What Is the Need for Atraumatic Extraction?
Numerous clinical conditions can lead to tooth loss, such as extensive lesions, periapical pathology, jaw and tooth fractures, and periodontal diseases. Though tooth removal or exodontia may be relatively simple to perform for the dental or maxillofacial surgeon, the most crucial factor for the extraction site's successful healing depends on how the tooth is removed without any trauma (atraumatic removal).
Traditionally and even in many dental clinics today, conventional extraction forceps and elevators are used to rotate the tooth in a buccolingual or labiolingual direction. The elevators are used mesially and distally (proximal surface of the tooth) with a wedging force or leverage effect. The advantage of this conventional method is that the extraction is easier to perform for the clinician but may often cause trauma to the buccal, labial, or lingual plates and the hard and soft tissues. This traumatic effect, in turn, produces disarray of pathologic events like disrupted blood supply, inflammation, and infection of the soft tissue surrounding and present adjacent to the tooth.
Hence the basic principles of atraumatic exodontia or extraction differ from this conventional approach and depend on four significant steps that minimize trauma and promote better healing of the socket area after extraction.
What Is the Need for Ridge Preservation Post-atraumatic Extraction?
The next step that immediately follows the procedure of atraumatic extraction by the maxillofacial surgeon or dentist is the primary prevention of bone loss and protecting the architecture of both the gingiva and the alveolar bone. It is because when the bone loss is pronounced after tooth extraction and without sufficient maintenance of the bulk of periodontium, a cosmetically or esthetically acceptable fixed prosthesis, be it an implant-supported, a crown, or bridge prosthesis, cannot be given efficiently while completing the prosthetic replacement in the patient's oral cavity. It is more true when the maxillary incisors or canines need to be replaced, given that the labial bone is fragile and resorbs very easily and fast.
One more major reason for following atraumatic extraction protocols is that significant resorption can be prevented by avoiding the direct impact on the alveolar bone due to the conventional method of using forceps and elevators and forceful instrumentation. The alveolar crestal height is also easily preserved mainly by ridge preservation, thus maintaining the integrity of the bone.
What Are the Steps in Atraumatic Exodontia?
The generalized steps that need to be followed by dental practitioners are:
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Circumferential Incision - A circumferential incision is given around the tooth, and Sharpey's fibers (the connective tissue fibers that project into the cementum and alveolar bone of the tooth) are removed. The periodontal ligament is severed with the help of a 15c surgical blade and thin periotome instruments.
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Minimal Soft Tissue Reflection - Vertical incisions should be avoided to prevent dimensional loss of the tooth socket post-extraction. The extraction should be performed without reflecting the sulcular tissue or interdental papillae. A minimal envelope flap can be raised if the clinician finds it challenging to extract the tooth without flap reflection.
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Sectioning of Multirooted or Large Crowns - Multirooted teeth like molars can be sectioned into individual units to reduce the fracture risk of the roots, especially if the tooth roots are divergent in some cases. Inverted Y incision with a surgical bur with sterile irrigation is the most adapted method for sectioning of maxillary molars. In contrast, mesial and distal root sectioning is mandatory for mandibular molars.
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Reduction of Contact Areas - The removal path is made more accessible by reducing the tooth's contact areas (mesial and distal points) to be extracted. It minimizes root fracture and mobilizes the tooth.
Flap vs. Flapless Surgery:
Studies and research have demonstrated that the physiologic remodeling of the extraction socket is affected by elevating the flap vs. avoiding the flap elevation and following the atraumatic extraction protocols.
Despite the absence of significant differences in the bone formation within the socket after flap versus flapless tooth extraction, it has been previously suggested that flapless tooth extraction may present clinical advantages such as:
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Periosteum preservation.
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Decreased surgical time.
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Lower patient discomfort.
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Earlier establishment of routine oral hygiene procedures after the surgery.
Why Is ARP or Alveolar Ridge Preservation Necessary?
The advantage of socket preservation techniques consists of the following:
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Soft-and hard-tissue maintenance.
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Preservation of a stable ridge volume.
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Improvement of subsequent treatment outcomes.
Several alveolar ridge preservation (ARP) techniques have been successfully implemented by oral and maxillofacial surgeons that include minimally traumatic tooth extraction like the following:
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Flapless instead of flap surgery.
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Guided tissue regeneration (GTR).
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Immediate grafting of the extraction sockets using particulate bone grafts or substitutes.
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Guided bone regeneration (GBR).
The alveolar process of the bone is a tooth-dependent tissue. Several dimensional changes during socket healing occur unavoidably. Subsequently, the patient's rehabilitation treatment may be compromised because of bone loss or resorption. Although the resorption process is not wholly inevitable, several ARP techniques have been recommended to maintain socket architecture.
What Is Guided Tissue Regeneration (GTR)?
The minimally invasive flapless approach to tooth extraction is known to be a simple and atraumatic method with improved clinical outcomes being reported that include reduced healing time, discomfort, and inflammation. In addition, guided tissue regeneration or GTR procedures, which consist of the coverage of the fresh extraction sockets membrane barrier, have been suggested to prevent epithelial down growth, allowing for both regenerations in a more restrained and protected environment.
Conclusion:
To conclude, for long-term success rates and survival outcomes of the alveolar bone after tooth extraction, atraumatic techniques help the clinician preserve the tooth socket area's architecture, functionality, and esthetics. Also, GTR or Guided tissue regeneration holds a promising future and ARP or alveolar ridge preservation to preserve and augment the alveolar bone.
