Why I Take Teeth Out First and Make Incision Second

I extract all teeth in the arch before I make my surgical incision. 

Cue the “Gasp”?!

I realize that I am in a very small minority, if not a loner when it comes to this technique. 

I did not always perform surgery this way. I used to be like many of you…an incision first surgeon. 

Early on in my career, while watching a much more experienced surgeon, I realized the error of my ways. 

From that day forward, I vowed to leave the herd and take the lonely, but incredibly beneficial path of Teeth First, Incision Second…

Now, after I administer local anesthesia, I proceed to remove each tooth and or root with an elevator and forceps (with the exception of small or fractured root tips, which I get after bone reduction). 

Only after the teeth in the arch are out, do I then turn my attention to the incision. 

For the purpose of this article I will focus on why I prefer this order (and why you should too)...

For a detailed explanation of how I make my incision keep your eyes out for an upcoming article: How I Perform My All-On-X Incision to Create Optimal Closure

Why Teeth First & Incision Second?

There are many perks of removing the teeth first and performing the incision second. Below is a list and explanation of each. 

1. It is easier to make an exact incision. 

In order to optimize closure you will need to remove the interdental papilla, but save keratinized tissue while doing so. I find it much more difficult to do this with the dentition in place. 

Trying to fit your blade in and around the cervical anatomy of the teeth can be difficult. This may lead to incomplete incision depth and subsequent tearing of tissue upon reflection. 

With the teeth removed, you have improved visual and surgical access for your blade.  This creates a simple, repeatable, exact incision with minimal to no tears and optimal re-alignment for closure.

2. The angles are in your favor.

With the dentition removed you are now free to place your hand at whatever angle is optimal for the desired movement and instrumentation.

With the teeth in place you are forced to work with your blade at a 45-90 degree angle. 

With the teeth removed first, you can freely lean the blade handle in any direction without dentition interference.

Furthermore, you can work at a more vertical angle with both your blade and periosteal elevator when beneficial.  

I find a more vertical positioning of the 15-blade and periosteal elevator is better in the following situations:

It allows for precision papilla removal while maintaining keratinized tissue. I often cut down at a more vertical angle onto the alveolar crest instead of at a 45-90 degree angle. This is most often true in the posterior and palatal aspects but can be done anywhere it’s advantageous. 

In addition this technique also lends to a more delicate and efficient flap reflection. I find being able to upright my periosteal elevator vertically and even leaning palatally/lingually into the previous dentition space leads to far less tissue tears and a more efficient flap reflection. This is not possible with the teeth in place.

3. It is easier to make a “straight line” for closure. 

In order to have ideal tissue re-approximation you will want a smooth, straight line of gingival tissue that follows and wraps around the arch. When approximated after reduction and implant placement it should come together evenly. 

I find this very difficult to achieve if the flap is reflected first. In this scenario you are trying to hold the tissue in a tissue forcep and remove the papilla with a blade or scissor at the end of the case. 

While doable, this tends to lead to lumpy, uneven tissue because you are holding the tissue out in space and have lost your reference of the arch form. When reapproximated this incision may have inadequate tissue in some spots, and excess tissue in others. 

In comparison, with the teeth removed, papilla removal at the time of incision can be easily accomplished. This is more efficient and exact.  

With this technique, my goal is a very straight, smooth line of facial gingival tissue (with as much keratinized tissue as feasibly possible).

While I also want as smooth and straight a line of palatal tissue, note that it is normal for the facial tissue to be “straighter” than the palatal tissue. I do remove the palatal papilla but let the remaining tissue follow a somewhat natural contour.  Why? Too much removal of the attached palatal tissue can make primary closure difficult.  

4. Less bleeding. 

We all know that the epinephrine in our local requires time to take effect. However, we do not always allow the epinephrine time to do its job. This is especially true for those of us who do this procedure under general anesthesia. 

Removing the teeth prior to incision allows us to start our surgery right away – no time wasted. However, the 5-10 min you spend removing the teeth will allow the local and epinephrine to sit in the tissue and exhibit not only its anesthetic effects but its vasoconstrictive effects too. This helps limit intra-operative bleeding. 

In comparison, if a flap is reflected right after local administration you are going to “spill out” a large amount of your local anesthetic and epinephrine. This will not only hinder the duration and effectiveness of the anesthesia, but it will also create more bleeding. 

5. Less swelling. 

The longer your flap is open, the more swelling you will have. 

The less swelling you have, the less post operative pain your patient will have and the easier it will be for your restorative doctor to manage the postoperative tissues and perform the pick up. 

Making incision after you remove teeth probably doesn’t seem like it would make that much difference. But let’s take a look…

As your experience grows you will become more efficient with this procedure. 

It takes me, on average, 45-60 min to complete an arch. 

Let’s assume 5-10 min for removal of teeth depending on difficulty. 

If I make incision after removing those teeth, the flap remained closed for an extra 15%-20% of the case. 

That’s an extra 15%-20% reduction in the total time the flap was open! This is time directly related to edema/swelling. Related to percentage of time, that’s a big difference! 

This is absolutely one of the most wonderful benefits of this technique.  

Well…what are you waiting for? 

Are you ready to leave the herd and head out on your own?

A Teeth First & Incision Second Surgeon…

Matt Krieger DMD 

P.S.

A special thank you to Dr. Nate Baxter for teaching me this technique many years ago.  It has forever changed the way I perform AOX surgery.