Surgical Extrusion Technique Update – Alternative to Ortho Extrusion or CLS – PDP249

[Teaser]
So what I’m referring to here is that the most sophisticated and complicated solutions are not always the smartest one. It’s not about most expensive. It’s not about most advanced. It’s not about most complicated. It’s about the best possible for the patient. We must keep that in mind that there is no such thing as a master key that opens up all of the doors for us.

Surgical extrusion, over the years… it actually was presented to dentistry in the early eighties. They were really trying to work on surgical extrusion. And guess who comes out? I have done over 200 cases with a follow-up of up to six, seven years. That is something that you can rely on. In such cases, I take out the tooth and rotate it and put it back in.

No way.

Jaz’s Introduction:
Yeah, so you have a retained root and you think this is hopeless and you’re headed towards an implant, denture, a bridge or whatever. But then this episode comes along and reminds you about the power of the surgical extrusion technique. In plain terms, you are partially extracting the root, and now you have the most important thing in restorative dentistry. You have ferrule, you have tooth structure, you can now crown. Whereas before everything was subgingival and it was impossible to restore.

Hello, Protruserati, I’m Jaz Gulati and welcome back to your Favorite Dental Podcast. This is the podcast where you make dentistry tangible and make you fall in love with dentistry again.

Four years ago, with Dr. Peter Raftery, the endodontist, we spoke about this very topic, the surgical extrusion technique. I’ll put that episode in the show notes ’cause that was really valuable as well. But in this episode it is special because it’s an update from someone who’s done more than 200 cases.

So what he believes, and what I also believe, is he is the most experienced clinician in the world when it comes to the surgical extrusion technique. I haven’t seen anywhere in the literature the kind of numbers that he’s done—so, so much.

We can learn from Dr. Vala Seif from Iran, and Protruserati, you’re gonna absolutely love him, right? His storytelling, his analogies. I actually really geeked out and had a great time, and I know you’re gonna love him. Even all the way to the end, the last few seconds, he still gave another tip of how to stop bleeding when you do this technique so you can then add your composite splint to secure the root. He’ll give you that right at the very end. So make sure you don’t miss any of this episode.

Dental Pearl
Now, every PDP episode I give you a Protrusive Dental Pearl. This one’s an occlusion conceptual one, a biomechanical one when it comes to restorative dentistry, but it’s also very relevant to this episode ’cause a really cool, fascinating technique was advised by Dr. Seif, which I really am excited to share with you.

So firstly, conceptually, the pearl I’m giving is to remember the following: that when you have supragingival structure all the way around 360 degrees, we call that the ferrule. Something a crown can grab onto, and it’s important that this ferrule is as tall as possible vertically—ideally two millimeters plus—but it’s also important that the tooth structure remaining is thick because if it’s very, like, if it’s paper thin, that’s not really a ferrule, that’s not really contributing biomechanically.

Now the conceptual pearl I’m giving to you is to think about the position of the ferrule. If you have three millimeters on the palatal side and one millimeter on the buccal side, then this is still pretty good, especially for upper teeth, because the location of the ferrule is actually really important.

Think of the way that the upper incisors are loaded in a class one and class two patient. When a patient is chewing, the palatal of the upper incisors is taking load in clenching, is taking load in mastication and chewing as the food is pushed into centrals, and as you are cutting and incising, the crown is kind of going in a buccal direction.

The tooth, the crown of an upper incisor, is heading in a buccal direction, and so it is trying to grip onto that palatal tooth structure. And in a lower incisor, the buccal part of tooth structure is gonna be under more strain because the lower incisor is trying to bend inwards.

So why is this important? Well, pragmatically speaking, if you have a scenario where you’re trying to restore a canine and you’ve got lots of tooth structure palatally and not very much tooth structure buccally, then probably you’re gonna still be okay because that palatal tooth structure for an upper tooth, that’s usually more valuable and more precious. It just helps us to remember how teeth are loaded in a biomechanical way.

Now, the absolutely fascinating thing that Dr. Vala Seif spoke about is: let’s say you have a scenario where we have a retained root, like a crown–root fracture, and let’s say you have loads of tooth structure buccally but you don’t have much palatally for an upper incisor. Remember: upper incisor, we want more palatal tooth structure.

Well, the fascinating thing that he spoke about is: let’s say you do the surgical extrusion technique. You partially extract this tooth out, and so now you’ve got more tooth structure to work with. And don’t worry, the entire protocol will be broken down in this episode. But the thing he said which really wowed me was: okay, you have this scenario.

But how about now? You partially extract it and then you basically twist it 180 degrees, and that’s the new position of this tooth. Suddenly you’ve gone from a situation where you had a lot of buccal tooth structure and not much palatal, to now rotating the tooth 180 degrees, and so now you’ve actually created ferrule palatally for this upper incisor.

I thought, wow, that’s really clever, because guess what? The PDL don’t care if it’s the buccal or the palatal. The PDL don’t know. The healing mechanism will still be the same, but now you’ve gained a biomechanical advantage. So thank you, Dr. Vala Seif, for sharing that, and I wanna just talk about it because it was just so awesome. It blew my mind.

So, dear friends, let’s check out this main interview. I know you’re gonna absolutely love it, and I’ll catch you in the outro. Don’t forget to pay close attention so you can get 80% on the quiz to get your CE credits.

Main Episode:
Dr. Vala Seif, thanks so much for joining us today. Where are you from? Where are you speaking from?

[Vala]
Thank you very much for having me. I’m very glad to be here today. I’m based in Tehran, Iran, and obviously I’m from Iran.

[Jaz]
Well, I appreciate you joining me. I try and think, have I had any guests from Iran before? I don’t… yeah. I’ve got lots of Iranian friends. I love Iranian food. I love you guys’ food. You know, my favorite thing ever to see on TikTok—like my TikTok, I rarely go on TikTok, but when I do, I just see that the algorithm knows what I love so much. It’s like that giant, giant rice dish that you turn upside down and you take off. Like is that an Iranian thing?

[Vala]
We do have something similar, but what you’re referring to more sounds like Arabic food. But you actually can find a lot of similarities between the food that we are making in Iran and Arabic countries, and obviously even Pakistan and India. So the taste is very close. There’s a good chance that you’re referring to.

[Jaz]
Man, I love it. I mean, Indian food, I love biryani. But when I see the—

[Vala]
Oh, I love that too.

[Jaz]
— the Iranian cuisine and the kebab and stuff, man. I’m a big fan of that. But it’s great to be speaking to you from Iran.

[Vala]
Thank you, sir.

[Jaz]
We’re talking about surgical extrusion today, so very excited about that. But just give us a bit of a background on yourself. Are you restorative dentist? What is your background? What are your passions within dentistry?

[Vala]
Sure.

[Jaz]
How did you fall to get to the stage where you’d like to talk more about surgical extrusion?

[Vala]
Yeah. Alright. I have been working as a… I got into university in early 2000. So basically I’m a graduate of 2008. So over 25 years—almost 25 years ago—I got into dental school. So after that, I actually completed a course in a master by research in oral surgery. And then I am a former resident of oral and maxillofacial surgery. For some reasons I had to stop the training for family matters, and I have been in private practice for the past 15 years, almost.

[Jaz]
And what do you love? What aspect of oral surgery do you enjoy the most? Is it wisdom teeth? Is it implants?

[Vala]
Area of interest is cosmetic dentistry and implants. So basically in my clinic I’m working on ceramic and porcelain veneers and also implant dentistry. But my passion for surgical extrusion started about seven years ago because I always had the problem with extracting teeth. Not a problem technically—ethically, basically. So that was when I was exposed to surgical extrusion because it’s actually a very forgotten type of treatment in dentistry. And I was very glad when I realized that you also shared the same passion as I have for surgical extrusion because it’s going to save millions of teeth probably if it becomes—

[Jaz]
It was approximately seven years ago when I came across it as well. I think that’s when some of the research, some of the Italian people were talking about it a lot more. And now recently I’ve been on orthodontic extrusion course actually, so that was wonderful. By Dr. Guido—Guido Fichera—I’m probably saying his name wrong. I mean, what a genius guy. And so that was really cool to learn how to use brackets to rapid orthodontic extrusion.

But you know what, in real terms, to have the materials, to have the patience, to have the technique to be able to do orthodontic extrusion… whilst when you compare to surgical, I do think it does have a lot of benefits doing the orthodontic, but it’s not accessible to every single dentist, right?

[Vala]
Correct.

[Jaz]
It’s more difficult to get by, and a lot of patients will not accept having brackets of any form, so I do like the more instant, if you like, potential of surgical extrusion. So I guess the best place to start is: define. Let’s define. What is surgical extrusion? And then when we go from there, we’ll talk about, okay, what were the earlier ways—seven years ago, ten years ago—they were doing it, and what changes may have happened? And I’d love to obviously learn about your protocols, but let’s start with that. What is surgical extrusion technique?

[Vala]
Alright, Dr. Jaz, I’m pretty sure this is going to be a wonderful chat between you and me because I have a lot to share with my colleagues. The first thing is we look at surgical extrusion from two different angles.

One is technical, the other one is ethical, or basically the philosophy behind doing surgical extrusion, right? So number one, technical, is that you are going to, through a very delicate surgery, you are going to reposition the tooth more coronally in order to have sound tooth structure with a 360-degree ferrule, as well as doing it in such a way that you are preserving gingiva and PDL and bone altogether.

And the reason that I’m a very big fan or defender of this idea is that many, many beautiful, great articles that I can share with you later are referring to this fact: that if highly damaged teeth get properly treated and correctly maintained, they are always going to outlive implants. So body is going to outperform titanium in any given circumstances.

[Jaz]
I totally agree. And I think implants are not the panacea we once thought they could be. And we are seeing so many more complications—peri-implantitis. Implants are great when you have a gap and there’s no other options. But when there’s one more chance—and then we’ll talk about case selection later—when there’s one more chance to work with nature, in a modified way, I guess, in enhanced way…

Then let’s take that, because it’s so much better to have an implant when you’re 50 or 60 than an implant when you’re 30. And I don’t think any—even the most astute implantologist in the world—will disagree that for their own daughter, for their own mouth, they’d like to save their teeth for as long as possible.

[Vala]
That is very true. And that’s when the philosophy behind a treatment comes up. Let me put it this way. May I give you two simple examples? That is going to help us understand this philosophy better.

You know that when NASA engineers were trying to send man to outer space—this is a funny story, it’s an interesting story—they were trying… there was no gravity. They were trying to make sure that they were gonna find a way to… when the astronauts were trying to write down the information necessary, there was no gravity so the ink could not flow to the tip of the pen.

So there was a project—thousands of dollars—they were trying to spend to make a pressurized pen. And I’m sure you know how the story ended, right? The Soviets used a pencil.

And I’m going to give you another, really, I’m gonna give you another example. It happened in my country many years ago. There was this company; they were making very nice chocolates and exporting it to the European countries. And there was a small problem. This was actually happening around 50 years ago, 40-plus years ago. And the small problem was this: some of the chocolate packagings were actually empty, so the machine was doing the packaging but there was no chocolate inside.

So there were some complaints and the board of directors sat together and they were deciding… they were trying to find a way to solve the issue. There were devices to detect the faulty packages, to get them out of the lines and everything. And one day, the board of directors were actually walking through the factory to locate a designated area for the machines, and they realized one of the very old workers of that company who was there for so many years, right in front of the rails that take the packaging to put in the boxes and everything, he actually put up a stool with a fan.

So the fan—the air that was flowing toward the empty packages—because they were very light, there was no chocolate inside, the empty packages were flying away. And the board of directors were actually very surprised by the fact that they were ready to spend thousands.

So what I’m referring to here is that most sophisticated and complicated solutions are not always the smartest ones, are not always the best ones, are not always the… because as dentists, we are trusted that we are coming up with the best decision for the patient. It’s not about most expensive. It’s not about most advanced. It’s not about most complicated. It’s about the best possible for the patient.

So we are working in patients’ best interest. Surgical extrusion… I’m not against implants. Please keep that in mind that I am a big fan of implants. It is one of my passions. I do implants every day in my practice. Sometimes implants are miracles. But we must understand one thing: if we are having weapons in our arsenal, if we are having tools in our toolbox in dentistry—veneers, onlays, inlays, implants, surgical extrusion, bone grafting—we must keep that in mind that there is no such thing as a master key that opens up all of the doors for us.

We must keep that in mind that each and every one of these tools are going to be great for us and for the patient if the case selection is correct, picking up the right tool is correct, applying it is done correctly, and at the end of the day, we are having promising long-term results that we can completely rely on. That’s the fact.

[Jaz]
That was so eloquently put. I absolutely love that—there’s stories that you weaved in there to really drive home the point there that we don’t need complicated solutions. Sometimes we need to look to simplicity.

And so you led very nicely to case selection as well. So which teeth, where in the mouth is this technique suitable? And there must be some radiographic markers of predictability. There must be some clinical markers of predictability. Do you mind just going through: which is the ideal case for whether it’s your first case, your 500th case—universal principles to adhere to?

[Vala]
I have worked on over 200-plus cases. It’s not 500—

[Jaz]
Two hundred is a significant amount for a very niche technique like this. That is a lot. You’re probably up there in the top five in the world probably who’s done this technique so many times, in my opinion, based on… it’s to actually find the case. That’s like sometimes you’re trying to find the perfect case to do this on, and then you have to wait for that case to walk through. To get 200 is a significant number.

[Vala]
Dr. Jaz, I’m very honored to say this: based on the searches that I have done through literature, actually this is the biggest data set in the world. I’m really honored to say that no one has done this before, because if you browse through all of the articles that have been published before, many of them are actually just case reports.

The biggest ones that I have come across are 50-plus or near 60 teeth. The rest of them were 10, 20, 30 cases. And normally there is no follow-up for the long term, but because I had enough time and I have done it in my practice—and these are the patients who are always showing up to make sure that everything is okay—in a university setup it is different. Sometimes you cannot call the patients back. But I have done over 200 cases with a follow up of up to six, seven years. That is something that you can rely on.

Anyhow, back to your question. Case selection is extremely important, because if the case selection is not done properly, you are actually getting ready for big failures. As there’s this idiom: if you fail to plan, you’re planning to fail.

So basically number one is: we need to make sure that, number one, the root length should be proper. Meaning after you have done your extrusion, after you have removed the decay or the fractured part, you need to make sure that after everything is done, the crown–root ratio of one-to-one is going to be there. That is number one.

[Jaz]
So what we’re looking for is that, by the end of it, you’re not having a crown that will be longer than the remaining root. So the first thing that comes to mind is someone who’s already had orthodontic resorption would then be a bit more difficult, and also someone who’s had periodontal disease. So whether they’ve lost the bone or whether they’ve lost the root from the apex—i.e., the resorption—or they’ve lost the bone from perio.

But usually these perio cases are not the ones that will come in your clinic with the fracture at that level because usually the mobility cushions it and all that weakest link theory. So yes. Okay, that’s a good point. So one-to-one is obviously… if you’re better than one-to-one, if your root is longer than the crown, that’s better. But bare minimum one-to-one. That’s a very good starting point.

[Vala]
Alright. If we want to go—let’s put it this way—if we want to look at the indications of doing this treatment: number one, some of the teeth, actually many of the teeth with… they say severely decayed, non-restorable teeth. So that is number one. Number two is crown–root fracture. Number three is even external resorption.

Alright. These are the cases that I have done and it worked wonderfully.

So when you want to pick the cases: crown–root ratio is important. Number two is: you don’t have to have active perio problem. Number three is: you don’t have to have active infection. We’ll get there.

Number four is—this is done especially to the colleagues that are going to start doing this for their patients—it is important to know that this extrusion works best for single-rooted teeth. Alright. And when it comes to morphology of the root, we must understand this: in order to be able to extrude the tooth properly, the shape of the root has to be conical. Otherwise, if you have a curve or you have hypercementosis, it is very difficult to get the root out. So it’s not going to be atraumatic. So if you cannot do it atraumatically, please don’t do it because we are negotiating with the body to talk the body into accepting something again.

And these are the important parts when you want to pick the cases. And obviously if we go further, I’m going to explain how we deal with infection and other problems.

[Jaz]
Okay. It’s the—classically—it’s central incisors, lateral incisors. The only thing I probably mention here that you haven’t mentioned yet, and something that with your experience you’ll know very well, is just a marker of predictability and success for the future could be some occlusal factors. Because if the patient—for a central incisor—if the patient’s very class three or class two div 2, a deep bite, then already… yes, you extrude the tooth, but you’re extruding the tooth in a mouth which is gonna be putting a lot of biomechanical loads as well.

And so therefore, pre-restorative orthodontics. But then if you’re doing orthodontics, you may as well extrude orthodontically. So I think maybe just having a good enough occlusion that you do all this effort that is gonna be working.

[Vala]
Correct.

[Jaz]
But that’s like a bigger global thing. Same thing like oral hygiene. You want a patient who looks after, like you said, no periodontal disease, and those are some wider factors. But when you are assessing for the case selection, is it just enough to have a periapical? Or do you feel as though the need for a cone beam CT scan—to do a proper assessment of not only the morphology in three dimensions but to be able to do this treatment with success?

[Vala]
Alright. Number one is yes, CBCT is always helpful, especially when you are coming across a patient who you feel, or you see, that the bone is very thin, the biotype is very thin. So it’s always better to get a CBCT.

However, if you allow me, I’m going to have a very small comparison between surgical extrusion and orthodontic extrusion, if I may. Or if you want to postpone it to the other part.

[Jaz]
No, no. Let’s talk about it because we’re talking about… you gave some case selection. So it’s totally fair to look at the alternatives, ’cause one alternative is: you extract the tooth, you do an implant or denture or a bridge or something. But the other good way to work with biology is orthodontic extrusion.

[Vala]
Yeah. Even if you allow me, we can also bring in crown lengthening surgery so I can explain better to the fellow colleagues how to do it. So please, you guide me which part of it you want me to explain first.

[Jaz]
Let’s do ortho extrusion first, and then we’ll talk about crown lengthening as well. I think that’s a very good point.

[Vala]
Sure. When we are doing orthodontic extrusion—as we have mentioned before—all of these are weapons in our arsenal. It’s not that one is the best and we should throw away everything else. I have done ortho extrusion as well, but for some reasons I find surgical extrusion more efficient and more effective.

Number one is: when you do orthodontic extrusion, obviously it takes time. And if you want to come up with best results, sometimes you need to call the patient for a fiberotomy to cut the fibers. And the other thing is: when you put all of those appliances or the—

[Jaz]
Brackets.

[Vala]
—brackets and everything in the patient’s mouth, it is more difficult for the patient to keep it clean. And sometimes, because of the appearance, patients are not really eager to go for the treatment. And the other thing is: sometimes when you are moving the tooth, the gum and the gingiva are also moving with it.

So at the end—

[Jaz]
But the reason for the fiberotomy that you mentioned is to minimize that, to reduce that. There are techniques for that. But yes, exactly—quite often a complication if you don’t get the protocol just right, or particular biotype, then you get the migration of the gingiva, which you don’t want because you want the ferrule, you want the tooth. You kind of want a pure extrusion without the dentoalveolar complex to come with it. So you have the pure ferrule. But yeah, sometimes it may not work fully that way.

[Vala]
Exactly. Especially if the patient is not fully cooperative. You may need to do an additional surgery. And the other reason that we are doing fiberotomy is because there is a chance of relapse to some extent.

[Jaz]
Relapse—I’m just saying for the listeners—is what we mean by relapse here is: relapse, i.e. intrusion of the tooth. Once you do orthodontic extrusion, the tooth will go back in. But also, sometimes you extrude but then the gingiva will just come down thereafter, which again—you don’t want to lose all that space that you gained.

[Vala]
That is very correct. So when you are trying to do it with surgical extrusion, it is done in one session. You get the results almost immediately and it’s much faster. You are sure that if you do it in an atraumatic way, nothing else is gonna come down with it—not the gingiva and the bone.

In terms of how it looks in the patient’s mouth, the patient is actually—in my experience—they accept it better. And one more thing: as compared to other treatments, like removing the tooth and replacing it with something else… in my experience, it is very interesting, Dr. Jaz. The patients are much more cooperative and thoughtful with keeping it clean because they see it as their last chance.

Emotionally, they don’t want to lose a tooth. So when you are giving them the warning, “Hey, this is the last bullet in the magazine, so please help me help you,” they’re very cooperative. So yes, I think for the reasons that I counted, surgical extrusion works—in many cases—works better.

[Jaz]
I get the patient aspect, especially for those who don’t want to go through a longer, regular recall for fiberotomy and the brackets and stuff. So I think it’s a very viable alternative for sure.

And then, with crown lengthening, it’s easy to say that with crown lengthening you are removing bone. Quite very often you are removing gingiva. And then therein lies the issue whereby now if you have the gingival zeniths that are even, now one tooth will migrate up and then you have to do it all together. And so there are some surgical considerations and complications there. Anything else you wanna add to crown lengthening as a disadvantage?

[Vala]
Yes, sir. Absolutely. Dr. Jaz, when we are doing crown lengthening surgery—especially in cases that are high lip lines or the ones who have a gummy smile—a big issue is this: you are going to have a long, whitish, ugly crown that most of the patients can’t live with.

So that is number one. Number two is: you’re gonna have probably dark triangles. Number three is: it is very difficult to keep them clean. So here comes the issue: when you have food getting stuck there, there is a chance that cavities or gum problems start again for the same tooth or the adjacent teeth.

So now you are facing a new challenge. There is a risk for perio problem or new cavities in this area.

And the things actually don’t stop here. I am trying to bring your attention and all of my colleagues’ attention who are viewing or listening to us to this matter. Let’s say—God forbid—one day you have to take that tooth out. What is going to happen? Obviously you are going to put an implant, right? What was the previous problem? You had a long, ugly, whitish crown and you couldn’t keep the area clean. So it’s either putting an implant there and redoing the whole scenario.

So at the end of the day, the same thing is gonna happen. The implant is going to have peri-implantitis, whatever. Or the adjacent teeth are going to face the problem. Or you are going to have to rebuild everything that you had removed before.

[Jaz]
So it’s removing the precious bone, and now you’ve lost it when you… yeah. You’re lost now in terms of this scarce resource.

[Vala]
That is very true. So I believe that surgical extrusion—for the very same reasons that I just explained—I believe that surgical extrusion is the treatment to go in cases like this.

[Jaz]
Right. So I think that’s a very nice overview of the alternative options. And so I think what we’d love to know now is: we’ve talked about case selection. We talked about ideally to have a CBCT—would be great—but I appreciate that, from what I’ve seen in the literature, sometimes periapicals are just fine. Especially if things are looking quite straightforward, and not everyone around the world has access to cone beam CT scan.

And so let’s talk about a classical case, and for those who are watching—obviously we’re being very good for the listeners on Spotify, Apple and whatnot. But those who are watching, I don’t know if you wanna maybe share a case and just be descriptive for the audio listeners for when we talk about the protocol. Step one, the patient comes in, presentation, this is what you say to them, and then that’s what you do. And then how many weeks—all the nitty-gritty details.

[Vala]
Sure. But before we go to that, part of your question was left unanswered, if you allow me to answer to that part. You were mentioning occlusion. Alright.

[Jaz]
Oh yeah. You’re such a great guest. You know that? You are an amazingly clear guest. Thank you so much.

[Vala]
I appreciate. Thank you. Thank you, sir. So what I want to point at is this: obviously you do implant in your practice. So when you want to do implants—especially in practices that the same doctor does the surgery and does the crown—the best way of doing it, we all know, is that it’s not surgically driven. It’s prosthetic driven in terms of putting the implant. Am I right?

[Jaz]
Mm-hmm. Yes, absolutely. Restoratively driven, basically.

[Vala]
Yes. So basically, Dr. Jaz, it’s kind of a reverse engineering. When I want to put implants, this is what I do: I’m going to try to imagine this: “Okay, this is where my crown needs to be in order to be beautiful, in order to be able to get cleaned very well, and in order to withstand all of the forces of mastication that are going to be applied on this tooth.”

Am I right? So the same thing happens with surgical extrusion. Please note this: surgical extrusion is not extracting a tooth. Surgical extrusion is not a simple extraction. Surgical extrusion is a very technique-sensitive surgical treatment. You are not just going to take the tooth out and put it back in and then, okay, boom, the crown comes on and everything is solved.

No. Same reverse engineering is going to happen. You have to keep that in mind, especially when it comes to front teeth, Dr. Jaz, because when you look at, for example, if you look at a central incisor—the upper one—or the upper canine, the tooth comes out of the gum and then there’s a divergence, and then it comes back, and the tip of the tooth becomes smaller and smaller. And the root is actually very thick.

So if you do not consider the occlusion or the bite—let’s say I’m having a canine extruded—if I do not adjust the angle correctly, there’s a good chance that a problem in occlusion is going to happen. Maybe sometimes when we are splinting the tooth, we are going to remove the excess and everything… okay. The healing is uneventful. But when it comes to the prosthetic part, then you don’t have enough space to put the crown.

[Jaz]
For someone here like—I don’t do implants, right—but I know this much: that if I’m doing an implant for the, let’s say, lower molar, right? Lower first molar. I want to make sure that the implant, when it’s pointing, that it’s gonna be going towards the fossa of the upper molar. You don’t want it pointing too much buccal so it’s in crossbite, or lingual so it’s in crossbite.

So what’s fascinating here is: you raise a good point that yes, when you extrude the canine or extrude the central, the sort of projection that’s gonna take is important to make sure you have enough overjet, enough clearance. It makes sense.

But here’s something I didn’t appreciate: how much wiggle room do you have? How much freedom do you have? So when you do a surgical extrusion, let’s say you surgically extruded three millimeters, right? Or four millimeters—and we’ll talk about exactly roughly how much it ends up being—but when you have it, obviously now the root is gonna be a little bit loose inside the socket, right? So how predictably can you change the angulation a bit more buccal to maybe not be so involved in the envelope of function?

[Vala]
Alright. Here’s the key. As I mentioned before, this technique is done on all of the single-rooted teeth. So we’re starting from the upper central incisors, laterals, canine, first premolars provided that they are single-rooted, or the furcation is very low—very apical—and then obviously second premolar. Same goes for the lower teeth.

So when you are talking about premolars, it’s okay to have the tooth extruded more than 2, 3, 4 millimeters if the root is really long and strong. But when it comes to front teeth, because we have overbite and overjet, you are not allowed to pull it out as much as you think it is okay. If you have two millimeters of ferrule, it should be enough for you. That is number one.

[Jaz]
And I think it’s important to talk about ferrule because we have so many episodes—we have done episodes about post crowns and ferrule and importance. But someone who may be listening to the podcast for the first time: a student, a young dentist… I think it’s really important to spend a couple of minutes to pay respect to the importance of ferrule and how it is one of the most important prognostic factors of our dentistry.

So, can you just tell us about: define ferrule? Which part is the ferrule? And if it’s subgingival and you can grab onto it—does that still… is that still good enough to call a ferrule because biomechanically it’s giving you something? Because some clinicians I see, they’re very strict, that they only see the bit that is supragingival—the clinical crown. They say, “That’s the ferrule. Anything subgingival, consider it not a ferrule.” It’s an interesting distinction.

Whereas I always say that, look, if I can do a vertical crown and go half a mil to a mil subgingival and I’m actually grabbing onto that tooth, that will biomechanically assist me. And I’m counting that as a ferrule very often. But where do you see that?

[Vala]
Dr. Jaz, I am very, very, very careful when it comes to going subgingival. I respect the gingiva and the periodontium a lot, so I really do not appreciate going subgingival too much. Maybe half a millimeter.

But basically yes, when I am doing surgical extrusion, to me ferrule is what is above our sulcus. What is above our gingival level. So yes, to me that is ferrule.

And for the listeners who are probably younger dentists or our future colleagues or the dental students: ferrule is defined as this—the supragingival structure of at least a minimum of two millimeters of the tooth with the thickness of at least one millimeter around the—

[Jaz]
That’s the bit we often forget, right? The thickness. We are all talking about, okay, the vertical ferrule, but we don’t appreciate the horizontal ferrule, right? Because there’s no point in you having a tooth—and we’ve all done this, right—and you think you’ve got two millimeters of ferrule, but actually the endodontic access is so huge, or the caries destruction was so huge, that actually it’s very thin and it’s just… it’s going to snap. That is not serving you in a biomechanical way.

[Vala]
That is correct. And when you forget that, what happens is your post and core is going to have a wedging effect. And then you’re gonna have a root fracture. So all of the effort that you have put in treating something that you were not diagnosing correctly in the beginning is going to end up terribly, and you’re going to—at least—lose your patient’s trust.

[Jaz]
And in your case studies so far of 200-plus cases…

[Vala]
Yes.

[Jaz]
The ideal gold standard will be that you do achieve 360-degree ferrule of two millimeters.

[Vala]
Correct.

[Jaz]
But there are some pragmatic concerns, that sometimes that may not be easy or not possible. And so in some schools of thought—depending on the occlusion—if you have someone who’s class two, a bit more class two, a bit more overjet, then maybe if you are getting a bit of palatal ferrule, maybe you get two, three millimeters palatal ferrule in the way that the tooth broke, but you only have one millimeter ferrule buccally, then maybe this could suffice.

Or do you think that you get such good results because you’re very strict? Like, how strict should we be with this 360 degrees, two millimeters? Because sometimes the way the teeth fracture, the crown–root fractures, you’ll end up with four millimeters ferrule buccally and two millimeters palatally—and that’s great. But sometimes you get three on one and one on the other side. How strict are you, Vala?

[Vala]
Okay, Dr. Jaz, that is an excellent question. I’m going to give you two answers. The second one is going to surprise you. I’ve already surprised you.

Alright. Number one is: you are absolutely correct, sir. In so many cases, for example, you are having a very deep cavity on the surface of the root and you remove everything and then you extrude, and then you realize that, okay, you cannot extrude more than this and you cannot achieve 360 degrees. But you realize that three-quarters of the tooth is going to give you good ferrule.

In that case, I have done so many and, so far—touch wood—they are in the patient’s mouth. Functional, clean, healthy. So yes, there are some flexibilities.

But please, I’m asking our listeners to bear in mind that if you want to start, please start with simpler cases. Just like when we are learning to put filling in patient’s mouth—we are starting with class one, and then class two, and then we go to cosmetic and all that. For implant, same thing applies.

So yes, there is a chance that you don’t achieve 360 degrees—you get three-quarters of a tooth. That is going to be enough.

And sometimes—this is gonna surprise you—sometimes you realize that, okay, if I had ferrule on this side, it was better. Or if I had ferrule on that side and the other side was a part of our casting post, it was much better. In such cases, I take out the tooth and rotate it and put it back in.

[Jaz]
No way.

[Vala]
Yeah.

[Jaz]
That’s so cool. Okay, cool. That’s like reimplantation. That’s pretty cool. I didn’t even consider that. That surprised me. But I love that because my mind always said that, okay, when you do this technique, you take it out a bit and then, you obviously do the suturing—we’ll come onto that—and then fixation. But I didn’t actually think that, okay, let’s say you have a lot of… for an upper incisor, that you have a lot of buccal ferrule and no palatal ferrule. But actually you want to have that palatal ferrule to resist, and then to do a 180-degree… that’s really clever. I like that.

[Vala]
Yeah. And sometimes—this is one more thing I need to talk about because there’s a chance that I forget—it’s not… sometimes when you are trying to extrude the tooth, you don’t need to do a full extraction. Especially if the tooth has not undergone endo treatment.

So you just try to take it out, and once you reach that ferrule, just leave it.

[Jaz]
Yeah. That’s what’s going to be your air-time, right? Your air-time is zero. Right? So every time you take it out, now it’s exposed to the environment that is coming against you. But I know that, like you said, if you’re going to do the 180, then you can take it out, inspect it, make sure there’s no cracks, that kind of stuff, and then put it back in. But I think you’re going to give us some nuances now.

[Vala]
Yeah. That is very true. What I wanted to refer—I wanted to point out—is normally, if you have a tooth that is having a severe decay but has not undergone endo treatment, you just need to pull it out a little bit, get the ferrule, and that’s it.

But if that tooth has undergone endo treatment, you need to do a full extraction. Take it out, do a complete careful visual inspection to make sure that there is no perforation, there is no crack whatsoever, and then you can put it back in. This is something I didn’t want to forget.

[Jaz]
Okay. Yeah, excellent point. Okay, lovely. I’m enjoying this so far.

Okay, so now let’s talk about the clinical protocol, because the question that will come is: okay, let’s say in the non-endodontically treated tooth, obviously it’s more than likely gonna be necrotic—it’ll need the root canal. But when you do extrude it, and you don’t need to take it all out all the way because there is no existing root canal, what are the different methods of fixation and stabilization? How long should you wait? And ideally, before in your protocols—before you do the root canal—any considerations that you need to do?

Like, sometimes you may even think that if you have pulled the tooth out and maybe it’s come out fully by accident in that moment in time, maybe you should get the ruler and get your perfect working length at that moment in time and put it back in. I don’t know if you’ve ever done that, but I’ve heard that one before.

But we’d just love to know the waiting times, the loading protocols, the temporization. Are antibiotics necessary? Last time I asked this question to a lecturer, he said, “No, we don’t think antibiotics are necessary.” However, someone else once I asked said, “Yeah, I just give antibiotics,” and I don’t know where you lie in your protocols.

And I think we can learn a lot, because something that one of our mentors, Lane Ochi, taught me is: you can have all the in-vitro studies in the world, you can have 500 simulations of this technique, but the one case study that you do—just the one clinical case study—is worth a thousand times more than all those in-vitro studies.

So your experiences are extremely valid because clinical experience is one-third of evidence-based dentistry, and your evidence is very, very important. So if you say that in those 200 cases you did it with or without antibiotics, or you have some clinical guidelines that you’ve made, that is very valid.

[Vala]
Sure. First of all, one thing that I would love to say here is that surgical extrusion over the years—it actually was presented to dentistry in early eighties—and the problem that it was not very popular, it did not become very popular, was that… try to imagine this: there is a singer, young, very talented, with great future in the music industry, who is going to be presented to the world of music and fans and everything.

But—I don’t know if I call it bad luck or whatever—the same time that this guy is going to be presented to the world is going to be exactly the same time that the fame and popularity, or the explosion of fame, of Michael Jackson happens. So this guy is always overshadowed by MJ. I’m a big fan of MJ, by the way.

So during those days, they were really trying to work on surgical extrusion. Guess who comes out?

[Jaz]
I’ve got his name now, the Godfather of Implants, who passed away a few years ago. I forget his name now.

[Vala]
Per-Ingvar Brånemark.

[Jaz]
Brånemark. That’s the one. Yeah, yeah, yeah. Rest in peace.

[Vala]
The implant. Yeah. Peace be upon him. The implant comes out, and the implant steals the show. Becomes the rockstar. Becomes the new technology and everything. Everyone is screaming and shouting. So this little guy was pushed away.

So here’s the thing—

[Jaz]
But also, you know what? It’s important to mention, Dr. Seif, that a lot of things that become mainstream in dentistry are not necessarily what’s the best for the patient or what’s best for clinical dentistry. It’s also dictated by the market, manufacturers, the industry, because you can’t—industries cannot monetize… they can a bit here and there—techniques to do atraumatic extraction. We talk the Benex, etc.—that kind of stuff, right? They exist.

You can’t sell lots of units of anything or market lots of units. 3M can’t produce anything for… so innovative and different types. So for the industry and the business of dentistry, implants are obviously where the money of research and all the attention and the conferences and education would go to as well. There’s something just worth considering.

[Vala]
Very true. So for the past few decades that here and there they were doing surgical extrusion, everyone was trying to do it in such a way that made sense to them. But after doing 200 cases and having a follow-up of seven years, I have come up with a final protocol. It is called the SEIF Protocol for Surgical Extrusion.

[Jaz]
I love that because guys—because his name is Vala, Dr. Vala Seif, right? Seif is spelled S-E-I-F. So do you call it “SEIF” or do you call it “SAFE”?

[Vala]
Alright. In this case it’s obviously my name, SEIF. But it’s still… it is actually—

[Jaz]
It’s pronounced “safe.” That’s awesome.

[Vala]
Yeah, correct.

[Jaz]
It’s the SAFE protocol. I love it.

[Vala]
Thank you very much. I appreciate it.

So finally we have a protocol, and in this protocol these are the 1-2-3 that we should go through.

Number one is obviously case selection. For case selection we are working on single-rooted teeth. I have done it on lower molars—I’ll send you the pictures. It works really well. It is actually similar to bicuspidization; however, you bicuspidize and you extrude it.

[Jaz]
Okay, so bicuspidization is like a hemisection, right?

[Vala]
That is true.

[Jaz]
And then maybe you remove one of the roots, or do you keep both as two separate units?

[Vala]
Alright. It really depends. For example, one of the cases that I did for one of my friends—it’s been in his mouth for two years now—the mesial root was fine; the distal one was not. So I extruded the distal one and splinted it to the mesial. Once everything was settled, then I did the prostho part.

And sometimes you have to take out both, and then the rest is obviously known to the listeners.

So number one, case selection: it is going to be single-rooted teeth, with conical shape, long enough, because after extrusion you’re gonna have to have a crown–root ratio of at least one-to-one in the absence of active infection.

And number two is atraumatic extrusion. Please understand this.

[Jaz]
Now, before we get to number two, I just wanna cross off a thought on number one.

Sure. So let’s go stage by stage. Okay. The only question mark I have now about stage one—case selection—is: you said no active infection. Okay, but what if you do have infection, but you’re gonna be root-canal treating it anyway, and therefore if it has an active infection but has got potential and structure is looking good, what’s the protocol like? Would you root-fill it? But then the problem with actually root-filling it is you don’t have enough ferrule to put the rubber dam on. So how do we talk about that scenario?

[Vala]
Alright. This is the way I’m going to do it. Normally, postpone endo treatment to the time that I’m sure that everything is healed and reattached.

However, if you have an abscess, if you have any kind of infection, this is what I do: we do the first stage of endo treatment. We put calcium hydroxide, and then we wait for the symptoms to subside, and then we do the surgical extrusion.

Once everything is done and the tooth is reattached to the PDL and the bone and then gingiva and it is stable, we go for the endo treatment and post, core, and the final or temporary restoration.

[Jaz]
That makes sense. Okay, great. I’m now fully happy with stage one, case selection—including the bonus tip of, okay, if you do have an active infection, this is what the SAFE protocol advises. Lovely.

Stage two, sir. The actual—the make or break—the bit where you’re doing it for the first time, you’re a little bit nervous. You’re sweating because everything now hinges on you taking this root out without it fracturing to pieces. Because then, okay, then you have to say, “Okay, yeah, we’re gonna do an implant.”

[Vala]
Yes, that is true. That is very true and that is the very important and the very difficult part because you have to be able—first, you need to be good at doing extractions. You have to have a very expert hand when it comes to extractions, because it is not a normal extraction. When you want to take the tooth out, it has to be done in a very atraumatic way, number one.

So we are talking periotomes. We are talking very delicate forceps. And you mentioned Benex. I also use that, but not in all cases, because if you want to extract a tooth that is hopeless, when you are trying Benex, even if the tooth breaks, it’s okay. But when you promised your patient that “I’m saving it for you anyway,” that one is a bit risky—unless the root is very thick and everything. So, we’ll get there.

[Jaz]
So this is because when you use the Benex, I think something screws inside the tooth, right?

[Vala]
That is true.

[Jaz]
That’s the point where it could induce some weaknesses and propagate a fracture. Is that what you mean—when the force applies?

[Vala]
Exactly.

[Jaz]
Okay.

[Vala]
Not the force applied by itself; when you are screwing the… engaging that screw inside the root—that is going to have a wedging effect sometimes, and then it gives you a vertical fracture.

So the important part when you are taking the tooth out is: you need to make sure that you are not doing it buccolingually. You have to be able to rotate it and take it out. So if you… that’s why we are emphasizing the shape of the root, that it has to be conical. Otherwise you cannot rotate it and take it out.

[Jaz]
So if a tooth… some centrals, they’re in a bit like—not rectangular—but you know what I mean. They’re very wide-ish; they’re not like a pure circle. They’re more like an oval. And that oval one… I didn’t know it makes hearts on the screen if I do that.

There we are. That’s the first time I’ve seen that. I’m loving this so much.

You see? So Vala, you’re saying that the oval-shaped one may be… because you can’t rotate that so well, that’s maybe something to consider as not an ideal root morphology.

[Vala]
No, no, no. It’s not that, Dr. Jaz. If you remember, I emphasized on doing it atraumatically. So atraumatically means minimal manipulation. When I’m asking everyone to do a rotation, it does not mean that you have to—it’s not a watch winding, alright?

[Jaz]
It’s very minuscule. It’s a micro-movement.

[Vala]
That’s meticulously—exactly what you referred to. The word that you picked was perfect. It’s a micro-movement. So please make sure that you’re spending enough time on it. There shouldn’t be any rush.

[Jaz]
How long does it take you—a central incisor—typically from your cases? Obviously every tooth is different, everyone’s different. But someone might think, okay, I’m gonna spend five minutes. Someone else might say, you know what, actually you might say that typically I spend half an hour and I spend my time. How many minutes?

Obviously for the novice it will take longer, but as a guideline, how long is a reasonable amount of time spent on this very crucial part?

[Vala]
Correct. When I started for the first time—obviously I didn’t take any courses whatsoever; I was just trying to self-educate myself on this. However, we are having courses now and I’m trying to teach other dentists.

For the first time when I did this—just like the first implant I placed 16, 17 years ago—it took me one hour and 55 minutes. After 16, 17 years, I do the same thing within 14 to 15 minutes. But I’m not proud of that because we are not setting a record here. We are doing the correct, perfect job for the patient.

Normally for a routine extrusion for me—after doing 200-plus cases over seven years—it takes around 10 to 15 minutes from the start to the end. But two weeks ago I was doing a lateral incisor for a young patient; it took me around 45 minutes to take the tooth out because the fracture line was palatally and very deep.

So I needed to spend as much time as necessary to make sure that I’m keeping this tooth for the young patient who came to my clinic with tears in her eyes saying, “I’m too young to lose a tooth.”

So that comes first. Take as much time as necessary to do the perfect job for the patient. Normally within a half hour you should be done, but for the first cases it goes up to one hour, which is okay. Practice makes perfect. So no rush.

[Jaz]
No rush. That’s the main lesson here. You gotta be so delicate—and no rush. But again, consent the patient that, look, we’re trying our best here, but sometimes the tooth can crack and whatnot, and therefore we always have our plan B but we will try our best. Nothing is promised.

[Vala]
Yes. Yes, correct.

[Jaz]
Has it happened to you before—when you tried to do it and then actually, no, it’s fragmented, it’s broken, and then you’ve had to no longer proceed?

[Vala]
Yes, there was. But one thing is very important, and that is: you must—if you feel that this case is going to be too risky—you must explain to the patient before you touch anything. Because if you are explaining to your patient before you start, it’s an explanation. But if you don’t, and you do the job and something happens that you predicted but you did not inform the patient—if you have all of the explanations, the correct ones in the world, to the patient—it is an excuse. It’s not explanation.

[Jaz]
Absolutely.

[Vala]
So I tell my patient: “Okay, I have done this for so many years; I know what I’m doing. But this specific tooth is too risky. So please understand that I am doing whatever in my power to save the tooth for you. There still is a chance that it fractures, it doesn’t work. So be prepared, because if you go to 99 out of 100 clinics, they would take the tooth out and place an implant for you. I’m trying to save it for you.

“So if something happens, please be aware or understand this.”

[Jaz]
That’s a good way to frame it, for them to understand that if you walk into any other clinic, there’s always still a plan B, and to be a bit more forgiving. So it’s all about adequate conversations before you do the treatment.

Okay. So atraumatic extraction: stage two. Obviously you teach this on your courses and stuff and there’s only so much we can talk about it now. But let’s just, for the sake of completing the SAFE Protocol:

Case selection, number one. SAFE atraumatic extraction, number two.

What’s number three, sir? How do you fixate the tooth?

[Vala]
Alright. There are different ways of doing it. Number one is: they used to suture the tooth. I am not a big fan because to me it is not reliable.

Others—they actually use wire and composite, which is fine. I have done this. But after a while, I started only using flowable composite, which works for me.

But the key here is: do not use too much composite. Because number one is: when you have a bulk of composite there, it is difficult to keep it clean. And the other thing is: we are talking about semi-rigid fixation. Semi-rigid fixation allows you to… it actually prevents ankylosis and root resorption, which are two risk factors here.

[Jaz]
Okay. But I’m just trying to visualize this now. The patient’s gonna walk around with flowable just like tags… like, let’s say it’s an upper left central incisor, some flowable is attached to the fragment and the adjacent teeth next door. So like the central and the lateral. But then that’s not a very aesthetic solution. How are you managing the patient expectations in terms of temporization during this time?

[Vala]
Alright. How are you going to deal with a patient who has lost enough bone to have an immediate insertion and needs bone grafting and soft tissue grafting, and you cannot give the patient an immediate prosthesis?

[Jaz]
Essix retainer with a composite inside or something is a popular choice?

[Vala]
Is that… is a choice, but not all the time you give it to the patient. Because sometimes you have to give the tissue enough time and space to heal.

Obviously aesthetic is a big part of the patient’s expectations, but we must understand that—and we must try to make the patient understand that—it is a part of the solution that we are having. The patient is going to walk around with that tooth for about probably four weeks. So it is much faster than implants in many cases.

So basically, no. My answer is always no to a temporary—unless you give the patient an Essix and the patient’s occlusion and bite allow you to place it inside the mouth and you can relieve around the, for example, palatal part of the root that you have extruded. Not in every case.

Initially I used to give the patient an acrylic temporary crown immediately after I did the extrusion, but I realized that gum healing is not best when we do it. So we really need to talk to the patient before the treatment and discuss everything and say that, okay, this is the healthiest type of treatment that we can do for you, and these are the facts you must understand, and try to help us help you to get the best results.

[Jaz]
Okay, so the no-temporary—while aesthetically is a downer—allows for the best healing and cleansability.

[Vala]
That is true.

[Jaz]
Okay, great. So now we’ve talked about flowable as a fixation. Obviously I’m sure there’s more nuances, other ways to do it. But in the interest of time, what’s the next step?

[Vala]
The next step is removing the splints. So after two to three weeks, the patient comes back in and then we remove the splints.

I’m asking my colleagues to not be terrified when they remove the composite and they realize the tooth is still moving—is mobile. It is going to be okay after a while, because very mild stimulation on PDL is actually good for reattachment and everything.

So after two to three weeks, we remove the splint. And normally after four weeks, I send the patient to our endodontist for endo. And then post and core comes, and then we are going to either give the patient a temporary crown or the final restoration, depending on the soft tissue, because at that time soft tissue may not be perfect. So we’re giving the patient the temporary, waiting for a while, and then we will go for the final restoration.

[Jaz]
Okay, great. And so that’s the full protocol explained, right? That’s all of it.

[Vala]
Obviously, as far as… I don’t remember.

[Jaz]
There’s so much deeper—obviously you go deeper in your education stuff. But as an overview, it’s okay.

Fine. So what questions do I have at this point? Let’s see. So just to summarize: the splint stays on for two to three weeks, the composite splint. Is that fair?

[Vala]
Yes, correct.

[Jaz]
Yep. And then, when you remove the splint, that’s the same time that you have the endo, or you give it a bit more time after you remove the splint but before the endo?

[Vala]
Dr. Jaz, when you remove the splint, the tooth is still mobile. And if you are going to do a perfect endo, we know that we have to put clamps and rubber dam is necessary. Sometimes you can put the clamp on the adjacent teeth, but usually I do not risk applying any force on that tooth. So I always ask the patient to wait for a while, and after probably four weeks the tooth is strong enough. So then we go for endo.

[Jaz]
Perfect. Okay, so now that’s making sense to me.

And then, the last consideration actually is about post crowns. There are some philosophies that if you have enough ferrule, then you don’t need a post, because now our core is being retained by our adhesive system. And therefore we can use the sort of canal space and stuff—or the access cavity area, if you like—to get it.

So how important do you think it is to have a post? Is this like, yeah, in your protocol it always gets a post? And then if so, does it matter for you if it’s a fiber or a metal cast—that kind of stuff. Tell us a bit more about your philosophies on posts, because it’s a very popular question we get from listeners, as you can imagine.

[Vala]
Alright, sure, sure. Absolutely. Number one is: we must understand one thing—that every case might be different from others.

So yes, sometimes for some of my cases, there is no need for a post. So a very good restoration—a buildup—is going to do the job. Sometimes, because the more and more I go into this technique, the cases that I am treating become more complicated.

So yes, most of the times I prefer to go for a post and core. And in many of the cases, I prefer casting posts and cores.

[Jaz]
Okay. It adds a bit more time and extra step, but I appreciate that philosophy, because the more tooth destruction you have, the more rigidity can help you. And basically, people always say about, oh, the fiber post is more retrievable—when it fails, the adhesive will fail. But the way I always view it is: when that fiber post fails, this is a complete disaster. Who’s going to retrieve that? It’s the end of the line.

So why don’t you give something that’s more rigid, and then it’s probably gonna last longer overall? Is that your thinking?

[Vala]
I have retrieved many, many, many posts before.

[Jaz]
Okay. Nice.

[Vala]
Fiber posts, those casting posts, and prefabricated posts—which I call the prefabricated ones the lazy posts. Because in my opinion, when there are better ways of doing something for the patient, you always should do that. I understand that sometimes time matters. Sometimes it’s the cost of treatment and everything. But most of the posts—with proper technique and spending enough time—they are retrievable, unless they have broken very deep inside the root, and then no, we’re done.

But you are absolutely correct. When the post fails, it’s a disaster.

[Jaz]
Fine. So your preference is cast post. I get it.

You’ve answered all my key questions. I’m so happy. I’ve really, really enjoyed it.

Dr. Seif, tell us, how can we learn more from you? Tell us about your Instagram page, about your courses. Are they all in Iran? Or are they around the world? Are they online? Tell us more about that. Because this hour is a really great introduction to the surgical extrusion technique.

You’ve told me you’ll send some papers—please send them to us so we can make them available. But to have absolutely spoken for eight hours on every little point and shown cases and stuff… I think that’s only fair from your education. So tell us more about that.

[Vala]
Sure. Basically, we are trying to connect with other colleagues around the world, especially in Europe, to organize courses which will be announced later.

But in order to have better access to colleagues all around the world—and for them to have access to me—I set up an Instagram page. The name is Extrusion Masters. Yes, in a very humble way, by the way. In a very humble way I chose the name.

So they can follow us on Instagram. I’m going to gradually put up a lot of my cases on that page, along with some good papers. I’m going to have a review on them. I’m going to write my opinion of the way they have done the work—again, in a very humble way.

And also we are having online courses. So for the people who are… for the colleagues that are not able to travel to different countries, or they are too busy, or they want to spend a weekend learning such techniques—it is available very soon again.

[Jaz]
So follow the Instagram Extrusion Masters to find more information about that, right?

[Vala]
Yes. Correct. Correct.

[Jaz]
Amazing. Dr. Seif, I really enjoyed the SAFE protocol and your humility, your storytelling. It was a perfect episode, right? A great introduction to surgical extrusion.

[Vala]
Thank you.

[Jaz]
A great revisit. I know I visited it once before, but it’s really nice to connect again—new colleagues, new ideas around the world. And you answered my questions so nicely. I wish you all the best. I’m gonna put all your links and everything in the show notes, and I really value your time. Thank you so much.

[Vala]
Thank you so much. Really enjoyed it. And I’m really glad that… obviously I texted you many times. I know you are a busy man. But let me—seriously—let me tell you this: the last message I sent to you, I was this close to actually deleting and unsending it because I waited for so long for an answer from your side. But I said, okay, it is worth it to send another text to you because many of my colleagues—and their patients, obviously, eventually all around the world—can benefit from this.

And I would like to add one more thing when it comes to technique, because a few years ago you talked to a colleague who was an endodontist from the UK, and he mentioned something that I… I came up with a very simple solution. It helps all of my colleagues.

Do you remember, when you were chatting with that endodontist, this esteemed colleague mentioned something. He said: “When I want to do the bonding to do the splinting, I’m having a very hard time to do the bonding because the saliva and the blood and everything comes out.” You remember that?

[Jaz]
Yes. Yes, yes.

[Vala]
Alright. The answer to that is very simple, my friend. You just take the tooth out, put it back in, blood is coming out—give it five minutes. Don’t do anything. Just give it five minutes. The bleeding stops. And then you irrigate, and then you can do the bonding without any hassles.

[Jaz]
There we are. Yeah. So actually, how important is the taking out and putting it back in? So let’s say it’s a non-endodontically treated tooth—for the sake—are you saying that for the sake of bleeding, to take it out and put it back in actually is…

[Vala]
No, no, no.

[Jaz]
Is it a secret? Okay.

[Vala]
No, no. The secret is: once you are done with repositioning—whether you are taking it out fully or you are partially taking the tooth out—obviously you’re gonna have bleeding.

[Jaz]
Yep, yep.

[Vala]
Don’t do anything. Leave it there for five, six, seven minutes. Try not to splint and bond and etch and everything. Just give it time. After five, six minutes, once you irrigate and you wash everything, there’s no blood coming up.

[Jaz]
Amazing. You’re the man that keeps giving, man. I appreciate that very much. I’ll have to put that episode in the show notes, let people revisit that as well. But yeah, I appreciate you tuning into that. And thanks for the messages. At the moment sometimes life gets very crazy with the DMs, and I appreciate sometimes that’s the best way people reach out.

But I’m so glad we did get this arranged. I wanna thank manager Alex who helped arrange this and the team. So this was an absolute goldmine of information. And hopefully if you’re in the UK one day, we’ll go out for some food and catch up again.

[Vala]
Absolutely.

[Jaz]
It was very, very lovely to talk to you, my friend.

[Vala]
Same here. I really appreciate it. And thanks for having me. And I hope that we have a chat in the future sometime soon.

[Jaz]
Absolutely, my friend.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. And even right at the end, he gave us that little tip.

The previous episode we did—which was episode 61, four years ago with Dr. Peter Raftery—I’ll put that in the show notes. I’ll put any papers that Dr. Seif sends me. I’ll put the link to his Instagram, Extrusion Masters, so you can see his cases and papers and join his courses and that kind of good stuff.

And I just want to thank him again for being such a wonderful guest. I want to thank you for liking this video, subscribing, or if you’re on Protrusive Guidance—the nicest and geekiest community of dentists in the world—please do drop a comment as well.

And if you’re not on our community, what are you waiting for? We have so many premium clinical videos, webinars, Verti Preps for Plonkers, the whole shebang. It’s there. Head over to protrusive.app to discover more.

We are a PACE-approved education provider, so if you are on Protrusive Guidance, scroll down, answer the quiz, and claim your CPD. You’ve done the hard work—you’ve listened, you’ve learned. Now it’s time to validate with reflection that forms part of your PDP and a certificate that’s valid everywhere in the world.

Thank you again, dear friends, and I want to thank Team Protrusive as ever. I’ll catch you same time, same place next week. Bye for now.