sort of sequence of things but then it’s a very innovative way i think to make an otherwise unrestorable tooth or needing a very extensive other slow work to make it restorable so that’s amazing. So tell us how many cases have you done and tell us a little bit about how you found it. So the course i went on was maybe a year ago and i’d say so. Funnily enough he’s running one soonish by the time this podcast goes out we’ll have the info for those who are interested is probably good timing but i about a year ago when the course bought the thing there and then and i maybe have done i’d say say 20. 18, 20 something like that I’d say. What i love about it is there’s nothing electric, nothing battery, no battery i’m you know no batteries, no iPads, no nothing rechargeable nothing to bluetooth to anything else and i love that it does rely on some really old school stuff that everyone is familiar with. So i’m talking probably everyone has in their window i do of their practice. What to do if a tooth gets knocked out right? Kid’s tooth knocked out everyone knows, put it back in again. So avulsed teeth on we all know can have a second lease of life if managed correctly and everyone also knows that chief among those priorities is get it back in quickly. So teeth that are extra alveolar for a short amount of time have a pretty rosy outlook future and another thing that really relies on is supposed to in a ParaPost, it’s a lot like in a ParaPost, so we’ve got this, the upper premolar roughly drill down to gum level you can certainly see the root canals, let’s say the pulp chamber is exposed in example the roughly decoronated example where we mentioned so i will then take an x-ray i want to know that the roots are not very curvy not like a banana because i’m trying to scooch this thing out so it is broadly limited to straight-ish rooted teeth What about not just the curves, what about if they’ve got a bulbosity at the end that is also gonna complicate matters Yeah i had a nice one just the other day it was about the curved, most curved one i’ve tackled and it came out without a bother again i’ll try and provide you know i’ll try and show you what i mean so 18,20 cases i’ve got a wild vast experience. I haven’t had the big bulbosity i might well resort to the more widely understood accepted known surgical crown lengthening but you get the extra long white crown that no one loves and the periodontist fee is big along with my endo fee along with some crown placing fee..- Might as well have an implant. I don’t know whether i think that once i as especially as endodontists have to involve a specialist periodontist and there’s a crown in the in the offing as well whether it’s realistic economically or whether the patient’s going to go you know what i’ve done a back of the fact packet some and an implant would suit me better or ortho extrusion, we’re talking months. The one time i formally saw that as a realistic you know from a specialist endodontist down here, it was three four months i’m pretty sure it was so long ago but i’m pretty sure it involves actual train tracks not just like three teeth i think it involved train tracks and certainly the build was even bigger. So i found it to be the most realistic an instance. So i’m i’ve got this tooth again i can see the canals so i will then put let’s say a gates glidden or an benex.. Can i stop you, Peter? If you don’t i can’t because i i’m liking the journey i want to put into chronological order. So you’ve identified your patient ,you’ve checked the PA, you’ve noticed that okay it’s not curved which is great you’re now going to use the benex device and maybe towards the end you can share a case showing how to use it and for those listening on the podcast i’m not going to bore you guys by having too many visuals for you to listen to it that wouldn’t make sense. So but go back and check the video and check Peter out on instagram and whatnot is social media to see the images whatnot but i think it was still interesting for you to listen to the workflow be exposed to this. So you’ve got your PA, you’ve used your benex, you’ve got it extruded now. Let’s have a little debate here because some of the images you sent me you took the tooth entirely out but I would say to you, is that really necessary? Can’t you just extrude it a little bit and keep it in and therefore you don’t get any air time of the cells Sure, yeah so desiccation or what have you of the PDL is the biggest deal of all but the argument and it’s a neat one and it’s not mine, i’m just parroting the what i heard on the course but it was that you want to know if you’ve perforated this tooth as you’ve sunk down the canal this like a ParaPost drill, it’s a lot like a ParaPost drill. So you want to know if you’ve perforated it, i guess you might want to know if it’s cracked you perhaps want to know if the root has come out intact or whether that banana hook on it has snapped off and those are the things. Kind of inspection of it really.. – That makes sense because I sort of forgot the long sort of post like ParaPost like structure of the benex and that makes sense now and also you know premolar is a teeth that raises, it’s acceptable to cracking and to be able to see that visually. I didn’t appreciate that before and now i can see that so you’ve inspected it, you’re gonna put it back in now tell us what happens now. yeah so you.. the device that is a winch-like thing that you’ve cause you’ve.. again you’ve sunk this ParaPost style, drill down the middle and you pick up the matched in dimensions. Let’s call it a screw because it then does tap down the hole you’ve drilled it does tap because they’re very sharp threads it taps in and you get this wonderfully firm grip and then you attach that we’ll call it we’ve done a ParaPost like hole and we’ve screwed the screw down and the screws got a very bulbous head on it and you attach that bulbous head to something that looks a little bit like i don’t know fishing reel but you then dial this, turn this device and it very very slowly winches that winch is on or winches at or yanks at that tooth and eventually i’d say four five minutes it just gives. Suddenly the tensions off the.. you start to see a little bit of bleeding in the sulcus you put away your apparatus, benex and you then pull out on that screw you then.. you’ve got the tooth on the stick and you inspect it and you get a photo for instagram and then put it back in again. You put it back in again less far so that you’ve.. you’re happy with the amount of supragingival tooth structure you’ve now got. And how much are you aiming for, Peter? How much very well are you aiming for? Supragingival? You could be a little bit greedy you know you could just be ‘hey you know i want a little bit more’ i mean how much is good? This is.. I’ve some of the cases I’ve got, i’ve only noticed in hindsight if that makes sense but there’s no post involved you’d think. So having done the benex to gain an adequate ferrule, i’ve then found i didn’t need a post whereas i would have thought i’d be maybe relying on a bit of extra ferrule and a post and i really switched on restorative dentist but you know it hasn’t required the complication of a post which has been great so far so yeah from the x-ray you’re identifying your non-curvy roots, bulbous roots and usually on these anterior single straight rooted teeth you’ve got a wealth of root buried in bone. So you can’t you can be greedy-ish. I guess case-dependent but you put it in less far the average seems to be an extrusion of order..three give or take, two three four millimeters and then you put it back in. Then i suppose you unscrew your screw so at this point you’ve taken it out had a look clearly you don’t want to touch the ligament which is why i’m emphasizing that you’re holding the stick and you’re not holding the root because these cells these nicely cleaved pdl cells are all important. Put it back in again and maybe now’s the time to mention i suppose you haven’t gone at it with forceps so you’re not risking damaging the cementum because you know there’s that no one understands external cervical absorption very well, me included but cemental damage is proposed as one of it. So with your full steps and you’re grabbing you haven’t damaged the cementum i know that when teeth are decoronated and i go after them with some forceps i’m often tearing the gingiva a little bit you know meaning to or not but if there’s no two structure there super gingivally that’s why we’re doing this any in the first place i think i’m often tearing a little bit of gum. So with the benex you’re avoiding the soft tissue damage the heart tissue damage and maybe the final point if i was cheerleading for it would be, can you imagine like the cross-sectional shape of that upper premolar? It’s not circular. So if i’ve got my forceps on it and i’m rotating it, because it’s not purely circular. It’s almost like an anti-rotation feature that you sometimes see in a post. When you go to grab that post hasn’t Endo on it, you’re turning it you’re like ‘oh my gosh i’ve snapped you know, you’ve maybe snapped..cracked the root but then so when you go to grab.. On the course,one of the most impressive videos was a guy trying to atraumatically but with forceps extract an upper anterior tooth but you could see in slo-mo as he rotated it with great skill but as he rotated it you could just see the buccal plate break because it’s vanishingly thin this as you rotate it it’s not circular so it got a bit fatter on i don’t know what the physics or the maths term phrases. The circumference got bigger suddenly and it just broke that buccal. So mark the benex way, you’re avoiding that hard tissue damage, soft tissue damage, you put it take it all the way out put it back in again. Less than 15 minutes is the absolute key number the longest i’ve ever got near was about eight minutes because that’s how long it takes my tricalcium you know my mta or biodentine to set. I’ll come back to that maybe later but more often than not ,if it’s a case, a simple case just one where there’s no tooth structure, the mta or biodentine i mentioned was like when i’m repairing say a perforation or an external cervical resorption defect or that you know i’ve got to get at a defect which is underground so to speak like external cycle absorption or something like that but if it’s just. There’s not enough tooth structure left and that would be the case to start with, no carries just a decoronated tooth. That’s someone to start with. Those they’re coming out for just as long as it takes to take a photo and inspect it and it’s going back in so we’re talking two minutes. Which makes it make sense you want to minimize extra time as much as possible and i mean that’s the most efficient way and when you see risk or decreased prognosis, stratified you know you’re always going to see the zero to sort of five minutes so i would argue you got like if you’re four minutes in and out you’re as good as zero minutes you’re in the best you know. So less time the better but you do want to inspect it put it back in. The shorter the amount of time the less coagulum you might be dealing with. I have found maybe on one of those. eight minute waiting for biodentine to set. It’s a little bit harder than i would have liked putting it back in i don’t know why but i wonder if it was a bit of a jelly-like clot i wonder but it goes back in easy you then de-thread the screw from your tooth and then you are splinting it which again i i’d go back then to trauma guidelines that’s probably a rigid..no semi-rigid ie flexible, two weeks one tooth either side or a couple of teeth per side? Well, it would be one. I’d say one one either side. – So if you’ve got the upper premolar you’re putting on the canine and the second premolar and you’re attacking some composite under any sort of enamel dentin and cementum maybe whatever you can get hold off and you’re probably being quite generous with imagine with the composite on the extruded tooth because you want as much locking as possible? I wish i was better at bonding so everyone will be better at me than the splinting of it. So i’ve found.. I’ve found a top tip for beginners at b2 with locals kicking in, I would be etching and bonding when ever the environment’s bone dry and everyone’s calm i would be etching and bonding my two teeth next door and perhaps even applying a layer of composite there and then so that when the tooth is out and it’s a little bit mild chaos isn’t the word but mildly stressful and there’s bleeding crucially, inevitably then you want to leave as little bonding to do at that point. So i’ve learned that the hard way i learned that myself.. -That’s the top tip right there. Has ever happened where you’ve you started to reintroduce the tooth back in and then blood has just squirted out the socket onto the adjacent teeth and you’d have to start the bonding again? Yeah absolutely i’ve had some you know 20 minute overruns trying to etch something for the 15th time. No one’s as bad as etching than me and adhesive dentistry all my buddies they were the one thing i’m going to be texting them is you know tell me again, how you get good.. I appreciate that insight. This is very very honestly good of you and this is the nitty gritty details that we love on this podcast but i want to ask you any sutures because the Italian chap Dr Bechiani, he because A) he wasn’t using a benex and i’m sure he’d love the idea of using benex because even in his lecture he said that you know he uses a luxator and he’s very gentle takes his time but you have to warn the patient that hey if by using the luxator a good chunk of the tooth breaks away which it can do then it’s capiche we’re going to commit to the extraction whereas with the benex, yes i’m sure there’s risks and issues and perforations and little things like that could happen in the benex but it just seems like a much smarter idea but then what he would do is suture either side and i actually forget whether he used a semi-rigid splint he may have just relied on suturing the papilla either side and that keeping it still. Do you think that’s enough? a bit like a..it almost looks like a spider web or like a you know sort of holding it in place and that’s what you see don’t well that’s what i see when when you’re looking at these ortho transplantation cases where they’re pulling out a i don’t know partly partly formed you know eight to put it into the say the you know a socket of a knocked out front tooth or whatever something maybe a bad example but yeah you’ve seen them stabilized with sutures but no i’ve and funnily enough one of the papers in the journal of endodontics recently Cho was the..C-H-O Intentional replantation.She was doing it with forceps and the interesting point was in the majority of cases there was no splinting whatsoever it was a snug fit yeah you’d be surprised yeah just a small fit um i haven’t tried that i’ve just are pretty dogmatic i’ve stuck to this fishing wire and composites and i’ve found that when i left it six weeks the teeth would come back rock solid but with no evidence that i’d ever put my splinting in the first place it had been chipped and broken away much to my embarrassment but the teeth were without fail rock solid not bad rock solid not ankylosed rock solid but just what incredible-ly, beautifully as they should be with all that ferrule and everything’s nice and pink and healed but i’m nibbling away at that because you know in the sort of private density world patients want you know done already and the trauma guidelines are four avulsed teeth two weeks semi-rigid and my splints aren’t lasting so i’ve moved towards two weeks and i would say that i’m finding my splints are there more often but the teeth are a little bit wobbly. So again my beginner’s top tip would be to start their first couple of cases would wanna be probably about a four week review you know remove the splint i would say four weeks later because i’m convinced they will find the teeth to be unequivocally rock solid and it will absolutely be very quick proof of concept you know I think the first time you probably see that after doing this the first time you see it come back rock solid you’re probably like whoa it actually worked right? So that’s crazy and the second thing is I just want to know.. They say you know there’s nothing new under the sun. We’re effectively talking about replanting avulsed teeth but i feel like I’m almost you know what’s the word privy to a secret that no one else knows about i’m banging on about it but i just feel yeah ultimately we’re talking about avulsed teeth and putting them back in again and then being amazed that they last even though we’ve been telling school mums to do it for forever but yeah it really does work and it’s so atraumatic that you know it you we shouldn’t be surprised but.. It’s a very very valid point. One idea i just had, just speaking to you the restorative dentist in me is just thinking right because you said private practice you know patience don’t want to have a gap so if someone’s broken their fore and like quick do something and you’re like well i kind of have to splodge it out a little bit and then you have to be like semi-toothless for four weeks or whatever, When you’re doing your splint, how about doing your split and then just building the tooth up in a massive blob of composite at the same time just shy of any sort of occlusion but then also telling the patient, ‘do not chew on this tooth at all.’ Have you tried that? Is that something that’s worth trying? Yeah well now i’ve shaving down the period to two weeks is okay. The patients are generally delighted and a little bit more forgiving. I’m sure that’ll wear off as it becomes you know more old hat but i have found that they will generally go from decoronated gap like i mean actual gap and suddenly you’re filling two thirds of that gap with tooth colored tooth you know tooth structure and you’re right the whitish composite that you’re.. they’re.. i went into endo for because of a lack of interest or ability with cosmetics. So I imagine your hunch is accurate but i couldn’t say that. It’s just something i probably will try when the right case comes along. Let’s talk longevity. What does the evidence say? Tell us, share with us, what is the existing evidence base for this and what can we learn from the evidence based? yeah so the.. i’ll go with this CHO paper because it’s you know high imp you know it’s in a proper journal, it’s recent you know peer reviewed and they’re..so with forceps extraction they found that or their hunch or their stat, their statistical thing was for 12 year. Odds of 12 year retention and 93% spectacular right? 20 odds of it still being there 12 years later 93% and that was with forceps removal so i’d argue that the benex only stands to last longer when it comes to the things we’re worried about is his ankylosis I guess. So i would say the way we’re handling this too gently you know gently and we’re putting it back in quickly those figures didn’t surprise me. Now things like endo and endo unraveling it or I get the thing that’s kind of within our remit that’s like off you know if that happens it’s kind of my fault if i introduce too aggressive a crown root ratio and you know. So there’ll be some i’m sure there’ll be some mechanical failures perhaps an over-ambitious project you know as it were a tooth candidate tooth but and there might be presumably a little bit of ankylosis external replacement resorption but i would argue to answer questions like very very good longevity is what i’m expecting. I’ve found all of them to be rock solid as i’ve seen you know as i’ve and i’ve had some i’ve been doing it you know just over a year and i’ve had a good few i review my under six months so i’ve reviewed i’d say about three of these cases so far and they don’t sound tinny ankylosed, they’re not on mobile or you know they’re the right mobility and i could see a nice outline of a root on my periapical. So ankylosis is the only thing i’m worried about to date the endo that i’m doing i feel like a responsibility or i’m able to eradicate the risk of external inflammatory resorption or things like that. So yeah the things that worry me i suppose are ankylosis and I have.. but i’m really encouraged by the evidence from that paper in the JOE, in journal of endodontics but this technique has been published in the BDJ by Thomas Dietrich, the professor of oral surgery at Birmingham dental school. It. wasn’t kind of a longevity thing but yeah it’s not as once you scratch the surface of pubmed it’s not as novel as you know you that we would both think it is. Well i’m glad you shared those with me in an email exchange so i’ll put them on on the Protrusive dental community facebook group and also on the website on the show notes and prior to you sending me all that. I only knew of the 14 year case report by presented by that gentleman who presented and he you know he said some great things an interesting question i asked him in the audience actually and for asking the the best question that I won a RelyX Fiber Post but thank you nick sethi and the bard team but the question i asked was in the trauma guidelines at the time i believe an avulsion of any sort i think they said antibiotics is a good idea and i sort of said hey do you think antibiotics would help and the guy was like no we don’t think so and would you agree with that? I’d agree with them with the lack of a need for antibiotics if I’m honest, i’d because yeah you’re right with trauma guidelines but we talk they’re probably the antitetanus and it is this dirty tooth etc but again i’m encouraged for benex to outlast traumatize in avulsed teeth because you know there’s no.. there’s nothing atraumatic about an avulsion right? There must be i’m thinking a cricket ball in the mouth, there must be a massive amount of crushing on the palatal aspect of that root and probably a bit of alveolar bone fracture as it’s knocked out intact whereas this can be the benex the winching and it just is like i don’t know shucking you know watermelon it just comes out. It cleaves out ever so neatly and you can really imagine that not a lot of structures were harmed during the making of this you know instagram case sort of thing. So you really are bypassing that cemental damage that maybe the the alveolar bone fracture the muck maybe this got into the sulcus and all those things. Quick question actually i just thought of. At the time where you successfully extrude the tooth do you ever get a ruler and quickly put it and measure the working length? So because I’ve take.. No Is that a daft idea. – No you know my bruiser ex says trustee for that job later but the the academic that i you know i’ve been bombarding this professor with cases trying to you know notice me notice me but he said oh look oh glad to hear someone else loves it like i do and he’s asking me to maybe keep some sort of you know formal of how much i’m you know so there might be a bit of measuring he wants to know how much i’m extruding it and all but so far i’m just kind of doing it by eye and i’m getting everything supragingival which is your bread and butter you know you’re endodontist this is something you do day in day out. Amazing i think we’ve covered well what the technique is, some of the nuances of it before i get to kindly share a case for those who will come on later to on dentinal tubules, claim cpd, watch the case that sort of stuff. If you can share me myself included i’ll they’ll come to a time then the reason i haven’t done it yet because covid happened and we’re all out of practice and i’ve joined a new practice and i’m waiting for that right case to come along and you being an endodontist you probably see you get much more exposure to this sort of stuff. I’m waiting for the right case to do it. I’m more than happy to give it a go, it’d be nice to have a benex so i do feel i would feel much more confident with the benex than current situation i’m probably using the the finest luxator with care like Dr Bachiani did but ideally with the benex but what advice would you give someone like me, you already gave a few little nuggets about the you know pre-etching, pre-bonding any other advice to a first timer? Let me think, so the yeah the benex kit it’s expensive but so it’s you know weight surprise is just more than one thousand pounds all said and done.. – I think that’s great because an implantologist because i think you know implantologists can use it, the endo when you’re doing Endodontics and they don’t take so in this way partial extrusion or surgical extrusion i think the application is brilliant but i’m sure you know even with the tricky extraction you can just set this on and then let it help you as well yeah absolutely so on the course the implant dentists were learning about sectioning let’s say an upper molar into the three roots and taking them out individually but yeah so if you want to get benex about this atraumatic extraction then yeah you’re sectioning the root but it’s a thousand pounds so yeah you’d be pre-bonding the tooth either side so I would have my lumps of composite either side you don’t want to be doing your first etching and bonding when there’s blood around you an ideal tooth would be probably a five because there isn’t the burden for the aesthetic you know you can more easily persuade someone who’s effectively not got a five to you don’t have to go to the ends of the earth to give them two weeks worth of some sort of cobbled together aesthetic thing there. I would also suggest that and i’ve stuck to what i learned on the course was to you.. i’m splitting my involvement into two visits because if the tooth is cracked or perforated or i’ve perforated it or yeah I’ll.. you wouldn’t want to have spent so much time on it so by that i mean i am on visit one i’m extruding the tooth and bonding it yeah splinting it and two weeks later i am doing the root canal treatment but clearly that second appointment goes by the wayside doesn’t happen if the tooth was two weeks earlier split cracked perforated or whatever or just you know proven to be unrestorable so you wouldn’t want to let’s say quote or promise or charge or set aside the chair time for the whole thing in one go you’re sort of extruding it and then two weeks later you might get reception to call the late the person two days before is the tooth still there, ou know our appointment in two days time you know you don’t want that wasted chair time for them to bring in the tooth in there in a little ziploc bag. So you’re sort of splitting treatment into two weeks apart. Let me see.. So i’d recommend some stiff putty one of my lab.. one of my clinical dental technician buddies put me onto some lab putty which is very hard i think sure hardness is the scale and the bigger the number the better in the case that i sent you with the blow by blow steps and stages, you’ll see that you you sort of put a sectional impression tray full of silicon onto the tooth and that and one either side and it acts like a little bit of a buffer or a bumper or a barrier as you start to apply this pressure because as you know newton’s laws the tooth getting yanked up there’s a fair bit of pressure intruding so to speak those teeth either side and i don’t think you’d want to have something very soft it’d be a bit bouncy and teary you want something a stiff silicon and that’s specifically to do with the benex technique obviously. It would be it would be i would beyond that i’d i think those are some great great gems there so um peter can you show us a case so that those people who once they’re off the podcast and they want to go home and catch it there’s some visuals they can check that out as well just share with us a case that you have lateral incisor post crown decoronated unrestored teeth either side a little bit of a prominent lower incisor with a wear facet on it which okay so that’s tough enough and pre-operatively we involved a prosthodontist in this about you know could we you know would an implant work and all because i assumed that this crown gave up the cusp after the proclamation of that lower incisor bashing on it but not a lot of ferrule i hope would agree the the gingival margin wouldn’t afford in my view to go very far north relative to the teeth either side not you can see it in all but you you could you would maybe image two can you see this, there i guess i’ve taken away the temporary filling and again I’m just..you could all you could yeah there are not a lot of two structure left that’s all next picture. The tooth out so uh a lot of root there which is which is the the whole point right a lot of root nothing supragingival but a big long root was sat in there this is my sort of stick as it were and i’m pleased to say that’s nicely parallel with the long axis of the tooth and there was no metal glinting out the side i was pleased to say because i’d before i put my gates before i put my ParaPost style benex drill down the canal i’d flared it a little bit with let’s say a gates glidden or an orifice flare that meant i felt that my benex drill preferentially fell down the canal rather than created its own path with a little bit of apical pressure it. Wanted to stay centered in the canal that i’ve done a little bit of flaring of more so than it wanted to wander off into a perforation brilliant next up i hope was uh six weeks later and brilliant subtle but that’s the yeah it’s just nice pink gum and i’d say a crucial bit of ferrule there. I won’t dwell on it i’ll just bring up next image I mean no but that’s great because if you’ve gone for a surgical crown lengthening there as you said you’re you’re changing yes this might be a low lip line patient but imagine when it’s a high lip line patient or a medium lip line patient then you know you’re changing the gingival zenith on the central tooth incisors you want as much symmetry as possible so that is phenomenal you maintain the exact gingival symmetry to the adjacent tooth that’s amazing. And I couldn’t as you can see, i couldn’t have excluded it more in terms of it bashing off that lower front tooth. It couldn’t really have come out more now the restoring dentist has got a job on his hands but we sort of agreed pre-op and again here’s the x-ray long root if you can.. in terms of trying to justify this you could maybe see the size of that little black triangle pre-operatively was more or less well tiny and i’m sure that this last image in this particular whatever will show it. This is a post-op and it’s a nice big long triangle idea i guess just of a decent amount of ferrule dentine there. So the.. an implant my understanding of implants is that they’re not a walk in the park when there’s gonna be from that lower incisor a lot of loading on it, it was enough loading to knock out that post crown after all. Resin bonded bridge you know likely go the same way so even though the restoring dentist has got a job in his hands i think having you know a pretty decent bulk of natural dentine will be the least bad option that was our thing. Fantastic. No, I really enjoyed that case and if you don’t would you would you be happy for me to share that with the listeners yeah do you mind sending me the image because I want in my introduction i want to say hey look at this radiograph that this is this tooth is unrestorable right but then look what yeah the likes of peter could do yeah and what’s the word ready presentable images no that was all fantastic and that was an ideal one because it was a bloke you could probably tell and he didn’t mind the gap and there was no carries, no resorption, a nice long root. There was no crown root ratio for me to worry about that was and i and there were natural teeth either side so my etching and bonding to enamel is ideal that was the perfect.. It’s like a unicorn patient minus the cluster div two but otherwise it was a pretty perfect patient E.xcellent. So yeah, banging on about it a lot i think it’s great Yeah don’t forget we’re just talking about putting avulsed teeth. An avulsed teeth for two minutes and putting them back in again but i’m you know i’m just crazy infused about it i just find that i’m saying to less people less patience and less dentists i can’t help which is good. I think it’s amazing and i’m so glad you’ve introduced this technique to people listening and watching and you have definitely deepened my understanding of the technique and i just love the benex device as well for it. I just think it’s very admirable what you’re doing to try and save these teeth i mean but we have to accept that some keep implant placing dentists will watch this and and they will spit their coffee out because they were like what the hell is this you might as well have an implant but it just depends on your mindset where you come from and i always say and this is nothing against implant blazing dentist but sometimes when all you have is a hammer everything looks like a screw but i just think it’s great that you’re doing that so thank you so much for coming on podcast to share that technique with us. Yeah no problem, yes funny so something i should have mentioned right the beginning was that remember on the podcast which was your 2019’s most listened to podcast i think you’d even said ‘i don’t think this extraction and put it back in again’ that you’d seen was being done much in the UK and you said if anyone is get in touch and you know lo and behold you know here we are how funny.. -That is amazing, that is so good and thank you to was it to David? Who maybe.. -Turned me onto it and I’ll.. a little community the Portsmouth dental academy gang yeah.. -Thank you so much David now the protruserati and thank you for recommending Peter to listen and then eventually you got in touch now i always say there’s never been a better time to be a dentist because now we’re so connected we can learn we can share techniques there’s never been a better time so with all the doom and gloom i hope to bring some positivity and thank you for joining me in that today. Thank you so much. Yep a pleasure. Good luck nice to meet you virtually, I’ll look you up with a you know conference to show and that sort of thing. I can’t wait. Brilliant.
Jaz’s Outro; So there we have it the surgical extrusion technique or the partial exodontic technique isn’t that fascinating right? I mean something that you would think is innately a bad idea it just seems too good to be true and it’s just fascinating. I think the true secret i guess is case selection like with anything like any technique case selection is always the key so choose your cases wisely and i really do think having something like a benex device if you’ve got access to a benex device wow. I mean you mean that’s half the battle, that’s more than half the battle i think because if you’re relying on luxators then things can chip and break and it may not be possible to this technique. So those are benex wow you’ve definitely got one leg up totally but I really thank doctor Raftery for coming and sharing his passion for saving hopeless teeth. So i hope you enjoy that episode and i’ll catch you in the next installment of the Protrusive Dental podcast. Thank you to all the Protruserati out there.