What is the recommended approach for accessing a tooth?

Recommended Approach for Accessing a Tooth

The recommended approach for accessing a tooth should be atraumatic extraction with maximum preservation of alveolar bone, without reflecting a flap or making releasing incisions to maintain blood supply and optimize outcomes. 1

Initial Assessment and Preparation

• Evaluate the condition of the tooth and surrounding structures
• Determine if the tooth is primary or permanent
• Consider radiographic examination to assess root morphology and surrounding bone
• Select appropriate anesthesia:
  • Articaine (4%) is preferred due to its high anesthetic potency, low systemic toxicity, and good tissue penetration 2
  • For patients with cardiovascular concerns, use articaine with lower epinephrine concentration (1:200,000) 3

Extraction Technique for Intact Teeth

1. Administer appropriate local anesthesia
2. Loosen periodontal ligament fibers with appropriate instruments
3. Apply controlled force with extraction forceps, avoiding excessive pressure
4. Consider root separation for multi-rooted teeth to minimize trauma 1
5. Maintain the integrity of surrounding bone, especially the buccal plate

Post-Extraction Socket Management

For nearly intact extraction sockets, follow this protocol 1:

1. Do not reflect a flap or make releasing incisions
2. Remove any blood clot that has formed
3. Insert 3-5 L-PRF plugs/membranes into the socket, compressing firmly with a graft condenser
4. Cover the socket with a double layer of L-PRF membranes by sliding margins between soft and hard tissues
5. Suture gingival margins without applying traction, allowing healing by secondary intention
6. Ensure sutures are placed over alveolar bone to avoid pulling on soft tissues

Special Considerations

For Primary Teeth

• Extraction approach depends on the condition of the tooth and its proximity to exfoliation
• For severely damaged primary teeth, extraction is indicated when interfering with occlusion 1
• Avulsed primary teeth should not be replanted to avoid damage to permanent tooth germs 1

For Permanent Teeth

• When immediate implant placement is planned, maintain a gap of at least 2mm between implant and facial bone wall 1
• Fill the gap with appropriate bone filler (preferably deproteinized bovine bone mineral) to reduce post-surgical bone resorption 1
• Place implant shoulder just apical to mid-facial bone crest to compensate for anticipated crestal bone resorption 1

Post-Procedure Care

• Soft diet for 10 days after procedure
• Restrict pacifier or digit sucking if possible
• Consider delaying chlorhexidine use until day 3-5 to avoid interfering with early soft tissue healing 1
• Antibiotics are generally not indicated unless medically necessary 1

Potential Complications

• Pulpal necrosis (watch for tooth discoloration, gingival swelling, or parulis formation)
• Alveolar bone loss
• Damage to adjacent teeth or structures
• Facial bone wall resorption (particularly common in anterior maxilla where only 4.6% of central incisor sites have thick wall phenotype) 1

By following these guidelines, clinicians can achieve optimal outcomes while minimizing trauma to surrounding tissues and preserving alveolar bone for future restorative options.