money tooth book

by

Ziv Simon, DMD,MScThe creator of SurgicalMasterTM

How to Extract the

Create a Great Implant Site&

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How to Extract the Money Tooth & Create a Great Implant Site 2

Meet Ziv Simon

Ziv wanted to be a dentist at 4 years oldA few decades later, Dr. Ziv Simon, is a leading periodontist in Beverly Hills and an authority-educator in the global dental community.Ziv is followed by thousands of doctors around the world who love his passion for the surgical craft, enthusiasm, charisma and generosity in sharing surgical knowledgeHe is the man behind the mask and loupes.Dr. Simon is the creator of SurgicalMaster.

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ForewordDr. Ziv Simon is a Rock Star in dentistry!He is teaching dentists how to become better, faster, and more efficient surgeons through his legendary SurgicalMaster. Run, and dont walk, to anywhere he is teaching.Howard Farran, DDS, MBA Founder and publisher of Dentaltown

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d/for YOUDear enthusiastic doctor,Of all interesting and sophisticated topics, why write a book about the extraction of a lower molar?Because you asked for it. For many years, I have been seeing comments, questions, heated discussions, controversies, and online engagement with my videos and teachings on this very topic.This is such a common procedure and in this book Im going to share my way of extracting the Money Tooth (lower first molar).It is seemingly easy to write about a procedure that I perform almost every day. Wellnot quite!When it comes to describing accurate details, there is just too much information about a relatively simple procedure. Imagine you had to describe in writing all the details about the process of driving from home to work, step-by-step, minute-by-minute. You would have to write dozens of detailed pages. It wont be conducive to learning.I considered the large amount of details involved with tooth extraction and concluded it would be too much to include it all. There is a fine balance between being informative and having information overload that can ruin your learning experience. So I literally had to cut into the flesh and break the process down to a bare minimum core while knowingly omitting certain details. I look forward to sharing all the rest with you in future training programs. I feel that this way you can go through this book with very little pain and learn more without getting confused or frustrated.

This eBook is my story of extracting the Money Tooth, the most commonly treated tooth in dentistry.

I tell you the story just the way it is. Its based on my surgical journey where I constantly learn, evolve and improve my surgical skills.

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My team tells me that I say the word Perfect! a lot. I actually do.The process Im describing is not perfect. Perfection is the ultimate goal but not easy to achieve. There is going to be some variability in your outcomes, but if you follow a sound protocol, your results will be excellent.I always consider myself work in progress. Knowing this keeps me fresh, humble and open to new ideas and influence from other great masters.I believe that I can confidently convey this process to you. I had great success with it for many years. It is predictable in my hands and I ENJOY performing it. Im also passionate about sharing this knowledge with you. I have no secrets and there will many more exciting procedures to share with you in the future.By now many dentists have read this book and provided feedback. I constantly update this book and newest version can be found at www.moneytoothbook. Head over there to download the newest version (whats a 1MB or 2 between friends?).If you feel frustrated with your results extracting lower molars, I know how you feel because I also had challenges at the beginning. You came to this world crying at the beginning of your lifes journey.

All beginnings are rough. Welcome to yours!I found that with education, persistence and constant improvements and adjustments you can be great at surgery.To your surgical success with the Money Tooth!

Ziv Simon, DMD, MSc Creator of SurgicalMaster - The Surgical Training for Dentists

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In this eBook YOU will:

Learn how to extract a lower molar

step-by-step, with less stress,

with less complications, & Faster

to help create a Beautiful Implant Site

Every dentist knows the Money Tooth. It is the lower 1st molar.You have treated it and you have extracted it. If its in your mouth, it probably has some type of restoration (is it missing or replaced?).

Why is it called the Money Tooth?Its the first permanent tooth that erupts at 6 years of age. Deep grooves on the occlusion, low pH and a cariogenic diet can lead to occlusal caries. No problem. Here comes the first treatment: Class I restoration.

The next scenario can follow:Proximal caries leads to a Class II restoration. Occasionally these need to be re-done because of fractures or secondary caries. The restoration margins get larger and deeper. With more caries and fractures, the tooth needs a full coverage restoration and crown lengthening surgery may be necessary. At this point root canal therapy is common which weakens the tooth internally.

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Crowns and root canal treatments need to be sometimes re-done. Thankfully apical surgery is rare. The next caries lesion or crack is a death sentence for the tooth.Extraction and replacement are next.

The Money Tooth moves on to the next step.The lower first molar is called the Money Tooth because patients invest great funds throughout the life cycle of this tooth. It is cumulatively a very costly treatment and dentists make a good living in the process.Can you guess the lifetime investment in this tooth?? = $ ____________________The Money Tooth has been there the longest, its heavily restored throughout its life cycle and it is the most commonly extracted tooth in your practice.

Many dentists are frustrated when extracting the Money Tooth and told me about their challenges.

If you too are frustrated and need some answers about the extraction of lower molars and creating a good implant site.

This book is for you, doctor.

DFASTERI have extracted a few thousand Money Teeth so far.Like you, I have been in the trenches as a full time clinician in private practice. Ive done just as many difficult extractions as simple ones. Ive seen the different levels of infection, bone destruction, abnormal anatomy and other challenges.

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By now, I have very predictable protocols that allow me to extract lower molars of all shapes and conditions and manage extraction sockets of all shapes and conditions.

Sounds interesting?The doctors Ive worked with and taught over the years and who use the protocols in this book get more bone and better bone for their implants, FASTER.The protocol forces you to assess the lower molar before you even touch it. You will be able to predict challenges and choose the best course of action for the challenge. The protocol has a plan A, B, C, D and E.That doesnt mean its necessarily easy. There are problems and complications that happen even under the best circumstances.The good news: it is all part of the protocol and the decision-making process.At this point I am very familiar with this process. I have already predicted most of the problems associated with their case and I can give a very accurate run-down of the procedure from A to Z. I can even predict the shape of the ridge at the end of the healing period and if additional grafting will be needed.You too will be able to create an accurate roadmap to follow and achieve success. This well-planned and predictable approach doesnt only create calmness and confidence within you. Your patients will also be more calm, trusting and confident in you as their surgeon.

Here are THE problems Its not always smooth sailing when extracting the Money ToothDentists often tell me about their frustrations, challenges and also complications such as:

o They cant grab the tooth because tooth is fractured or decayed subgingivally.

o The roots are curved and keep breaking to pieces.

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Sounds familiar? There are more:

o The buccal plate is missing or breaks during the extraction.o Your patient is still feeling the procedure even after you had given a

block multiple times.o The soft tissue is poor and keeps tearing.o Hard to fit and stabilize a membrane and its not clear which one to use. o The bone graft particles keep coming out.o Socket is full of pus and youre hesitating to graft.o Healing is compromised and implant site is poor.

If this sounds familiar, you are not alone. These are true problems experienced by hundreds of thousands of dentists. You are in a good group.

The great news: These problems have solutions.

tWhen a procedure doesnt go well. Patients can tell everyone about the nightmare of tooth extraction they had with you. That then, unfortunately, becomes your nightmare.The issue of patient perception is very important to me.A good patient experience and your perception as a great surgeon is part of your success. I always recommend learning about patient communication and management skills in addition to learning techniques. You will be perceived based on how you represent yourself.

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A good attitude doesnt make up for a bad performance and the other way around: Great technique doesnt make up for poor bedside manner.So be great in both aspects.

t You can do the same. Im now very comfortable

when it comes to extracting lower molars.Carl D. Werts, DDS

Glendale, CA

Its TRULY inspirational.Dr. Kit Patel

Sydney, Australia

Dr. Simon and SurgicalMaster gave me the confidence to deal with extractions. Its a gift to be able to create great implant sites!

Rick Glassman, DDS Westlake Village, CA

I followed Dr. Simons exact treatment protocol and had excellent results with less stress and great patient experience.

Rawad Riman, DDS Beverly Hills, CA

Thank you for the inspiration!

Dr. Jesus Munoz Penalver, Spain

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Thank you for your valuable inputes to uplift dentistry.

I am highly motivated!Dr. Navdeep Singh Khurana

India

Dr. Ziv Simon is the most knowledgable, practical, down to earth expert, speaker and mentor I worked with in 37 years of practice.

Mark Leopold, DDS Sun Luis Obispo, CA

(also for the doctor)My first lower molar extraction was not a great experience.It had many of the Extraction Enemies (the EEs will be discussed later in detail):Root canal treatment, curved roots, severe caries and very dense bone.It broke into many many pieces and I needed to remove precious bone to retrieve them. At the end of the process the socket was very damaged. Several bony walls including the inter-radicular bone were missing. It looked like a war zone! :-( I didnt do any bone grafting either because I didnt have enough knowledge on how to handle this mess.

3 months laterIt turned out to be a very compromised implant site. It had horizontal and vertical deficiencies with poor tissue quality.

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When I look back, it was obvious I had no defined extraction protocol (plan A) or alternatives (plans B and C), a defined armamentarium and a step-by-step-sequence. I used the instruments handed to me by my assistant without too much thought. There was no plan, no attention to extraction mechanics, identifying complicating factors and biologic principles that are critical in bone grafting. The results were accordingly. Poor.One more negative thing. I didnt enjoy performing this procedure. It was a painful process not just for the patient but also for me.There was something fundamentally wrong with the approach I took and if things kept going this way I would have lost my confidence and retired from exodontia. It was clear that keeping doing the same and expecting different results is not going to work.

This was all about to changedramaticallyMore of the same will get you to more of the same. Every problem has a solution so keep finding ways around the current issues.The first step was recognizing that the current method is not going to work for me. I then started researching what the great surgical masters were doing when extracting and grafting lower molars. There was so much to learn and apply. I copied and emulated. I took the best of each and combined with some of my surgical knowledge and came up with something that really works!The road to success started with a very simple thing. So simple.

A Periapical radiograph More specifically: a proper evaluation of a PA before the procedure.You may be thinking: Are you kidding? Isnt that obvious? You obviously need to look at a radiograph before a procedureYes. You need to look but looking is not enough.

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Are you just quickly glancing at it before? Do you spend enough time not only to see but also to study all the details in a simple periapical radiograph? Are you considering all the data you are collecting? Are you listing out the extraction enemies? The very simple periapical image will give you 95% of all the necessary details you need. Study it well according to the guidelines in this book.There were more steps to getting better:I spent more time analyzing and identifying the challenges and preparing myself. I studied the differences between the instruments and why they were different. I took any course I could find on exodontia and picked up pearls and techniques from different clinicians I trusted. More than anything, I learned to be methodical and to have a detailed plan for every procedure. Great results soon followed. A clear extraction protocol soon followed and Im sharing it with you in this book.

^ ^ ^I adapted methods that were relatively simple to execute. The less steps, the less time, the less trauma, the less swelling, the less pain the better the outcomes.I didnt make this up:

Simplicity is the ultimate sophistication - Leonardo de Vinci, 1452-1519

I was able to create a Plan A and also alternatives I could resort to. I gained good knowledge about the mechanics of exodontia and what actually happens biologically.

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I learned how to use bone grafts, membranes and biologics to preserve the alveolar ridge. I kept documenting and analyzing my results. Wherever needed, I made necessary adjustments and the results kept improving.Its very similar to any other craft not related to dentistry, may it be in the sports or music world. The more your practice, the better you perform. This process never ends. You may hit some plateaus but there are always new things to learn. The process of learning and getting better NEVER EVER stops.I refer to this process as Perfectionization (not an English word)Its the continues effort to achieve ultimate perfection. Its never ending and you actually never reach it. Dont get discouraged. You will get quite close.Following the protocol allows you to create a beautiful implant site = A site with good bone quantity and quality and as early as 8 weeks after the extraction. All of this with less stress and a great patient experience.This eBooks focus is on the extraction process and in the next one Ill describe bone grafting.

This is not only for experts You may be thinking that this protocol is technique-sensitive and that you need have extensive training or even be a specialist to get good results. This is not quite true.You will need to understand the biological and mechanical principles and be methodical to gain success. You will need to put efforts and dedication into it. Its not about extracting thousands of teeth to get it right. If your method is wrong, youll get bad results thousands of times.Start fresh. Do it properly from the beginning, follow a good protocol and you will be successful as well.

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How about complications?Some doctors are scared of complications and concerned about getting bad results. These will happen every once in a while. Even under the best circumstances results are not guaranteed. Dont let fear hold you back. Fear is a normal human emotion. Fear will kill your creativity and any type of innovation or potential change. To fight your fear of doing this procedure, educate yourself, get prepared and BE in the KNOW. If you feel insecure and hesitant thats a good sign. You are on the right path. Going out of your comfort zone means you are making progress and learning something completely different and better. You are on your way to doing great things.Doctors are concerned with infection in the socket and that their bone grafts could fail. Grafting infected sites has been very controversial for years. Its a very important issue and it is definitely doable. Its actually an advantage to some degree as youll see in my teachings.How about deciding between the different types of bone grafts, membranes and sutures? Is that confusing to you? Many doctors are.Although the selection is huge, Ill give you very specific guidelines in the next eBook on grafting (this one is about the extraction process). Secret #1: I use very few materials.There are lots more myths and misconceptions that are fueled by lack of knowledge and experience. You can find any excuse to hold you back but if youre still reading this, you want to know more and get better.

Are you ready to handle the Money Tooth? Lets go and take care of this one!

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d,^zZ^,DdIm going to start going over some details now. Have patience as I walk you through the process (dont skip to the photo of forceps!). Every step builds on the previous one. Every detail matters. You may think some points are obvious so bare with me. Im tackling this topic from angles you were probably not aware of. Besides, this book is meant for thousands of doctors at different levels of experience and expertise. We all need to be on the same page.Im starting with the most basic thing:

tthis one?This is a must-know answer. You have to have a diagnosis that leads to a recommendation for an extraction and replacement.The tooth needed an extraction is not a diagnosis.Poor prognosis is also not a diagnosis (its a prognosis!).The tooth needs a diagnosis and then a reason for extraction side by side.The combination of the two needs to be such that extraction would be the best solution for the tooth.Also, both have to be discussed with the patient and documented in the chart. You need hard proof to support it and make a case for extraction.

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Diagnosis examples:o Tooth #30 vertical root fracture, hopeless prognosis.o Tooth #19 severe chronic periodontitis, hopeless prognosis.o Tooth #30 combined perio-endo infection, poor prognosis.

1ST STEP: Prepare your patient.

Reach a diagnosis; discuss the need for extraction and type of replacement you recommend. Its good to discuss different treatment options and their advantages and disadvantages. Let your patient know about the consequences of no-treatment (for example: if the tooth is not extracted, infection will persist, get larger and affect the adjacent teeth).

2ND STEP: Prepare yourself for the procedure.

Study the pre-operative radiograph. Dont be fast to refer for a 3D scan. 95% of your preparation comes from evaluating a recent diagnostic periapical radiograph. Most of the small and important details are just in front of your eyes. The saying the devil is in the details is so true. Attention to all the small details will make a HUGE difference in achieving a success. Which is more difficult to extract? A or B?

Answer: Money Teeth A and B have different types of challenges so there is really no right or wrong answer. Understand the difficulties by studying the Extraction Enemies next.

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dWhen Im planning my extraction procedure I look at the radiographs very carefully. I take advantage of every possible view. It can be a periapical from different angles as well as a bitewing radiograph. They all add useful information that comes handy during the extraction process. Im basically looking for factors that would challenge me during the procedure. Everything that stands between me and performing an effective and a least-traumatic extraction, I consider an enemy. Its like a battle. To win, you need to know everything about your enemy (or enemies). Understand their strengths and weaknesses and the challenges that they pose. To beat an enemy, you need to create a great and effective plan of action. Its only when you are a step ahead of your enemies, you will able to beat them.Extractions work the very same way. Evaluate the tooth to be extracted very carefully and understand the extraction challenges. I call them the Extraction Enemies. Know about them to win the extraction battle.I combined 10 Extraction Enemies (or EE) into a list and will later elaborate on each one separately. Dont just glance over this list. This one is important and can make a difference between success and a miserable failure in case you miss one of the EE. It helps if you can describe each one. You can say them out loud, write down in the chart or discuss with another doctor. When your observation gets expressed, you are truly internalizing what you are seeing and have a good chance of overcoming the challenges.

The 10 Extraction Enemies checklisto Endodontic

treatment o Restorationo PA pathologyo Poor tissue

o Shape of rootso Adjacent

restorationso Nerve & space

proximity

o Root proximity o Caries &

resorption o Dense bone

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Extraction Enemies the detailsYou will be facing different challenges during the extraction. This is your time to plan some solutions ahead of time. The Extraction Enemies are the potential pitfalls you will be facing. The more you identify the more challenging the extraction. Recognizing them comes through your radiographic and clinical exam.

o If you identify 2-4 this is normal and very typical for lower molars. o If you identify >7-8 youre in for a struggle PREPARE for BATTLE!

No need to feel overwhelmed or deterred by these obstacles. You might as well know about the ahead of time and not be surprised during the procedure.Read about each Extraction Enemy in the next section. Try to understand each and every one especially why it poses a problem. Trust me. Its better to know than to be oblivious. Itll make you better.

Endodontic treatment: Evaluate the endodontic treatment that was performed. Check how well it was done and if there are any signs of persistent periapical radiolucencies. Were the canals over-instrumented creating thin walls? How long and wide is a post space? Was periapical surgery done? Endodontically treated teeth will be very fragile because the internal tooth structure is compromised. If you see evidence of peri-apical surgery, you can often expect a compromised buccal plate. This is the most common Extraction Enemy.

The existing restoration: There is a big difference in the extraction process depending on if the tooth is restored and how. For an intact tooth structure (rare) you will be able to use universal forceps and split with no problems. However, most Money Teeth are restored and the remaining tooth structure is fragile. You will have to section the restoration prior to extracting the tooth and that requires some preparation.

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Periapical pathology: The shape and size of the lesion will dictate how you debride and graft the defect. Commonly, periapical lesions have already perforated the buccal plate. That is important to know because you will need to graft the buccal plate. Large and chronic infections will also create trouble with local anesthesia. Your inferior alveolar block takes but the infected is area still felt by the patient. I will discuss the management of this Enemy later.

Poor tissue: Minimal or no attached and keratinized tissue is a big challenge and very often underestimated or even overlooked. It requires extra caution in flap manipulation and suturing. This type of tissue is friable and can tear if handled incorrectly. Keeping the soft tissue integrity is important for the success of your procedure and also for the future implant site. The tissue is the issue! coined by Dr. David Garber from the Atlanta team still holds for the past 30 years.

Shape of roots: Thin curved roots break easily. If you dont approach them properly, they will keep breaking until the last apical part. Do you look at the roots in great detail? Long roots? Is the apical third wider than the middle third? If yes, prepare for a difficult one. Try to envision the path of exit of each root separately. This visualization will help you create the needed space in the correct aspect of the roots as well as the right momentum when removing them.

Adjacent restoration: You are applying various forces to extract a tooth. There is a chance that adjacent teeth will move and potentially sustain trauma. This is a commonly overlooked factor. Pay attention to that and take the necessary steps to avoid breakage of the adjacent restorations (full porcelain is notorious) and even virgin teeth. Make a habit to warn your patients about this risk and take the necessary precautions to prevent it.

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Nerve & space Proximity: The chance for inferior alveolar nerve damage is low (more common for second molars). However, always check and see how close it is. It will become relevant when you try to retrieve broken roots by bypassing them with long burs. Knowing the relationship with the nerve will help you exercise caution with your surgical instru-mentation. Lingual concavities are often overlooked. Remember that the ridge is not always wider at the base.

Root proximity: This is tricky and challenging for 2 reasons. There is lack of space to maneuver your instruments and there is also risk of damaging the adjacent roots. Make sure to identify this issue before the procedure and take the precautions to avoid damage.

Caries & resorption: If extensive, tooth structure will crumble. You can already see this on the radiograph and anticipate that the use of forceps will not be needed. Identify the solid tooth structure you have to work with.

Dense bone: Increased radiopacity is not a perfect predictor but gives you a good idea about bone density around the roots. Dont expect an easy luxation and root mobilization. If you recognize it ahead of time, you can prepare for a difficult extraction process. Dense bone is also a healing enemy. It is less vascular and healing is sometimes slower with increased incidents of pain and alveolar osteitis (dry socket). I really hate this one.

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'So this is what you did so far:

o You determined a diagnosis and recommended an extraction of a lower molar. o You discussed the process with your patient including the extraction

procedure, bone grafting and implant replacement. o Your patient, after being well informed, gave you permission to move

forward with the extraction and it is all in writing with a signed informed consent.

o Medical clearance was obtained (if necessary) o You prepared by studying the periapical radiograph.o You know the Extraction Enemies specific to this tooth.o Your team scheduled the patient for the procedure (make sure you have

enough time).o Your assistants prepared the room for the procedure with the proper

instruments. For the extraction process you will need a basic surgical kit, high-speed handpiece as well as extraction tools and burs. Bone grafting materials and tools are also needed and will be discussed in a different publication.

Basic surgical kitIt is important to use a good, simple and reliable basic kit. Your kit should consist of tools that can be used for most surgical procedures. This is a basic set up that can be modified as needed. Make this book available to your assistants.

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Forceps3 types are usually needed: Universal, specialized and root forceps. The universal is able to grab relatively intact tooth structure, specialized is for compromised tooth structure and the purpose of the root forceps is obvious. Follow the protocol to know when to use each one. Logically, assess the remaining tooth structure and type of restoration and determine what forceps would be the most appropriate.

BursBurs will be needed to split the coronal part of the tooth and between the roots. For that purpose we use two type of long straight carbide burs. One is thin (#700XL) and one is thick (#702L). Additionally, if a restoration needs to be cut off initially, use a combination of diamond and carbide burs that you would normally use in restorative dentistry.

Straight elevatorsStraight elevators create a lever effect on the tooth or root tip. Placement is in between the tooth structure and bone, which is the fulcrum. Most commonly I use a medium size and am always careful. Damage to adjacent tooth, restoration and even bone is possible. The can be wedged between the roots of the Money Tooth after they were split.

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High speed handpiece Ideally an electric handpiece with good torque is recommended. You will need it to remove a restoration, split the tooth in between the roots and also for creating space between the roots and bone for more difficult extractions. Have it prepared even if you end up not using it. It is part of your surgical set-up.

Bone grafting tools and materialsI will describe everything that is needed and how to use in the next publication on the Grafting the Money Tooth. Stay tuned!

SurgicalMaster team extracting the Money Tooth

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d/DKhdZNo, its not time to send your kids to their room as punishment (if youre a parent, you know what Im talking about).Its the time to STOP and make sure everything has been done correctly so far and also going forward. The Time out principle comes from the medical world. It is meant to confirm that that the whole team is on the same page and also to prevent medical errors. For example, in orthopedic surgery the hip requiring surgery will be visibly marked and sometimes by the patient as well (Its ok to mark the tooth). So just before you are ready to make some irreversible changes, Stop. Its time for time out!.Make sure you have the right patient, the right tooth, consent obtained and signed and the medical history was reviewed and that there are no contraindications. The purpose of this step is to prevent mishaps like anesthetizing the wrong side, proceeding without permission and even extraction of the wrong tooth (it still happens in this day and age and you need to make sure it never happens to you).I do a few things as part of my time out!. I look at the chart and confirm the patients name. I then match it with the consent form and look at the radiograph of the tooth. I then ask the patient if they are clear about what we are doing today. I even ask them to point to the tooth needing extraction or the area of the extraction.I state out loud: tooth #30, lower right (for example). I involve my assistant in the Time out! process. My assistant will also confirm the tooth to be extracted. During the procedure, I would say something like Im placing it on tooth #30 (as an example) for my assistant to confirm. Thats another safety step.Patients will sometimes joke with you, saying Doc, dont pull the wrong tooth. Although its a silly joke, what they are really expressing is some sort of concern or anxiety because everybody heard about medical errors.. Tell your patient about your Time out! protocol. They will appreciate your care and focus on safety and harm prevention.We dentists always work fast and effectively. This is your time to stop, take a breath, take a time out! and make sure you are doing the right thing. Your patients will be grateful and you will have created more value for your treatment.

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>'Local anesthesia is one of the most important aspects of treatment. The surgery has to be painless and there is no other way around it. Your patients not only deserve it but also expect it. Make sure your local anesthesia is profound throughout the procedure. I also recommend you administer a long-lasting anesthetic at the end of the procedure. This will give your patient relief for several hours after the surgery and allow for the pain medications take effect.For the Money Tooth, give a slow inferior alveolar nerve block and add a long buccal infiltration. Then sit the patient up in the chair and wait. It allows for better and faster anesthesia (I learned this from Dr. Stanley Malamed, author of the Handbook of Local Anesthesia. Look up my interview with Dr. Malamed on YouTube). Confirm that local anesthesia is profound and that the block took as well as lingual anesthesia. You will have a comfortable patient and be able to operate efficiently and quickly and without interruptions.

Why do some patients feel pain even when the block took?

In the presence of infection that has been either chronic or acute, the localized extraction area is resisting your anesthesia. It has to do with the pH in the site affecting the anesthetic and also with the fact that the lesion gets encapsulated. Try to anticipate this problem and prescribe systemic antibiotics a few days before the procedure. For most patients this method will work great and your local anesthesia will be effective. A different problem is an anatomical variation with an accessory nerve. Study the art of local anesthesia to overcome these challenges.

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If your anesthesia technique is improper, stop! Go back and study it. The extraction process cant be done without profound local anesthesia. Excel in it!

&All of your patients are different and have different needs and clinical situations. Sometimes these differences are very subtle. I recommend you keep an open mind and be prepared to execute different treatments based on the clinical scenarios you are faced with. There will be several forks in the road where you will have to use your clinical judgment and make the right decision. Try not to get confused. Decisions need to be made by clinicians at all levels.Each decision should have logic behind it. Its not a guarantee for success. However, if you make more decisions with a good rationale behind them, your success rates will be very high. Youll consider alternatives and evaluate risks versus benefits for each decision.There will be Forks in the road and you are expected to walk the right path. From this point on, the treatment of the Money Tooth depends on the particular scenario you are facing. I gave this issue a lot of thought. Decision trees and algorithms are very confusing and not always applicable in oral surgery. I therefore decided to give you a few general guidelines and be more specific later on in this eBook. Quick disclaimer: This is not the only way to do things and there are other and perhaps even better ways out there. It is simply my current methodology that works great for me at the time of writing this eBook. You should explore the wealth of knowledge that is in this world and decide on the best way yourself.Just making sure we are all on the same page and the following are general guidelines for extraction of the Money Tooth.

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E/E' If possible, use forceps to only luxate the tooth around its axis between 30-40 seconds before attempting removal.

If the tooth has a crown, remove it first. It often comes off by luxating with universal forceps. If not, section the restoration off.

Remove the roots separately (with or without their coronal part).

Flap reflection is very common. Often youll need to repair the buccal plate and proper defect exposure is important.

Dont lean against adjacent restored teeth. You may end up creating damage.

When dealing with thin, curved roots in dense bone, almost automatically, create a space between the roots and supporting bone. This trough will allow you to place instruments, exert the proper forces to elevate the roots with more predictability and a lower chance of further breakage.

Socket grafting is always recommended with very few exceptions.

Resorbable gut sutures and membranes are my first preference.

(AND THE MOST IMPORTANT ONE) Secondary intention healing is the best option. You will get more and better soft tissue. Dont aim for primary closure so you dont compromise blood supply and the tissue quality.

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^

Your patient is anesthetized, relaxed and ready to go

Safety: Safety is the most important aspect of surgery. Keep it at high priority. Always. I like to use two 2X2 gauze around the tooth to be extracted. I fold one gauze and place it in the vestibule (arrow 1). This protects the buccal tissue and is a cushion for the instruments. The second gauze is opened and placed on the lingual aspect above on the lateral aspect of the tongue (arrow 2). It acts as a safety net to prevent anything from being swallowed or aspirated by your patient. Explain what you are doing (especially for gaggers). All patients will appreciate your careful approach and will be very understanding.

Start by separating the soft tissues using #15 blade or an Orban knife. If the tooth structure is relatively intact, I use universal forceps first. I place them below the height of contour and find the best grab. Its not always buccal-lingual. Sometimes the best position is at the line angles. Take your time and test the best position that will allow you to do rotational motions around the tooths axis.

I take care not to pinch the gingiva especially when the tissue quality is poor (a gingivectomy is not welcome!)Remember. Im not extracting the tooth yet. Im only carefully moving and vibrating it to create inflammation in the PDL space. Some bleeding occurs too. The inflammation increases with time and will facilitates the next steps.

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I tell my patient about feeling vibrations and light pressure. You are creating small and repeating motions around the tooth axis which will be perceived as vibrations. You need to have patience and not go for the removal yet. 30-40 seconds is a good start. If I detected many Extraction Enemies I may do this 2 or 3 rounds of vibration a few minutes apart (between 5-10 minutes).During the process I gauge how tight the tooth feels. For mobile periodontally involved teeth, this process will naturally result in a quick extraction. For most cases the process takes some time but is well worth the effort.If the adjacent teeth are not restored, I also use a medium size straight elevator. When placed in mesial aspect of the tooth (between the premolar and the molar), the elevator will luxate the tooth in a distal direction. Its a classic lever effect and you will see movement. Still, try to only mobilize the tooth without attempting an extraction. Using both the forceps and elevator will cause inflammation in the PDL that will gradually increase. There will be an increase in mobility due to socket expansion in some cases but also increase in inflammation in the PDL space. To see a substantial change may take a few rounds of vibrations and rest. Pay attention to the increasing mobility. In cases of relatively straight and parallel roots and when the mobility becomes substantial, extraction can be attempted. You can move your forceps in a coronal direction while vibrating and an extraction can be completed. Success!If you are gauging no significant change in mobilization after a few attempts, you are dealing with very dense bone and/or significant curvature. Dont get discouraged about the time you spent vibrating with no extraction. The inflammation you created is beneficial for the next steps.You can now proceed with the splitting process.

I Use the #702L bur to split the tooth initially. It is large and aggressive enough to do this effectively. Make sure your split is through-and-through in a buccal-lingual direction. Ensure that the roots are completely separated.

Teeth with long root trunks may require you to pass the bur several times. During this process be cautious not to traumatize the buccal and lingual bone as well as the furcation bone. Its important to preserve as much of the inter-radicular bone as possible (it is your future osteotomy).

#702L

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Once both roots have been separated, I use the same medium straight elevator and very carefully try to mobilize both parts. Dont apply too much pressure as at this point the coronal part can easily break off. Too much pressure can also break the inter-septal bone. At this point the goal is to increase the mobility of the two fragments. Constantly test and gauge how tight they feel. You can use root forceps to rotate each fragment. Your success with the forceps will depend on the bone density and root configuration. Very curved roots or in very dense bone (or both) will not agree with rotational motions.Once both roots are mobile, you can complete the extraction process with root forceps. Success! The grafting may now begin.

Now, roots can breakKeep calm This will be the time to execute PLAN B (described later). You will identify the area of breakage and make sure you have good visibility. Removing the broken fragments is by using small root picks that is preceded by creating space with a small straight fissure bur.If the tooth is restored you can expect for it to come off when using your forceps for luxation. If it doesnt, you can proceed with the a few rounds of vibrations with breaks I described before (luxation around the axis of the tooth for 30-40 seconds). Unless the tooth is periodontally involved or very mobile, it always advantageous to split the roots. The difference in this scenario is you will have to section the restoration first before you can get to the underlying tooth structure. Use the proper burs to split the restoration (combination of straight diamonds and carbides). Apply the same principles described before in regards to careful separation in the root trunk area.In case flap reflection is needed, its best to delay it until after the restoration has been removed. This way metal debris will not get embedded in the tissue. With the restoration removed, you can proceed with the split and removal of both parts as described before.

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THIS WAS PLAN AHere is a little summary of what plan A was all about:

o Luxation around the vertical axis using forceps for 30-40 seconds.o A few round of the above with breaks in between.o Careful mobilization using a straight elevator.o Splitting the tooth between the roots.o Extraction of each root individually.

It can get more difficult and youll need another option. This is where plan B is useful. The removal challenge starts when coronal tooth structure is compromised due to significant caries or fracture. Using forceps and straight elevators is not always feasible or effective. You will then have to resort to other methods.

Heres your PLAN BUniversal forceps will simply not grab the remaining compromised tooth structure. Now is the time to utilize specialized forceps that engage in the furcation area. Place your specialized forceps and start your rotational movements (around the tooths axis). Repeat the same process for 30-40 seconds and gauge tooth mobility. Dont be surprised if you are not making as much or as quick of a progress compared to PLAN A. Repeat the process a few times with breaks.You can then proceed with creating the split between the roots. A flap is not a bad wordYou probably heard about negative side effects of flap reflection (soft tissue trauma and bone loss being two examples). As much as I like performing flapless procedures, flap reflection has its place and it is not so detrimental. In my opinion, it is better to reflect a flap in cases where your tools may create damage to the soft tissue. You will also gain access and visibility to facilitate the extraction. On a side note: you will see bone loss even in flapless procedure. That is just reality and more on that in my training. The bottom line: Flap reflection has pros and cons and is up to your clinical judgment.

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The Money Tooth Flap:Your flap will extend one tooth on each side. Start with a #15 blade and create an intrasulcular incision between the distal line angles of the second molar and mesial line angles of the first premolar (assuming they are present). Preserve the MAXIMUM amount of tissue. Repeat your incision with an Orban knife. This will ensure proper fiber separation and an easier and cleaner flap reflection. You always want to handle an intact flap with no tears and perforations.

Your suturing and overall healing will be much better if you take good care of the soft tissues. So as basic as it may sound, take your time and focus on good flap reflection.Now you have full access to the remaining tooth structure. Retract the flap with a periosteal elevator and protect it while you section the tooth with straight fissure bur. Similar to the previous plan, you can use a medium straight elevator to mobilize the roots. You can also carefully use a thin carbide bur to create some space between the root and the bone. Create this space at the expense of the root an not the bone as best as you can. With the proper access, using leverage or root forceps, both parts can be removed. Success!The key in Plan B is creating access and visibility while preventing damage to the soft tissues.

#15 blade

Orban knife

Periosteal elevator

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WHAT IF PLAN B DOESNT WORKYou followed PLAN A, switched to PLAN B

You reflected a full thickness flap, split the tooth, created a slight space to bone, tried to mobilize the roots but with no results. The roots are also starting to break into a million pieces and you feel some pressure and stress.Keep calm.Time to go to

PLAN CYou are now in a more challenging extraction process. On one hand, youd like to preserve as much as the surrounding bone as possible. On the other hand, you are tempted move fast forward and be more aggressive with bone removal for a faster extraction. There is a fine balance between the 2 goals.Dont rush. Think.Try to understand what is holding the procedure back.

o Are you dealing with very dense bone and a challenge creating mobility?o Are the roots not completely separated?o Is the root curvature an issue?o Is the tooth structure very compromised and fragile and thats why it

breaks easily?o Do you have poor access and visibility?o Ankylosis? (quite rare).

There could also be a combination of the above. You can go back and look at the Extraction Enemies. They are now haunting you and making the extraction process more difficult.

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Take a deep breath, keep cool and maintain your composure.Identify the problematic root. You will need excellent visibility. Identify the root curvature and determine how much access you need for your instrumentation. This will help you make a decision on how much bone removal is possible and if sacrificed will not be detrimental to sacrifice. Plan C consists of very careful and selective bone removal around the stubborn root(s). This will be done in key areas (mesial or distal) without damaging the integrity of the buccal plate. You will use the thin long carbide bur used in the previous plans or the extra long carbide bur (#151L). This step may be slightly frustrating to you. You will need to focus on good visibility through illumination and suction. You may need to take a few radiographs to document your progress and also the completion. Small root picks and proximators will assist you in retrieving the root tips. Doctors run into trouble when rushing and breaking the roots prior to sufficient mobilization. If you followed the protocol and applied plans A and B, you will now reap the benefits. The luxation around the axis at the beginning of the procedure, has hopefully mobilized the roots before they broke. This in turn will facilitate their removal

PLAN DYou followed plans A, B and C. In spite of your best efforts, you still cant retrieve the root tip(s). It may be due to very long roots and your burs are not long enough. Root tips can get caught deep in bone and the area is in an undercut of an adjacent tooth (therefore with no direct access). Root ankylosis or hypercementosis could also a hopeless situation for broken root tips. Regardless of the reason, if PLAN C didnt work, its time to execute PLAN D.Its almost the last resort.PLAN D involves drilling out the residual root tip (grinding it down until its gone). Yes. It is possible to do that. This is not ideal but it is certainly acceptable under these circumstances.

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The challenge of PLAN D is having long enough drills to execute this. PLAN D is not very common in my practice but happens once or twice a year. The bur of choice is a surgical length medium size round diamond bur. You will need to know the location of the residual root tip and aim for it with the bur. Complete the extraction process by taking a final radiograph that shows a socket without tooth remnants. The heat that is generated and additional trauma can cause slower healing and occasionally alveolar osteitis (dry socket).

DONE!You survived a simple Money Tooth extraction using PLAN A all the way to a difficult extraction with PLAN D.You followed the protocol through the different plans and applied the appropriate methods. Resorting to PLAN D doesnt mean that you did something wrong or that you dont have good surgical skills. Resorting to PLAN D is a testament to a difficult situation and your methodical extraction approach that lead to it. You can be proud of yourself.

You extracted the Money Tooth To create a great implant site.

Is there a PLAN E?Yes.PLAN E occurs when a root tip breaks and you are not able to retrieve it or if the retrieval will cause more harm then good.

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Basically, in PLAN E you are forced to leave a root tip behind. That scenario can happen to you and is luckily uncommon. If you went through PLANS A -> D and the final radiograph still shows a root tip, you are in the last fork in the road. Evaluation the situation carefully and ask yourself the following question: Is it realistic for me under the current circumstances to remove this root tip without causing damage and harm?If the answer is Yes: Keep working at it.If the answer is no: PLAN EYour transition into PLAN E is after you tried your best with all the previous protocols. The timing of this step can vary between clinicians and depends on experience and expertise. As an example, a root tip laying on top of a nerve canal should ideally be left behind so nerve damage doesnt occur (PLAN E). The risks and potential damage from retrieval attempt are greater then the minor issues of leaving it.If you resorted to PLAN E, discuss this with your patient and explain the reasons a root tip was left behind. If you feel that leaving a root tip is detrimental, refer the patient to another expert to assess the situation and treat it as necessary. For your information and not just to make you feel better: Retained root tips rarely cause a problem. In a world of dentin grafting and the socket shield technique, I personally dont see it as a challenge. PLAN E is technically not a PLAN. It is rare occurrence and you deserve to know about it.

DIf you followed all the steps I described, you will be able to remove at least 50-70% of Money Teeth very predictably using PLAN A and PLAN B. Less frequently (~29-49%), youll need to execute PLAN C and rarely (

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Being systematic will also keep you calm and your patients will have a better treatment experience and outcome. So now that the extraction protocol of the Money Tooth has been completed confirm that the socket is empty and repeat after me:

A good socket is an EMPTY socket!

Not for long. The next step involves bone grafting and I have a lot to share with on how to do this. We are not just filling a cavity with a material. There is a thought process behind and as you may have guessed, I have a protocol for that too. All of this will be found in Part 2: GRAFTING the Money Tooth. After reading, understanding and implementing all the protocols you too will achieve a

GREAT IMPLANT SITE!

Now, start with implant planning and work towards replacing the tooth (yes, I will also reveal my protocol to place a Money Tooth implant).

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Final words Be understanding and sensitive communicating with your patient. Loosing a tooth that has been there since 6 years of age is not easy for anyone. The Money Tooth has a lot of history and you now know why its called this way.

o Be a good communicator. o Talk and listen to your patients. o Explain and answer questions. o Put your patient at ease and be present in the moment with confidence

now that you have more knowledge. After reading this eBook you can now be more confident and replicate the methods I described to you. Creating a great patient experience will mean the world for the patient. Creating a great implant site and providing a good replacement is an incredible service. You can be great at this.

It works! Its YOUR turn now.

Start slow, follow the steps and focus on patient safety. If there is one thing you need to know, its the tissues and structures you are operating on. You need to know the anatomy because anatomy is life (-saving)!If you found this eBook helpful, I would be delighted if you share it with other dentists. We can all learn together and get better by sharing knowledge. I certainly learned a lot just by writing this book. The most up-to-date version of the eBook can be found on www.moneytoothbook.com. Go there now and download the latest version. It gets updated all the time. Sign up for my videos and blogs is at www.surgicalmaster.com.It would be awesome if you could e-mail and give me feedback on this eBook (good and bad). Let me know if it was helpful and if there are any other problems youd like me to help you solve.

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You have a lot to think, digest and implement with the many Money Teeth in your practice.In the meanwhile, To your surgical success with the Money Tooth!

Ziv Simon, DMD, MSc Creator of SurgicalMaster - The Surgical Training for Dentists

How to Extract the

&Create a Great Implant Site

money tooth book

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