Surgical Extrusion Technique – S.E.T. – An alternative to dental implant

Surgical extrusion technique is a dental procedure that we use to save someone’s natural tooth. It is a fairly uncommon procedure due to the fact few doctors know about it. This is unfortunate because it is likely that a large number of teeth we deem unrestorable could be restorable with S.E.T. Krug 2018 found they could save 82% of the teeth sent to them for extraction via surgical extrusion.

Surgical extrusion criteria

The ideal tooth is broken at the gum line and is un-restorable in it’s current condition.  It needs to have a long enough root so that after the procedure the crown to root ratio is not too bad, preferably at least 1:1.  We need a straight single root that doesn’t have periodontal disease.  Hygiene and overall health is also a consideration, as diabetics tend not to have as good of results with this procedure.  We think this is a great treatment for a kid that is too young for a dental implant or someone older that doesn’t need it to last as long.  Surgical extrusion technique is in the literature as immediate surgical extrusion and partial exodontic technique, but the term P.E.T. is mainly a language translation issue.

Perfect candidate for surgical extrusion technique. Too young for dental implant and we were able to temporize his tooth throughout the entire healing process with the use of nylon splinting. The steps and reasons for using nylon splinting are found below.

Is surgical extrusion technique only for front teeth?

No, we can also use this technique to save some back teeth as long as they have only a single root or the roots divide deep within the bone. The image below is a case of a lower premolar that we were able to save using the surgical extrusion technique.

Premolar surgical extrusion technique

Surgical extrusion technique on same tooth as above

Do you need to do a root canal on a surgical extrusion case?

The answer to that seems to be yes as all of the cases that exist in the literature do. However, I feel that for the right case a root canal is not a necessity. A young patient with an apex that is still open may be fine to just monitor.

Pre-op. Immediate after surgery and suture. After temporization day surgery (how she left) – made essix for this case to wear for 2 days and no splinting. Final (day of cementing).

This is the same case seen above and yes I attempted to forgo the RCT. We’ll see how that decision plays out. I would bet against her not needing a RCT long term, but long term for this patient may not be in the cards.

This is Dr. Guazzi Paolo performing this procedure.  He is calling this technique a partial exodontic technique P.E.T.  I like the video.  I like the music too.

What is the cost for surgical extrusion technique (partial exodontic technique)?

We charge $780 (2017) for the surgical portion itself and that includes any temporary that we need to make for the tooth and any splinting. The tooth will still require a root canal, possibly a post, and a dental crown as well. If you have dental insurance it will cover some percentage of the procedure but that will depend on how good your dental plan is. The total cost without insurance from start to finish costs around $3500.

Steps that we take for surgical extrusion technique

• Check probings of teeth in area and the general oral hygiene of patient.
• Gently elevate tooth with the aim of at least 4mm of tooth above the crestal bone
• Suture tight with a horizontal mattress.
• You can leave the tooth free to “self-position” so as not to ankylosis or do a flexible splint with nylon wire (fishing line) as seen below. Others do rigid splinting without apparent issues, Krug 2018.
• No chewing in area, brush normal, and CHX for 2 weeks
• No AB necessary, even if infected tooth.  Can if want though
• You can make an essix to wear at night so the patient does not suck out the remaining tooth and swallow or aspirate it, but that is really not necessary.  Only need any essix made for a short time and only if no nylon splinting was done.
• 1 week healing check and then a 2 month healing check with PA
• Wait 2 months then RCT, post , crown etc

Essix made for safety for first few nights by taking an impression with a pre-form crown in place over the fracture. Must ensure essix is not touching tooth after eruption.

What are the options for surgical extrusion technique temporization?

The temporization technique varies in the literature.  In the posterior you should not do anything except maybe an essix. In the anterior my personal opinion is that you can place an immediate temporary with or without an essix over it OR the you can lightly splint the temporary with nylon fishing wire.  You must be sure that the temporary tooth is not touching any other teeth IP, and also ensure not hitting during bite or any excursions. The immediate temporary I do exactly the same as a shrink wrap veneer temporary. Another method is to bond the remaining tooth to the other teeth IP just be sure to hollow out the tooth so no pressure is on the extruded portion of the tooth.

The final method is to prep a tooth next to the tooth with treatment and make a one unit cantilever bridge. This is obviously only for cases where the other tooth next door needs treatment. This case can be seen in our case of the week posts.

Temporary cantilever bridge for a surgical extrusion.

ADA Dental Code D7290: Tooth Repositioning for Surgical extrusion

D7290 is surgical repositioning of teeth. According the ADA code book grafting procedures are additional. We charge about $780 (2017) for this and that includes the temporary crown that we make as well as the splinting.

Another alternative dental code is D7272. D7272 is tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization). This technique can be thought of as an intra-alveolar transplanted root.

Surgical extrusion technique complications

Like every procedure there are complications with SET. Things can and do go wrong, somethings could be avoided but happen anyway and some things may be unavoidable.

• Complete extraction of tooth.
• Poor healing and/or infection
• Temporary in hyper-occlusion
• The extrusion is excessive

Complete extraction of tooth

The complete extraction of the tooth is fine. Just put the tooth back in and you will not have an issue. The issue comes about if the tooth comes out overnight or at some point while the patient is not in your office. Then you go back to the 2 hour rule for a knocked out tooth. Longer than that then the SET procedure may not be successful.

Poor healing and/or infection

Not much you can do to control poor healing. If you know someone is a poor healer due to alcohol or diabetes then using a CHX rinse may help but sometimes you just get unlucky.

Patient with poor healing and the resulting bone loss. The tissue seen was 4 weeks post extrusion and a CO2 laser was utilized to remove the tissue. This did fix the problem but the resulting bone loss was almost 2.5mm.

Temporary in hyper-occlusion

Hyper-occlusion of a temporary when the tooth is in the healing state will result in bone loss. This is avoidable but things can and do happen. Below I had a patient with an anterior open bite on the day I made a temporary and did the surgery, however when he returned in 2 weeks I found out that he had two bites and the second was hitting very hard on my temporary. In the photo below the tooth was longer on the incisal by about 2mm. From the PA x-rays it does not seem that there was bone loss but there easily could have been. The bottom photo shows just how short I had to make that edge so that he couldn’t hit it in protrusive.

The extrusion is excessive

Excessive extrusion is also avoidable but this can happen as well. The dentist and patient can decide whether to abandon the procedure or try to move forward with a possible compromised long term result. The 1:1 crown to root ratio is not a super strict rule as you must consider age and habits of patient as well.

Long term results and complications of SET

• Ankylosis
• Root resorption
• Failure of RCT
• Marginal bone loss

There is very few reports of ankylosis no matter what the temporization type. The most common issue seen is non progressive root resorption, which is seen in around 30% of the teeth. The other issues are minimal at under 5% according to Elkhadem 2014.  Krug 2018 found much higher rates of marginal bone loss. Although 20% of their teeth show bone loss, it is mostly minor. I only bring this up because it is more in line with what I see as well.

Surgical Extrusion Technique, Immediate surgical extrusion intra-alveolar transplantation, and partial exodontic technique (P.E.T.) are all synonyms.

Depending on the journal you are reading or the language you are reading it in the name of this procedure varies. If you look at the research below the term Surgical Extrusion Technique and intra-alveolar transplantation are the most common, however, many dentists also know this as partial exodontic technique (P.E.T.).

Magnetic extrusion technique is an interesting yet overly complex novel idea for extrusion of a tooth.

Surgical Extrusion Technique, Immediate surgical extrusion and partial exodontic technique (P.E.T.) Research

Kahnberg had a bunch of studies on this back in the 80’s and 90’s including 1- year follow ups. If that link does not work just scroll down to see all of Kahnberg articles about S.E.T.

Tegsjö, a Swedish dentist, has the first cases in publication that I know of in 1978. He refers to this as intra-alveolar transplantation.

Calişkan 1999 Int J Endo

Kim 2004 Int J Perio and Rest Dent

Case report 18 month follow up Lee Dent Traumatology 2015 April

Paolo Gaetani and Paolo Guazzi in EC Dental Science 1.4 (2015): 164-166

Best Practices in Endodontics have a chapter by Chien and Patel on Immediate Surgical Extrusion (I think the word Immediate is redundant)

Systemic review by Das 2013 finds surgical extrusion to be a viable option but notes no RCT exists. A good one would be denatl implant vs. surgical extrusion.

Patient take home sheet after surgical extrusion technique.

Kahnberg artciles about surgical extrusion

1.Surgical extrusion of root-fractured teeth–a follow-up study of two surgical methods.
Kahnberg KE.
Endod Dent Traumatol. 1988 Apr;4(2):85-9. No abstract available.

2.Intraalveolar transplantation of teeth with crown-root fractures.
Kahnberg KE.
J Oral Maxillofac Surg. 1985 Jan;43(1):38-42.

3.Intraalveolar transplantation. (I). The use of autologous bone transplants in the periapical region.
Kahnberg KE, Warfvinge J, Birgersson B.
Int J Oral Surg. 1982 Dec;11(6):372-9.

4.Intraalveolar transplantation of teeth. IV. Endodontic considerations.
Warfvinge J, Kahnberg KE.
Swed Dent J. 1989;13(6):229-33.

5.Intra-alveolar transplantation. I. A 10-year follow-up of a method for surgical extrusion of root fractured teeth.
Kahnberg KE.
Swed Dent J. 1996;20(5):165-72.