Use of Flexible Periotomes and Conventional Periotomes in Atraumatic Extractions: A Comparative Study ()
1. Introduction
Methods for extracting teeth have remained remarkably static over the decades, with trauma to the surrounding tissues continuing to be a common occurrence. [1] [2] While conventional dental extraction techniques encourage minimal trauma, the use of elevators and forceps in tooth extraction can often result in fracture or alteration of the dentoalveolar socket. This trauma usually could result in some type of post-extraction ridge defect. These defects may hamper treatment with dental implants and could even result in food traps when traditional fixed partial dentures using pontics are used. These problems could be avoided with “atraumatic” extraction techniques. A method to reduce trauma to the adjacent bone during tooth extraction and maintain the dentoalveolar unit is via the use of the periotome. [3] With the advent of implantology, atraumatic extraction has come into vogue again, and proponents of periotome have claimed that it not only reduces soft tissue injury but also aids in salvaging the bony integrity of the socket as well. [4]
Periotomes are instruments used in extraction. They work on the mechanisms of “wedging” and “severing” to facilitate tooth removal. Periotomes are made of very thin metallic blades that are wedged down the periodontal ligament (PDL). This is done in a circumferential fashion repeatedly in addition to the minimally invasive luxation, the periotome blade severe sharpey’s fibers. Due to the repeated wedging, the majority of sharpey’s fibers get separated from the root surface, and rotational movements allow for the extraction of the tooth with minimal lateral pressure. This can reduce the potential trauma to adjacent bone and gingival structures. Disadvantages of the periotome include provider fatigue, adding a significant amount of time to the extraction procedure, and, eventually, they wear away due to usage. [3]
The benefits of using this technology include preservation of the adjacent papillae and underlying host bone, along with dramatically improved patient experiences. Traditional periotome has thinner blades that are prone to fracture as well as higher time duration for extraction. These disadvantages have been compensated by the use of flexible periotomes with more wear resistance thinner blades which allows for better access with the advantage of shape memory. This provides better access to periodontal space to break the periodontal ligaments. All these may promote better healing of the socket with fewer traumas being induced.
There are not many studies or case reports regarding the usage of flexible periotome in exodontia and their efficiency versus regular periotomes, so we decided to conduct a prospective, randomized, controlled trial to compare the efficacy of per extraction.
2. Aims
To compare the efficiency of flexible periotome versus non-flexible conventional periotome in atraumatic dental extraction of similar teeth.
● To compare the wound healing following the use of flexible periotome and non-flexible conventional periotome.
● To compare the duration of the procedure of flexible periotome and non-flexible conventional periotome for extraction of a tooth.
● To compare the level of gingival laceration in the use of flexible periotome and non-flexible conventional periotome.
Settings
● Convenience sampling method was used.
● Even-Odd method was used for randomization.
Design
● Randomized controlled trial.
Methods
Inclusion criteria:
● Patients who require extraction of bilateral similar sound teeth for orthodontic treatment or implant placement.
● Age: 17 - 45 years
Exclusion criteria:
● Patients who gave an allergic history.
● Patients who are pregnant.
● Patients suffering from any systemic disease.
● Periodontally and/or endodontically compromised teeth.
3. Methodology
The study was approved by the Research and Ethics Committee of the institution. Before enrolment, the objectives, implications, and possible complications of this clinical trial were explained to all the patients and informed consent was obtained.
Protocol no: YEC2/987.
The study was conducted on patients who have teeth that are indicated for bilateral extraction of similar teeth on the same jaw and were divided into two groups. The control group was in which conventional periotome (GDC P1), and the study group was in which flexible periotome (GDC PTF1) (Figure 1). The study was approved by the Research and Ethics Committee of the institution. Before enrolment, the objectives, implications and possible complications of this clinical trial were explained to all the patients and informed consent was obtained.
In the control group, after clinical assessment of the tooth to be extracted, conventional periotome (GDC P1) was to be held with a modified pen grasp. It is inserted into the long axis of the tooth at 20 degrees into the gingival sulcus (Figure 2). It was used to detach the cervical gingival fibers, reaching into periodontal ligament space, first mesially and then distally to the root surface. Once the access is obtained, the instrument is gradually moved forward into the PDL space, repeating the same motion until two-thirds of the distance toward the apex of the root is reached. Then the tooth was extracted using extraction forceps.
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Figure 1. GDC—flexible periotome (PTF1) and GDC—conventional peritome (PT1).
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Figure 2. Conventional periotome being used to detach the periodontal ligament wrt 24.
In the test group, after clinical assessment of the tooth to be extracted, flexible periotome (GDC PTF1) was held with a modified pen grasp and inserted at 20 degrees to the long axis of the tooth into the gingival sulcus (Figure 3). It was used to sever the cervical gingival attachment fibers first and then proceed several millimeters into periodontal ligament space and inclined first mesially and then distally tangential to the root surface. Once the access was obtained, the instrument would be gradually moved forward into the PDL space, repeating the same motion until two-thirds of the distance toward the apex of the root was reached. Then tooth would be extracted using extraction forceps.
During the intraoperative phase, the duration of the procedure was noted from the beginning of the procedure till the completion of tooth extraction. Immediate post-op complications, if any, were recorded.
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Figure 3. Flexible periotome being used to detach the periodontal ligament attachment.
Gingival lacerations would be graded using the following scale [1] .
Landry’s healing index was used to assess early wound healing [5] .
Statistical analysis
Descriptive statistics
● Two independent sample t-test will be used to compare the average time duration, gingival laceration, and healing of socket in both groups.
Ethical and humane considerations
● The study was ethically conducted in accordance with the declaration of Helsinki.
4. Results
A total of 26 patients were considered for the study that needed similar bilateral extractions. The duration of extractions was found to be lesser in the usage of flexible Periotome, where the mean average was 4.43 minutes, whereas, with conventional periotome, the mean average was 7.2 minutes. The p-value was <0.001 showing significance (Table 1).
The gingival laceration was calculated in the study and control group using Wilcoxon signed rank test, and the p-value of the test is 0.011. The scores of the two groups differ significantly (Table 2), where the study group showed less amount of gingival lacerations.
Total healing was calculated in both the groups immediately and on the seventh day, where the study group showed superior results in the healing based on the laundry healing index, where excellent healing was achieved in all but two cases in the study group. In contrast, only 17 cases achieved excellent healing in the control group. On post-op day 7, all patients in both groups showed excellent healing.
5. Discussion
Conventional tooth extraction methods can cause damage to the surrounding bone and reshaping of the socket. Leveraging the interproximal bone results in damage to the interproximal bone. Even the use of forceps to luxate the tooth from its socket can often result in modifying the socket or alveolus. Atraumatic extraction is a better option for preserving bone and gingival architecture and
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Table 1. Comparison between duration of surgery in both groups.
Comparison of duration of procedure in study and control group using Wilcoxon Signed rank test.
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Table 2. Comparison between gingival lacerations in the study group and control group.
The P value of the test is 0.011, the scores of two groups differ significantly.
allowing for future or immediate implant placement. Various minimally invasive tooth extraction tools are available, including Easy X-Trac system physics forceps and periotomes.
Pj Thomson’s study spoke about the disadvantage of a regular periotome, where the duration of the procedure is higher, as well as operator fatigue. Another disadvantage is the fracture of the instrument due to high pressure and more trauma to soft tissue, as stated by Sneha D. Sharma. In this study, the maximum number of gingival lacerations occurred in the control group [1] [2] .
The flexible periotomes, due to their wider size and serrated edges, helps break the periodontal ligament. Its flexibility allows greater access to the periodontal ligament space without traumatizing the adjacent bone. This could be helpful in leaving the extracted socket undisturbed and the alveolus intact. In the test group where flexible periotome was used, the duration of surgery was found to be lesser
Other methods are available that support atraumatic extractions but are not available easily and require a learning curve. [3]
Many other complications are also prevalent in exodontia cases due to conventional methods. Bortoluzzi et al. [6] in their study observed an incidence of 0.6% (2 cases each) for both alveolar infection and dry socket. Schropp et al. [7] , in their study on bone healing of extracted sockets, mentioned the major chances of bone loss at the extraction site one year after tooth extraction.
In another study by Adeyemo et al. [8] , they discussed the various pre-operative complications such as accidental crown, root, or alveolar bone fractures, which often lead to healing complications and even increased time of extraction due to such complications leading to disturbance in healing. Adeyemo et al. [8] have mentioned the presence of alveolitis in 11% of sockets and mild pain in 12% of cases. Venkateshwar et al. found tooth fracture, trismus, fracture of cortical plates, and dry socket to be the most common complications, while wound dehiscence and postoperative pain were the rare complications, and luxation of adjacent teeth, fracture of maxillary tuberosity and displacement to adjacent spaces among the rarest complications encountered during tooth extraction [9]
Similar outcomes to the above studies were observed in our study in the control group, where postoperative pain, buccal cortical plate fracture, bleeding till 2nd day, dry socket, apical third root fracture, and erythematous margins were observed. Even the oral health-related quality of life following nonsurgical routine tooth extraction deteriorates with the conventional method of extraction, as in the control group of our study [10] . The greater the amount of trauma to the surrounding bone, the greater the incidence of the dry socket.
Marco cicciù et al., in their study, have mentioned that extraction of teeth was not affected by the amount of strength applied or the quality of bone surrounding the tooth but is more technique sensitive. With the advent of periotomes in 2013, atraumatic extractions for immediate implant placement have now become a common occurrence [11] .
The use of flexible peristomes is to overcome these demerits and help in better operator handling and wound healing. Their usage may help provide a supportive environment for immediate and delayed implant placement. The limitations involved the lack of use of radiographic assessment in assessing the level of bone healing, and no long-term follow-up was done for the patients.
6. Conclusion
On the basis of the study, we are of the opinion that the use of flexible periotome in tooth extractions gives a superior result compared to extractions carried out using the traditional periotome. Due to the lesser time they require to carry out the extractions, more fracture resistance and better wound healing.