In the past decade, much attention has been placed on flapless tooth extraction. The concept was developed to minimize the loss of vascularization derived from elevating the periosteum and soft tissues. Since then, clini- cians have explored the concept of “atraumatic” tooth extraction. While the term atraumatic may be excessive (and should likely be referred to as minimally traumatic), the concept was developed to indicate minimal trauma, espe- cially to the labial plate. Tooth extraction should therefore be performed using a relatively atraumatic and flapless approach, ideally involving the use of a periotome, rotary burs, and extraction forceps (Fig 3-4). Radiographic imaging of the surgical site should be used to identify root morphology, surrounding anatomical structures, and bony pathology.A sulcular incision should be performed to initiate separation of epithelial and connective tissue attachments to the tooth surface. Deepithelialization of the sulcular tissue can then be accomplished using either a blade or diamond bur to provide a vascular supply for any necessary soft tissue augmentation.The use of sharp surgical blades will minimize trauma and loss of the gingival tissues. Straight-handle periotomes can be used to luxate the tooth within the depth of the gingival sulcus, which will result in circumferential separation of the gingival attach- ment. Using continued apical pressure, the instrument should be inserted into the periodontal ligament space along the root surfaces to sever the periodontal ligament directly below the alveolar crest. This process is then continued until the periotome penetrates to a depth sufficient to initi- ate adequate tooth mobility for simple forceps extraction. Use of the periotome should be limited to interproximal and palatal areas. Preservation of the labial plate is critical to achieve an optimal esthetic result. Conventional rotary instrumentation as well as piezosurgical burs can be used as needed for ankylosed teeth and fractured subgingival roots. After tooth removal, the alveolar socket is debrided of all granulation tissue. Bleeding is stimulated from the osseous walls through the use of rotary instruments or curettes.This protocol has been shown to trigger the regional acceleratory phenomenon, which stimulates new bone formation and graft incorporation.
Next, the extraction socket should be evaluated visually and tactilely.A periodontal probe can be used to sound the labial, palatal, and interproximal bone morphology. Special attention should be given to direct visualization of the labial plate’s integrity.This examination can identify fenestration as well as dehiscence defects. Labial and palatal plate thickness should also be examined. Ideally, a minimum of 2 mm of labial plate thickness is adequate for implant support without esthetic or functional compromise. A thin labial plate (< 2 mm) can lead to further bone loss, often resulting in partial or complete cortical plate compromise.Vertical bone loss also can be present at the labial and palatal plates as well as at the interproximal bone.
Figure 3-5 demonstrates a failing mandibular right first molar.The molar was first separated buccolingually with a no. 8 round bur. Thereafter, the remaining tooth structure was conservatively removed one root at a time to mini- mize trauma to the surrounding tissues, most notably the buccal plate.
Next, the extraction socket should be evaluated visually and tactilely.A periodontal probe can be used to sound the labial, palatal, and interproximal bone morphology. Special attention should be given to direct visualization of the labial plate’s integrity.This examination can identify fenestration as well as dehiscence defects. Labial and palatal plate thickness should also be examined. Ideally, a minimum of 2 mm of labial plate thickness is adequate for implant support without esthetic or functional compromise. A thin labial plate (< 2 mm) can lead to further bone loss, often resulting in partial or complete cortical plate compromise.Vertical bone loss also can be present at the labial and palatal plates as well as at the interproximal bone.
Figure 3-5 demonstrates a failing mandibular right first molar.The molar was first separated buccolingually with a no. 8 round bur. Thereafter, the remaining tooth structure was conservatively removed one root at a time to mini- mize trauma to the surrounding tissues, most notably the buccal plate.
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