Atraumatic extractions-Indications and treatment modalities

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.

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.