The establishment of Atraumatic Tooth Extraction

Originally published in Dental Tribune Latin America

Chapter eight of the book "Cirugía piezoeléctrica. Generalidades y aplicaciones clínicas" highlights the increasing importance of atraumatic tooth extraction. This technique has become crucial with the widespread adoption of dental implant therapy, which depends on proper preparation of the alveolar bone for subsequent prosthetic restoration.

The authors outline the clinical steps involved in performing atraumatic tooth extraction using piezoelectric surgery. This technique simplifies the procedure and yields superior outcomes compared to conventional methods.

Tooth extraction is a surgical procedure routinely performed by most dental practitioners. However, with the emergence of dental implants meticulous management of both hard and soft tissues during the extraction has become increasingly evident.^1,2

Post-extraction, significant dimensional changes occur in the remaining structures due to horizontal and vertical crestal bone resorption. These changes coincide with the progressive replacement of the empty socket by granulation tissue, connective tissue, provisional bone, and eventually, mature lamellar bone.^2,3

Post-extraction horizontal bone loss affects approximately 30% of the buccal plate and 10% of the lingual plate.³ Studies indicate that up to 50% of the buccal plate may be lost within the first year.⁴ These dimensional changes correspond to reductions ranging from 2.6 mm to 4.5 mm in width and from 0.4 mm to 3.9 mm in height at the crestal level.⁵

Pre-existing conditions, such as thin buccal bone plates (< 1 mm), can further exacerbate this situation leading to post-extraction bone loss of up to 1.17 mm in height and 2.67 mm in width. Conversely, thick buccal plates (> than 1 mm) exhibit significantly less resorption, with losses of approximately 0.5 mm in height and 1.17 mm in width.⁶ Additionally, greater crestal resorption has been reported following multiple extractions compared to single-tooth extractions.⁶

Atraumatic tooth extraction refers to the meticulous removal of the tooth, aimed at minimising iatrogenic trauma commonly associated with conventional extraction methods. This approach preserves both soft and hard tissues, fostering an enhanced biological response for bone formation and socket filling, mitigating the risk of postoperative infection, maintaining the natural gingival tissue contour, improving the aesthetic outcome of the final restoration, and providing a more favourable environment for immediate implant placement or alveolar ridge preservation.⁷

Whenever feasible, atraumatic tooth extractions are conducted via flapless techniques, thereby fostering optimal bone regeneration by preventing soft tissue invagination and reducing postoperative gingival recession. Flapless surgical approaches were introduced due to their potential biological advantages, such as accelerated healing and, most importantly, the reduction of bone resorption associated with the loss of gingival perfusion when soft tissues are detached from the underlying bone.⁸ This technique is particularly well-suited for patients with a thin gingival biotype, where it helps to prevent aesthetic complications.⁹

Numerous consensus reports agree that the integrity of the buccal bone plate is the key determinant for a favourable aesthetic outcome, particularly in the anterior region. ^7,10-12

Traditional extraction techniques remove the tooth utilising rotational movements and strong traction, thereby tearing Sharpey’s fibres from the bundle bone. This aggressive disruption of the periodontal ligament and associated fibres results in uncontrolled trauma within the alveolar socket, leading to a more pronounced collapse of the vascular network and subsequent resorption in the affected area.¹³ In contrast, the atraumatic piezoelectric technique allows precise positioning of instruments at the gingival sulcus level. These instruments advance between the root surface and the alveolar socket walls to a depth of up to 10 mm, facilitating the selective severing of only the most apical fibres. This approach enables gentle extraction and preservation of the crestal area, thereby significantly reducing the risk of bone resorption.¹⁴

Beyond its well-documented advantages in generating clean and precise cuts, piezoelectric surgery enhances the operator’s visibility, particularly when working in proximity to critical anatomical structures (e.g. vascular or neural bundles) and/or adjacent teeth exhibiting compromised proximal bone.¹⁵ This improved control helps to prevent iatrogenic complications.^16,17 Furthermore, the technique requires minimal applied pressure thereby reducing heat generation at the surgical site.¹⁸ Bone removal around the tooth is characterised by its minimal and multidirectional nature, a distinct advantage over conventional techniques, which apply variable and unidirectional forces.¹¹

When planning an atraumatic extraction, it is essential to consider key anatomical criteria such as root length, number of roots, and complex root morphology, as well as the presence of coronal remnants, previous endodontic treatment, or ankylosis. In such cases, it is important to highlight that piezoelectric devices offer a wide range of insert designs, which can be selected to match the specific morphology and spatial configuration of the root structure.¹⁴

Figure 1: Single-rooted tooth remnant with extensive coronal destruction and a subcrestal fracture.

Figure 2: Intrasulcular incision around the entire tooth.

Figure 3: Mesiodistal odontosection design using either a cutting insert or long-shank bur.

Figure 4: Initiation of the odontosection emplying a rotary instrument.

Figure 5: Completion of the odontosection using a piezoelectric instrument (B1 by W&H).

Figure 6: Fracture of the root remnant into two segments: buccal and palatal.

Figure 7: Debridement of the palatal fragment performed with the piezoelectric periotome (EX1 by W&H). This fragment is specifically targeted due to the typically greater thickness of the palatal bone plate.

Figure 8: Displacement of the palatal fragment.

Figure 9: Avulsion of the palatal fragment

Figure 10: Debridement of the buccal root fragment. If tomographic imaging reveals that it is very thin, it is recommended to avoid using periotomes or cutting instruments directly on the buccal aspect; instead, access should be gained via the internal borders of the adjacent root.

Figure 11: Displacement of the buccal fragment into the palatal aspect of the alveolus.

Upon completion of atraumatic tooth extraction, either alveolar ridge preservation or immediate implant placement with concomitant regeneration will be performed, as indicated by the individual case.

Figure 12: Completion of atraumatic tooth extraction with preservation of the bony plates and alveolar ridge.