Until about 10 years ago, it was common practice to reflect a flap and excise buccal bone to remove a tooth if more conservative methods were unsuccessful. With single-rooted teeth this meant removing buccal bone to wedge an elevator and/or place a forceps beak on exposed root. With molars, it involved removing bone to the furcation so the tooth could be grasped with forceps or sectioned.

Today, dentists are expected to maintain as much bone around the tooth’s socket as possible. The alveolus is frequently preserved to a greater extent by adding bone graft materials into the socket or augmenting the ridge with special materials and techniques after extraction.

There are techniques and instruments that allow us to remove teeth while conserving as much osseous structure as possible. Below are examples of instruments and techniques you can use for atraumatic extractions and better outcomes for your patients.

Periotomes

	Dr. Koerner’s keys to success No matter what instrument or technique you use for atraumatic extractions, there are a few things you can do to help give your patients the best care possible—which in turn will lead to greater satisfaction in the treatment you provide. These sound surgical procedures include: * Proper hard- and soft-tissue management * A knowledge and respect for oral anatomy * The ability to prevent and/or manage surgical complications * Helping patients feel comfortable and anxiety-free throughout the process
	RELATED CONTENT Courses at the Scottsdale Center for Dentistry Performing atraumatic extractions RELATED PRODUCTS  A. Titan Instruments Periotomes Golden Misch Physics Extraction Forceps Laschal Surgical Inc. Surgical Instruments Catalog

A periotome is a thin, narrow metal blade attached to a handle. Some are double-ended, others have a straight handle that can be gently malleted. This latter type may have interchangeable blades (Figs. 1 and 2). Periotomes are used to sever gingival attachments to the root of a tooth. These attachments can also be severed with a #11 or #12 scalpel blade or a mini-surgical blade. This technique is especially valuable for immediate implant placement.

Periotomes also are used to cut periodontal ligament fibers by pushing into the periodontal ligament space, allowing for easier extraction. Success depends on the blade’s width, the width of the periodontal ligament space, the density of bone surrounding the root, the amount of pressure that can be exerted on the blade and the blade’s strength.

Luxators

Luxators have become the standard of care in exodontia. They look like straight elevators but are applied in the long axis of the tooth into the periodontal ligament space. The tip is much thinner than an elevator and is more like a scalpel blade (Figs. 3 and 4). The tips come in different widths that correspond to the curvature of the root, with the most common ones 3 mm and 5 mm. They are available with curved shanks to facilitate application in the mouth’s posterior.

Because more pressure can be applied, luxators more effectively navigate the PDL and get further apically than periotomes. When in their most apical position (up to half way to the apex), they are twisted to engage and displace the root.

The safest position around a root to engage luxators is more proximally where bone is stronger and often supported by an adjacent tooth. If placed buccally or lingually, they can fracture thin bone.

Mechanical leverage devices

These devices allow clinicians to pull teeth by turning a knob. Two examples are the Benex Bone Preservation Root Extraction System (Salvin and Meisinger) and the Easy X-Trac system (A. Titan Instruments). If the crown is not already broken down near the gumline, it is reduced to only a few millimeters high (Figs. 5 and 6).

The operator must drill deep into the root and secure the drill with a ratchet (Fig. 7). After fabricating a “fulcrum” with a quadrant tray and impression material, the device’s fork end should be positioned under the drill’s head (Figs. 8 and 9). By slowly turning the knob, coronal pressure is applied to the drill’s head. When the periodontal ligament is stretched to the breaking point, the tooth breaks free and can be removed with the operator’s fingers (Fig. 10).

More effective forceps

Before the apical retention forceps, 150 and 151 forceps had not changed for 200 years. The new forceps feature wider, less pointed beaks, providing a more uniform, solid grip that holds a tooth with more surface area (Fig. 11). Thinner beaks, which feature serrations on the inner surface, make it easy to “re-grasp” the tooth at a more apical level. This lessens the chance of root fracture.

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