A New Technique for Utilizing a Powered Periotome for Preserving Bone During Odotectomy
Implant driven restorative dentistry has superseded traditional crown and bridge and heroic endodontics as the preferred treatment planning modality of many dentists for treatment of the pulpally involved tooth. As the discipline progresses and the surgical and restorative materials reach new heights of perfection, attention must be turned to other details of the implant process which can directly affect quality of outcome. One of these areas is the preservation of alveolar bone during the dental extraction. The importance of the maintenance of alveolar bone has a direct bearing on the long term functional and esthetic outcome of the restoration. Certainly for the single tooth restoration in the esthetic zone the data supporting the relationship between the interdental papilla and alveolar bone height is abundant. However, the utility of alveolar bone extends to all four quadrants. In the maxillary premolar region buccal alveolar cortex is often sacrificed in the removal of a grossly decayed tooth. Posteriorly, loss of alveolar bone can lead to need for future sinus elevation and/or onlay graft prior to implant placement. In the mandible, buccal alveolar bone is commonly lost after dental extraction causing the implant too be placed lingual to the ideal position leading to a prosthetic buccal cantilever force. Additionally, loss of alveolar bone in the posterior mandible leads to concern of inferior alveolar bone involvement in the implant osteotomy. Ideally the alveolar bone should be preserved during dental extraction, both for immediate and delayed implant placement.
Traditional means of extracting teeth often involving creation of a mucoperiosteal flap, elevation, and luxation with forceps often results in fracture or deformation of the dentoalveolar complex. This trauma could lead to ridge defects making the placement of implants very difficult or even impossible in some cases. Also, elevation of the mucoperiosteum may compromise the periosteal blood supply to the alveolus leading to loss of marginal alveolar bone even in relatively atraumatic extractions. Additionally, if the adjacent teeth to the tooth be extracted have extensive restorations or crown coverage, the powered periotome eliminates the need to elevate against and possible damage these restorations.
A powered periotome as shown in figure 1 has been created that allows for the precise extraction of a tooth while producing minimal or no alveolar bone loss. This atraumatic means of dental extraction preserves bone and gingival architecture and gives the clinician the option of placing future or even immediate implants. Periotomes function by using the mechanisms of “wedging” and “severing” to aid in tooth extraction. As shown in figure 2, these instruments are made of very thin metal blades that are gently wedged down the periodontal ligament space in a circumferential manner. This device severs Sharpey’s fibers which function to secure the tooth within the alveolar socket. After most of the Sharpey’s fibers have been severed from the root surface, gentle rotational movement with minimal lateral pressure will facilitate tooth removal.
A powered periotome is an electric unit that contains a handpiece with a periotome that is activated by a foot control. This device allows precise control over the quantity of force that the periotome tip exerts and the distance it travels into the periodontal ligament space. This instrument has a microprocessor-run actuator which eliminates uncertainty while extracting a tooth. As shown in Figure1, this device comes with a controller box that can be adjusted to 10 different power settings. Additionally, the use of the Powertome 100S system frequently allows flapless removal of teeth decreasing postoperative pain and discomfort while maintaining the periosteal blood supply to the alveolus. The use of a standard periotome is a much more tedious process and can actually cause unneeded discomfort for the patient especially if a mallet is also needed to separate the tooth from bone.
When using the powered periotome, we have found that starting interproximally seems to work most efficiently due to the thickness of the interproximal bone. It is important to keep the blade parallel along the long axis of the tooth being removed. The blade should follow the tooth anatomy circumferentially in an apical direction in 2-3 mm increments. When extracting a multi-rooted tooth, we have found it most efficient to section the tooth and treat each sectioned root as a single rooted tooth. This instrument has a very small learning curve and has been used by both general practice and oral surgery residents for tooth extractions. Photographs from a clinical case taken in our clinic is shown in this article.
In conclusion, regardless of whether an implant is placed immediately post extraction or if the socket is grafted in preparation for future implant placement, the preservation of alveolar bone allows for more esthetic and functional implant restorations. Millimeters do count when it comes to implants.
Figure 1: The Powered Periotome
Figure 2: Thin Metal Blade Component of Powered Periotome
Figure 3: Preoperative Photograph
Figure 4: Operative Photograph
Figure 5: Operative Photograph
Figure 6: Postoperative photograph
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