|Year : 2012 | Volume
| Issue : 2 | Page : 121-126
Strategic extraction: An unexampled epitome altering our profession
Saurabh S Patil, Purshottam S Rakhewar, Satish S Doiphode
Department of Periodontology and Oral Implantology, C. S. M. S. S Dental college, Aurangabad, India
|Date of Web Publication||10-Oct-2012|
Saurabh S Patil
7-B, Shivganga Bunglow, Shrirang Nagar, Pumping Station Road, Gangapur Road, Nashik, Maharashtra - 422013
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Tooth extraction socket typically undergoes remodeling and resorption; the resulting ridge deformation may cause severe functional and esthetic problems. Several techniques are available to augment the ridge/socket following extraction by means of soft and hard tissue regenerative procedures with the goal of establishing functional and esthetically pleasing implant restoration sites. However, most of these procedures are technically demanding and thus predicting a positive outcome becomes difficult in the hands of most clinicians. Strategic extraction reduces the need for restoring such challenging ridge defects by providing an alternative in the form of a simple, minimally invasive socket-preservation procedure immediately following atraumatic tooth extraction. This article reviews the rational of ridge preservation following atraumatic tooth extraction in order to minimize bone loss and the different treatment modalities for that purpose.
Keywords: Ridge preservation, socket grafting, strategic extraction
|How to cite this article:|
Patil SS, Rakhewar PS, Doiphode SS. Strategic extraction: An unexampled epitome altering our profession. J Dent Implant 2012;2:121-6
| Introduction|| |
Managing the periodontal environment is a permanent challenge for the periodontist. The periodontium is an entity wherein the superficial periodontium is closely related to the deep periodontium. The alveolar bone partially determines the stability of the periodontal attachment and thus contributes to the periodontal health as far as esthetics and function are concerned. Different techniques and surgical protocols have been proposed to treat bone loss, be it during periodontal disease, after extractions, infections, or trauma, or within the context of placing osseointegrated dental implants.
Immediately after extraction, the socket walls undergo internal and external turnover, resulting in crestal bone loss as well as horizontal reduction. Several investigations report horizontal and vertical deficits of 3.0-6.0 mm and 1.0--2.0 mm, respectively, per site after an initial healing period of 4 months. ,,,, Postextraction disuse atrophy causes a 25% decrease in the width of the alveolar bone during the first year, and an average of a 4 mm decrease in height during the first year following multiple extractions. , Recession and atrophy continue, with the jawbone eventually losing nearly 40--60% of its original height and width within 2--3 years.  After that, an average rate of bone loss of 0.5--1.0% per year for life is expected.  This condition creates implant and cosmetic difficulties. Adjacent teeth shift to fill the void, chewing problems develop, muscular collapse causes facial wrinkles, and placement of future implants or other cosmetic/esthetic dentistry is hampered. These conditions occur regardless of the patient's age, sex, or health.
Various researches as well as early extraction site studies have shown that following extraction, the height and width of the anterior alveolus predictably undergoes a loss of 1--2 mm in all three dimensions. This generally results in a mid-socket depression followed by a remodeling of the crestal socket walls. There are two ways to effectively prevent this disuse atrophy. ,,,,,,,, The first is performing an immediate dental implant after extraction. Due to financial or other issues, however, an immediate implant is not always an option. In these cases, using bone-grafting material is necessary to minimize bone resorption, prevent the ridge from collapsing and preserve the socket for future implants. Achieving optimal results begins with atraumatic extraction.
Strategic extraction originally described the removal of a tooth or root to create a more hygienic environment.  The objective was to enhance the status and prognosis of an adjacent tooth or the overall prosthetic treatment plan; that is, eliminate the high-risk element to improve the overall periodontal prosthetic prognosis. Prosthodontists began using the strategy to extract teeth that did not contribute to the removable partial denture design or that compromised the final prosthesis. Orthodontists expanded the tactic to include extracting healthy teeth in crowded dentitions to achieve ideal occlusion. With the acceptance of dental implants, the concept of strategic extraction in preparation for dental implant merits reexamination.
Atraumatic tooth extraction is a technique that our specialists use to carefully remove a tooth and that dramatically reduces or eliminates the trauma to the tissues preserving the remaining bone around your teeth.
The advantages of the atraumatic tooth removal are as follows:
- Preserves the tissue and bone around the teeth
- Improves the potential of the body to regenerate bone and "fill-in" the socket
- Reduces the risk of infection
- Reduces or eliminates the discomfort after the extraction
- Preserves the natural contour of the gums
- Enhances the esthetics of the final restoration
Immediately after a tooth is extracted, a natural process of remodeling starts where the remaining bone begins to resorb. This process continues for months and years and compromises the esthetics and or function if a tooth replacement is desired. Thus, this technique helps to minimize this problem in two ways, first it will minimize the trauma to surrounding tissues and second, it will comprise a ridge preservation technique otherwise known as "socket preservation" by adding material into the socket that will serve as a scaffold for the bone cells to better repair and heal the socket allowing the jawbone to have the necessary dimensions and quality that are needed if an implant is to be placed in that area.
Maintenance of harmonious gingival/osseous architecture around implant restorations can be a demanding task. Tooth extraction and full thickness/muco-periosteal flap reflection for implant surgery often result in resorption of the osseous tissue, gingival recession, and/or loss of dental papillae. ,, Reflection of a full-thickness periosteal flap compromises the blood supply to the bone and may result in marginal bone loss. , To reduce the effect of bone remodeling at the extraction site, immediate implant placement into fresh extraction sockets has been proposed. 
Instead of the conventional buccal-lingual luxating method, the atraumatic approach employs gentle, circumferential rotation for 30 seconds. This stretches the periodontal ligament and stimulates the release of lysozomal enzymes and bleeding in the periodontal ligament space. This, in turn, initiates a process which begins to dissolve the periodontal ligament fibers and creates a hydrolic pressure in the ligament, further helping to loosen the tooth. Following application of the rotational forces described above, the gingival attachment and most coronal portion of the periodontal ligament are severed around the entire circumference of the tooth. This is accomplished using a thin-bladed ligament knife or periotome [Figure 1], which protects the periosteum from being torn when the tooth is extracted. An additional benefit to this approach is that it permits less traumatic access to the sulcus. When the tooth is sufficiently mobile, it may then be gently removed using a reciprocating rotational movement while elevating along its long axis. No lateral (buccal-lingual) forces are applied until the tooth can be moved superiorly at least 2 mm. This avoids fracture of the root or trauma to the labial plate of the bone. In most cases, a 12-minute waiting period following the first 30 seconds of rotation will release sufficient periodontal ligament enzymes to further loosen the tooth. One has to be patient, permitting this "physiologic" loosening of the tooth to occur. If the tooth cannot be gently removed after 12 minutes, an additional 10 minutes is generally sufficient.
The atraumatic approach to tooth removal employs a modified set of principles designed to carefully preserve the socket bone and the periosteum, which lines it. To predictably achieve preservation of the socket, one must use specially designed, nontraditional instrumentation. From an historical perspective it is interesting to note that the design of extraction forceps has not changed substantially in the last 150 years.
A number of tools and techniques have been proposed for minimally invasive tooth removal including the #15 scalpel blades and periotomes  which are routinely used during the atraumatic extraction procedure. Apart from these instruments, there are some advanced tools like Physics Forceps,  Powertomes, and some novel techniques like the Ogram system, , Easy X-TRAC system,  specially designed for atraumatic extraction procedures.
The principle of biomechanics is the basis for the development of a different type of dental forceps called "Physics Forceps" [Figure 2] and [Figure 3]a-c.
The physics forceps is a dental extractor that uses first-class lever mechanics. It has a bumper on one beak, which is placed below the tooth, usually at or above the MGJ. The other beak is placed on the tooth root in the gingival sulcus. The handles of the forceps act as a lever to rotate the tooth from the socket. Once in position, it is used as a one unit (no squeezing of the handles). A few degrees of rotation facially places moment forces on the tooth, which is held for 60 seconds. Another few degrees of rotation are then applied, and the tooth releases and elevates.
Powertome [Figure 4 ] is nothing but an automated periotome. It combines the atraumatic extraction advantages of the periotome with mechanized speed.
The Ogram System (a specific protocol and instrumentation to use fingertip pressure to minimize the force and surrounding tissue damage) and the Easy X-TRAC system [Figure 5]a, b (to hollow out the tooth with rotating instruments and remove remaining tooth fragments from the inside) both specifically designed for atraumatic extraction are considered to be highly effective compared to the other techniques. They allow a vast majority of teeth be removed without traumatizing the bone, gums, and adjacent teeth (with less bone resorption and postoperative discomfort).
The use of implant drills to thin the root walls provided atraumatic tooth extraction protecting the thin buccal bone  and the use of elastics in bis-phosphonate-treated patients to prevent osteonecrosis of the jaws  are some other methods which are tried and proven effective.
Once the tooth is extracted, the site may heal by repair or regeneration of the bone. Repair occurs when there is injury/absence of the labial plate/<1.5 mm thick bony wall/exudate/gross apical pathology/excessive heat from the drill, whereas regeneration (by secondary intention) is usually seen in tooth sockets with five bony walls. The healing sequence includes inflammation, epithelialization, fibroplasia, and remodeling.
Bone loss following an extraction can have negative cosmetic, hygienic, prosthetic, and structural consequences. Bone grafting into an extraction site can reduce these negative sequelae. , Therefore, ridge preservation techniques are often indicated after tooth extraction.
The methodology which has gained the most universal support advocates the use of allograft or xenograft materials, or composite grafts of autogenous bone and bioactive glass; a resorbable barrier membrane may also be used to maximize the osseous fill of the socket.
According to Misch,  some of the keys to ensure successfully grafting bone into extraction sites include the following: (1) atraumatic tooth removal; (2) asepsis and complete removal of granulomatous tissue; (3) an evaluation of the remaining walls of bone following the extraction and evaluation of the size of the defect; (4) ensuring adequate blood supply to the graft site; (5) graft containment and soft-tissue closure; (6) choice of the appropriate graft material; and (7) ensuring adequate time for healing.
In 1993, Misch and Dietsh  suggested different graft materials and techniques based on the number of bony walls that remained after extraction  [Table 1].
|Table 1: Number of bony walls remaining after extraction and the recommended treatment modality|
Click here to view
A composite graft (used for socket fill surgery in the case of four to five bony wall defect) is composed of connective tissue, periosteum, and trabecular bone (obtained from the maxillary tuberosity donor site using trephine burs) used to seal fresh extraction socket [Figure 6]a-c.
|Figures 6(a-c): The composite graft harvested from the tuberosity area, placed into the socket and sutured|
Click here to view
The layers in the GBR process (used in the case of one bony wall defect) include the following:
- The host bone
- An autograft
- A mixture of DFDB (30%), FDB (70%), and PRP
- A BM and tent screw (decreases mobility of the particulate particles and helps ensure space maintenance for bone to form)
- Primary closure without tension.
The layered approach improves the success rates and decreases the healing time.
Current techniques used for ridge and site preservation include the use of bone graft materials and/or resorbable membranes. Ideally, at the end of the process the area should be filled with vital, mineralized bone. A combination technique using a bone grafting material and a resorbable collagen membrane has been found to produce a consistently preserved alveolar ridge at the site.
The addition of a temporary ovate pontic helps to preserve and develop soft tissue contours during healing. Use of an appropriate technique preserves alveolar ridge anatomy, facilitates prosthetic management, optimizes function and esthetics, and enables the patient to be treated in a shorter time and with fewer surgical procedures.
| Discussion|| |
The greatest challenge in treatment planning is to assign an accurate prognosis and develop a predictable protocol. In the era of evidence-based dentistry, outcome studies have forced us to reexamine our treatment approaches and decide if superior treatment options should be pursued.
As endosseous dental implants gain greater acceptance because of high-success rates, the critical question is whether a tooth with a questionable prognosis should be managed conservatively in a traditional fashion or be strategically extracted in preparation for a dental implant.
The driving philosophy behind current implant/restorative protocols is preservation. The preservation of existing and intact oral structures requires a sensitive and conservative treatment approach. Careful case selection and comprehensive treatment planning are essential for final success. The following parameters must be present in each tooth for optimal clinical success with immediate implant placement:
- Normal dentogingival complex (3 mm from the free gingival margin to the bone crest on the buccal aspect and 4.5 mm interproximally)
- Tooth position centered with the buccolingual bone plates and normal orientation within the arch
- Medium-to-thick gingival biotype
Choosing the best treatment plan for our patients is an important facet of our practice. In general, it would appear that following the precepts of evidence-based dentistry and comparing therapeutic outcomes of implant versus traditional therapies often will result in a decision favoring implant replacement therapy. Sometimes, however, it is known that the best treatment plan is the one the patient will accept.
Currently, one of the main limitations to successful implant placement is inadequate bone volume at the recipient site. One's ability to work with compromised sites has improved with the variety of techniques available for increasing bone volume through ridge preservation, augmentation, sinus grafting, and distraction osteogenesis. , Incorporating recombinant biological modifiers such as human recombinant bone morphogenetic protein and platelet-derived growth factors can enhance bone formation. , Should these recombinant biologic modifiers become an integral part of implant site preparation, this may change how we define the critical time point to implement strategic extraction.
The treatment success in oral surgery, periodontology, and implant dentistry must take into account more precise biologic criteria which include using atraumatic surgical procedures; limiting risks to the surrounding tissue; and improving visibility, hemostasis, and postoperative conditions. Most of the instruments available so far have not met all of these criteria. Nowadays, it seems desirable to have at one's disposal precision instruments tailored to every aspect of periodontal and implant surgery of hard tissues. Moreover, the narrow access to the sites of the oral cavity, efforts by the practitioner, and trauma inflicted on the patient (immediate and mediate postoperative conditions) are difficulties that at present cannot be ignored.
It is extremely important to envision a functionally and cosmetically acceptable tooth replacement and consider ridge preservation or immediate implant placement before the removal of any tooth.
| Conclusion|| |
There is an ingrained tendency for dentists to try to save teeth. This article applying the precepts of evidence-based dentistry would suggest there are many occasions where strategic extraction is an appropriate alternative. In summary, due to the acceptance of dental implants, the emergence of biologic modifiers as potential enhancers of implant site preparation, and the growing reliance on evidence-based dentistry, our profession needs to change our view of prognosis, and its clinical implications for treatment.
When extracting a tooth, the dental professional should consider performing a ridge preservation procedure according to the accepted indications. The knowledge of the various options as well as their pros and cones will help the clinician in providing this kind of treatment, ultimately optimizing the success of implant placement in terms of esthetics and function.
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