Introduction
Atraumatic extractions comprise of those instruments and methods that use vertical rather than translational forces to extract teeth. These procedures primarily make use of devices like physics forceps, luxators and piezoelectric instruments. Newer techniques like endoscopically assisted root splitting are carried out to further enhance the outcome of the procedure.1
Indications
Use of atraumatic modalities for extractions include extractions for orthodontic treatment, extractions to be followed by implant placement, medically compromised patients, deciduous teeth with underlying permanent teeth and teeth which have undergone endodontic treatment.2
Modalities for atraumatic extractions
Physics forceps [GoldenDent, USA] (Figure 1)
It is the most clinically effective and easy to use method which places a constant and steady load on the teeth. This results in build-up of creep followed by release of hyaluronic acid and breakdown of periodontal ligaments. The Physics Forceps operate as an elevator, rather than forceps, using first-class lever mechanics.3 One handle is connected to a bumper, which acts as the fulcrum, which is placed deep in the vestibule. The other handle is connected to the beak, which is positioned most often on the lingual or palatal root of the tooth into the gingival sulcus. No aspect of the instrument grasps the crown and there is no advanced elevation needed. Once the instrument is properly placed, the handles are rotated a few degrees with only wrist movement in a slow, steady and controlled manner.
Luxators: [© Directa]
These instruments have an ergonomically designed handle to facilitate a better grip and thinner, sharper and stronger blades which help in inserting the instrument in the periodontal space with minimal trauma to alveolar bone.
They are categorised into 2 main types:
Luxator Periotomes
Luxator Elevators
Luxator Periotomes (Figure 2)
Luxator periotomes cause significantly less trauma and preserve the alveolar bone socket. They comprise of a fine tapering blade and an ergonomic handle. They act by wedging and severing periodontal ligament fibres and compression of alveolar bone.
Luxator elevators (Figure 3)
Luxator elevators are used in a semi-circular rocking and cutting motion while applying apical pressure. A deeply wedged luxator can also be used to push against a tooth root to assist in tearing the periodontal ligament and luxating the tooth. Luxators should not be used in a prying motion or to apply significant rotational torque. Incorrect use results in damage to the tip. They are not robust instruments, and they chip and break when used in an inappropriate manner.
Endoscopically assisted root splitting
It is employed primarily in the anterior aesthetic zone. The surgeon operates at the 9 o’clock position while watching the operating site on a video screen via Storz -Hopkins support endoscope [KARL STORZ SE & Co. KG] (Figure 4). The crown of the tooth removed using transversal separation at the level of gingiva. This is followed by identification of root canal, enlargement of the canals using Gates’ and Lindemann’s burs and splitting the roots using straight or curved elevators. Implosion technique is utilised in this case by moving bone fragments towards the centre of the alveolus. The root pieces can be removed under endoscopic guidance with root forceps.
Piezoelectric instruments (Figure 5)
These instruments work at a modulated frequency of 24 to 29 Hz and amplitude of 60 to 200 mm/s. The prominent advantage is that they produce a clean and neat cut with no damage to nerves or other soft tissue on accidental contact.4 There is no requirement of stabilising force to compensate for rotary or translational motion as in the case of burs or saws, and they reduce postoperative swelling and trismus.
Powertome (Figure 5)
The Powertome combines the atraumatic extraction advantages of the periotome with mechanized speed. It comprises of a handpiece with a periotome blade that is controlled by a foot switch. The procedure started by placing the blade of periotome in the PDL space interproximally. Keeping the blade parallel to the long axis of the tooth, the blade should follow the contours of the tooth in a sweeping motion, advancing apically in 2-4 millimetre increments.4 It advances easily with minimal hand pressure yielding much faster and less fatiguing results than traditional periotomes. Following use of the Powertome the tooth in question should be gently removed with forceps in a rotational fashion. In some instances, simple suction is all that is required to remove smaller single rooted teeth. Multirooted teeth, on the other hand, may require surgical sectioning to convert the tooth into multiple “single rooted” teeth.
Conclusion
Extractions for orthodontic purposes requiring minimal trauma to the surrounding structures of a tooth, particularly the bone, call for a far more atraumatic procedure than the conventional tooth extraction. With the advent of physics forceps, periotomes, luxators, piezoelectric instruments and root traction devices atraumatic extractions by preservation of the alveolar bone, the socket, gingival architecture and without trauma to the periodontium has become a necessary skill in the repertoire of the general dental practitioner. This facilitates better implant outcomes or better orthodontic therapy. However, one needs to keep in mind the duration required for such procedure and the cost of instruments required. To make dental practitioners embrace these procedures, inadequate literature availability and time limitations remain the biggest constraints.
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