International Journal of Clinical Dentistry ISSN: 1939-5833

Volume 12, Issue 3 © Nova Science Publishers, Inc.

ATRAUMATIC EXTRACTIONS:
A REVOLUTION IN EXODONTIA - A REVIEW

Mariyam Niyas1 and Nabeel Nazar2,

1
Graduate Student, Saveetha Dental College,
Saveetha Institute of Medical and Technical Sciences, Saveetha University
2
Reader, Department of Oral and Maxillofacial Surgery, Saveetha Dental College,
Saveetha Institute of Medical and Technical Sciences, Saveetha University

ABSTRACT
Exodontia is one of the most common procedures performed in dental practice.
Historically, dental extractions have been done to treat a variety of illnesses, mostly those
associated with a toothache. The history of dental extraction dates back to the days of
Aristotle (384 to 322 BC) in which he describes the mechanics of extraction forceps. An
ideal tooth extraction is defined as the painless removal of the whole tooth or tooth roots
with minimal trauma to the investing tissues, so the wound heals uneventfully with no
postoperative problems. The need for good supporting structures for dental rehabilitation
such as dental implants makes it even more imperative that the extraction is performed in
an atraumatic manner. The various extraction techniques available all have one
fundamental objective, which is to remove the tooth from the dentoalveolar housing. This
goal may be achieved either by simple tooth removal or involving surgical removal of
surrounding bone A good skill set in both simple and complex extractions is of prime
importance for those who wish to be clinically involved in this aspect of their practice. This
article reviews and discusses new techniques to make simple and complex exodontias more
predictable and efficient with improved patient outcomes. This includes physics forceps,
benex extractor, periotome, piezosurgery, Sonic instruments for bone surgery, lasers and
Endoscopically assisted root splitting.

Keywords: benex extractor, EARS, LASERS, peizosurgery, periotome, physics forceps, SIBS

Clinical Significance

Atraumatic extractions aid in better and faster healing of extraction sockets. They also help
in preserving the adjacent supporting structures which are vital for prosthetic rehabilitation.


Corresponding Author’s E-mail: nabeel_nazar@yahoo.com.
190 Mariyam Niyas and Nabeel Nazar

Therefore a review of the techniques of atraumatic extractions is important to apply them in

clinical practice.

INTRODUCTION
The specialty of maxillofacial surgery has made tremendous strides in the past few decades
encompassing such diverse fields as craniofacial surgery, microvascular reconstruction, etc.
[1]. But the most commonly performed procedure by maxillofacial surgeons in many countries
continues to be exodontia, comprising non-surgical routine tooth extractions as well as
impacted tooth removal. Dental extractions or exodontia is the removal of teeth from the dental
alveolus or socket in the alveolar bone. Historically, dental extractions have been done to treat
a variety of illnesses, mostly those associated with a toothache. It dates back to the days of
Aristotle (384 to 322 BC) where the mechanics of extraction forceps are described [2]. An ideal
tooth extraction is defined as the painless removal of the whole tooth or tooth roots with
minimal trauma to the investing tissues, so the wound heals uneventfully with no postoperative
problems [3].
Improvements in local anaesthetics as well as its delivery armamentarium have resulted in
painless extractions but the fear of post extraction pain deters many patients from undergoing
this procedure [4]. The various extraction techniques available all have one fundamental
objective, which is to remove the tooth from the dentoalveolar housing. This goal may be
achieved either by simple tooth removal or involving surgical removal of surrounding bone [5].
Substantial resorption of the alveolar process occurs during the first months after tooth
extraction and compromises the rehabilitation of the edentulous area [6]. Alveolar ridge volume
loss post extraction is an irreversible process that involves both horizontal and vertical
reduction [7]. Numerous methods have been established for the minimization of residual ridge
resorption and soft tissue preservation following tooth extraction. Atraumatic extraction is a
technique of high esteem and may ultimately become the standard technique of extraction. This
is because it is concerned with preservation of bone, gingival architecture and to improve the
potential of the body to regenerate bone and ‘fill- in’ the socket with the aim of future
replacement using implant or other fixed prosthesis [8]. Studies have also shown that if a tooth
is extracted atraumatically under proper aseptic conditions, post-operative antibiotic therapy is
not essential [9].

Physics Forceps

Dr. Richard Golden designed physics forceps in 2004, which has since been modified. It
permits removal of even the most grossly broken down tooth with little or no trauma to the
surrounding tissues [10]. It comes in various designs,

1. Standard series (GMX 100/200)

It is a set of four forceps, which include
 Upper right
 Upper left
 Atraumatic Extractions 191

 Upper anterior
 Lower universal
2. Molar series (GMX 400)
3. Pedodontic series (GMX 50)

Biomechanics

The conventional forceps are actually two first-class levers, connected with a hinge. The
forces applied to the handles are the long side of the lever, the beaks on the tooth are the short
side of the lever, and the hinge acts as a fulcrum. Therefore, the force on the handles is amplified
to allow the forceps to grasp the tooth with great force. The handles of the forceps allow
grasping of the tooth, but do not assist in the mechanical advantage to remove it [11].
The physics forceps is a single first class lever completely changing the physics behind
extractions. One handle of the device is connected to a bumper, which acts as a fulcrum during
the extraction. The beak of the extractor is positioned on the palatal or lingual root of the tooth
and into the gingival sulcus. The bumper is placed on the facial aspect of the dental alveolus
typically at the mucogingival junction. No squeezing pressure is applied to the handles or to
the tooth. Instead, the handles (once in position) are rotated as one unit for a few degrees, and
then the action is stopped for approximately 1 minute. The torque force generated on the tooth,
periodontal ligament, and bone is related to the length of the handle to the bumper (8 cm),
divided by the distance from the bumper to the forceps beak (1 cm). As a result, a force on the
handle connected to the bumper will increase the force on the tooth, periodontal ligament, and
bone by 8 times. No force is required to be placed on the beak, which is only on the lingual
aspect of the tooth root. Therefore, the tooth does not split, crush, or fracture. This unique
design delivers a powerful mechanical advantage [9]. There is no need to raise a mucoperiosteal
flap or use an elevator before attempting extraction with the Physics Forceps [12]. This is a
major advantage, particularly in cases that require atraumatic extraction.

Creep

Creep is a phenomenon whereby a material under a constant load continues to change shape
over time. In terms of extraction, these changes apply to the bone and periodontal ligament.
Reilly established the creep curve of bone, whereby a constant load of 60Mpa, the bone over
time changes shape in 3 different stages [13]. The majority of the bone changes over the first
minute, whereby the strain of the bone is modified. Higher the force applied, greater the
deformation of the bone. This process allows the tooth socket to expand and permits the tooth
to exit the socket. A secondary creep action occurs over time and allows the bone to further
deform when the force is applied during a 1 to 5-minutes period. The longer the time, the greater
the deformation; however, it expresses only a 10% to 20% difference compared to the initial
one-minute strain. Eventually, the third phase of the curve causes the bone to fracture if the
load is applied over a long time frame, representing creep rupture. Once creep has expanded
and weakened the bone and periodontal ligament, the handle of the extraction device is slowly
rotated another few degrees for 10 to 30 seconds. This action contributes to the creep rupture
192 Mariyam Niyas and Nabeel Nazar

of the ligament and usually elevates the tooth a few millimeters from the socket. At this point
the tooth is loose and ready to be removed from the socket using any device such as extraction
forceps or hemostats.

Stress

It is the internal distribution of force per unit area that balances and reacts to external loads
applied to a body. Stress can be broken down into its shear, tensile, and compressive
components. Materials in general are weakest to shear forces and strongest to compressive
loads. For example, bone is strongest to force in compression, 30% weaker to tension, and 65%
weaker to shear forces. When a rotating force is applied to the Physics Forceps on a tooth, the
stress to the tooth and the periodontal complex is a shear component of force. The force applied
to the gums and bone by the bumper of the Physics Forceps is over a greater surface area and
is a compressive force, thus bracing the buccal bone. This permits the lingual plate to expand
more and protects the facial plate from fracture. This unique design provides a powerful
mechanical advantage.
According to Dym and Weiss, there is no need to raise a mucoperiosteal flap or use an
elevator before attempting extraction with the Physics Forceps [12]. This is a major advantage,
particularly in cases that require atraumatic extraction. The use of Physics Forceps makes
extractions a faster procedure, and most assuredly, less traumatic physically and
psychologically to the patient [14].
Madathanapalli et al., studied on extraction of maxillary first molars, because they are
considered to be the most difficult to extract due to their variable crown bulk and multiple roots
with variable anatomy. They showed that there was a significant difference pertaining to the
time taken and pain on the 3rd postoperative day for extraction between the conventional and
Physics Forceps [15]. These differences could be attributed to the unique design of the Physics
Forceps, which reduces the time frame as it allows building up internal force or creep within
60 to 90 seconds, allowing the bone to slowly expand and the periodontal ligament to release
at the point at which the tooth will disengage from its socket. The working mechanism of
Physics Forceps allows the tooth to be removed atraumatically unlike conventional forceps,
thus reducing trauma at the surgical site and pain in the early postoperative period. There was
no statistically significant difference found between pain on 5th and 7th postoperative days and
intra-operative complications, such as buccal plate fracture, root fracture, or buccal bone
adherence to the root. On comparing all of the above parameters, they have found out that the
utility of the instrument is better in comparison to the conventional forceps.
Hariharan et al., compared operative complications, inflammatory complications, and
operating time in patients undergoing orthodontic extraction of upper premolars with the
Physics Forceps and the universal extraction forceps. A split-mouth clinical trial was conducted
to compare the outcomes of the two groups. The Physics Forceps group had lower mean VAS
for pain on the first postoperative day than the other group. There were no other significant
differences between the groups in any other variable studied [16].
 Atraumatic Extractions 193

BENEX EXTRACTOR
The Benex extraction system represents an innovative system that permits easy, gentle and
secure extraction of the root. Benex extractor system was developed by Hager & Meisinger and
Helmut Zepf Medizintechnik from Germany. It has benex extractor, a pull string, a sectional
impression tray, self-tapping screws and matching diamond burs in 2 different diameters (1.6
mm and 1.8 mm) [17]. This works on the principle that the tooth is extracted exclusively by
pulling along its long axis, vertically out of its socket. Similar systems to benex extractor
include easy X-TRAC, Apex control. It can be used to extract single rooted teeth, multi rooted
teeth with non-divergent roots. Sometimes multi-rooted divergent teeth can be sectioned and
removed. A further advantage of the new Benex Extractor is to be found in the field of
germectomy – germs of the teeth are also removed in a gentle and time saving manner.
Any grossly carious hard tissue is initially removed with a bur or hand instruments.
Multirooted lower molars are sectioned. A conventional probe and/or Gates-Glidden burs are
used to identify the root canal if appropriate. Using diamond burs, screw hole is prepared in the
canal for subsequent insertion of self-tapping anchor screw with the provided screwdriver.
After insertion of the pull string into the screw head, the extractor is applied and the rope
inserted into the hook of the extraction slide. To achieve axial alignment of the pull rope and/or
a stable support for the support disk of the extractor, a small impression tray with silicone putty
impression material is used if deemed to be necessary by the operator. The tooth is then
extracted by gradually increasing the traction force using the extractor by turning the knob
clockwise, which results in controlled severance of the periodontal ligament fibres and
emergence of the retained root/tooth from the alveolus. If resistance is encountered to a
moderate to severe traction force, a constant force is to be applied for 30-40 seconds before a
further increase of the traction force. Reports have shown atraumatic extractions done using
benex extraction system followed by successful placement of immediate implants [5, 18]. In
one study, Seventy seven teeth in 52 cases were successfully removed without radical fracture
and no serious post-extraction reaction was reported with a success ratio of 95%. The study
concluded Benex extractor to be an effective way of minimally invasive tooth extraction for its
simple and convenient application [19]. Muska et al., in their study, successfully extracted
Ninety-eight out of 111 teeth which were not suitable for forceps extraction with the benex
device, indicating an overall success rate of 83%. The success rate was higher in single-rooted
teeth (89%), whereas less than one-half (43%) of multirooted teeth were successfully extracted.
They concluded that: 1) the Benex extractor system may be successfully used for atraumatic
tooth extraction; 2) the system has a higher success rate with single-rooted teeth compared with
multirooted teeth; and 3) extraction failure is mostly associated with insufficient retention or
misplacement of the screw and root fracture [17]. Saund et al., recommend benex system for
extraction of incisors, canines, premolars, in selected cases for extraction of molar roots, in
particular distal roots of mandibular molars, and the palatal roots of the maxillary molars, rarely
in extraction of impacted teeth [8].
The advantages of using this system is that there is reduced trauma to alveolar bone and
soft tissues in high-risk patients such as post-radiotherapy or bisphosphonate therapy, suitable
for anxious patients, reduced post- extraction bone resorption and preservation of alveolar ridge
height and width which is suitable for immediate implant placement [20].
194 Mariyam Niyas and Nabeel Nazar

PERIOTOME
A periotome is used in severing of the periodontal liagments. These instruments are made
of very thin metal blades that are gently wedged down the periodontal ligament space in a
circumferential manner which severes Sharpey fibers, which function to secure the tooth within
the alveolar socket. After most of the Sharpey fibers have been severed from the root surface,
gentle rotational movement with minimal lateral pressure facilitates tooth removal [21]. After
clinical assessment of tooth to be extracted Amron periotome with blade attachments was held
in modified pen grasp and inserted at 20 degrees to the long axis of tooth into the gingival
sulcus. It was used to sever the cervical gingival attachment fibers first and then proceed several
millimetres into periodontal ligament space and inclined first mesially and then distally
tangential to root surface. Once the access was obtained, the instrument was gradually advanced
into the PDL space repeating the same motion until two-thirds of the distance towards the apex
of root was reached. Then tooth was extracted using extraction forceps exerting rotational force
in a coronal direction. The instrument helped in removing firm tooth and retained roots without
damaging the surrounding thin alveolar plates of bone and minimally lacerating the soft tissue
as well.
In a randomized control clinical trial by Sharma et al, based on the preservation of
periodontium, pain and healing outcomes of the subjects they concluded that use of periotome
in single-rooted tooth extractions gives a superior result compared to extractions carried out
using the traditional periosteal elevator [22]. A powered periotome (Powertome 100S, Westport
Medical Inc., Salem, OR, USA), is an electric unit that contains a handpiece with a periotome
that is activated by a foot control. The powered periotome also functions by using the
mechanisms of wedging and severing periodontal ligaments to aid in tooth extraction [23]. With
multirooted teeth it is most efficient to section the tooth and treat each sectioned root as a single
rooted tooth [10].
The main advantages of using a periotome is that the surgery can be flapless with minimal
or no alveolar bone loss and less risk of fracture of the lingual or buccal cortical plate. Patient
also experiences reduced swelling and a faster recovery time. Hence it preserves bone and
gingival architecture maintaining the periosteal blood supply with a reduced extraction time
than with conventional techniques. Advantages of an electric periotome is that it is faster and
provides an extremely sensitive tactile feedback than a manual one.

PIEZOSURGERY
Ultrasonic surgery, also known as Piezosurgery, was introduced in 1988 by Mectron
medical technology, Carasco, Italy and has improved since then [24, 25, 26]. Instruments
involved in Piezosurgery are versatile because their novel vibrating tips lead to new therapeutic
applications e.g., gingival cutting without bleeding [27], tooth extraction, and implant
osteotomy preparation. Vibrating syndesmotomes are among these recently developed tips for
tooth and root extraction. They are brought through the gingival sulcus into the space occupied
by the PDL between the root and socket to cut the periodontal ligament fibers surrounding the
tooth socket up to or greater than 10 mm. Thus, when the roots or teeth are mobilized due to
 Atraumatic Extractions 195

severing of the most apical fibers, the coronal portion of the socket has not been submitted to a
violent “rip.” At this stage, a nearly atraumatic extraction can be achieved.
The equipment works on the principle of ultrasound and consists of a piezoelectric
handpiece and a foot switch that are connected to a main unit, which supplies power and has
holders for the handpiece and irrigation fluids. The system produces a modulated ultrasonic
frequency of 24-29 kHz, and a mirovibration amplitude between 60 and 200 microm/s [28].
For the handpiece several autoclavable ‘inserts’, are available in various grades. The system
has a peristaltic pump for cooling with a jet of solution that discharges from the insert with an
adjustable flow of 0-60 ml/min and removes detritus from the cutting area. During osteotomy
procedure, the working tip is cooled with physiologic saline at 4oC.
This system utilizes piezoelectric principle: certain ceramics and crystals deform when an
electric current is passed across them, resulting in oscillations of ultrasonic frequency.
Microstreaming and cavitation phenomenon are the peculiar features of piezosurgery [29]. The
microstreaming is generated by a continuous whirling movement of a fluid generated by a little
vibrating insert that favors a mechanical action of debris removal. The cavitation phenomenon,
caused by implosion of gas bullae into blood vessels during osteotomy, produces an important
hemostatic effect to optimize intraoperative visibility.
The advantages include reduced facial swelling and trismus, less bleeding in surgical site,
allows a very clean and precise surgical cut, does not harm soft tissues such as nerves and blood
vessels even with accidental contact with the cutting tip [prevents damage to inferior alveolar
and lingual nerves during lower impacted third molar surgeries], safer than traditional burs and
surgical saws, effortless and efficient control of the device [30, 31].

SIBS (SONIC Instrument for Bone Surgery)

A sonic instrument for bone surgery (SIBS) (air driven Sonic handpiece SF1LM; Komet,
Rock Hill, SC) has been developed and various inserts (Sonosurgery, Komet) were designed
by Dr Ivo Agabiti, Pesaro, Italy, which can also be used for sectioning teeth and separating the
periodontal ligament (syndesmotomy). This handpiece was originally introduced for tooth
preparation in fixed prosthodontics to finish the marginal preparation of abutment teeth, but the
specifically designed inserts also allows for atraumatic tooth extraction. The SIBS vibrates at a
high frequency (6 kHz) and provides an efficient and precise cut as well as allowing the
clinician to work close to soft tissue without risking injury. SIBS is an excellent technique for
preserving the alveolar bone in clinical situations where an extraction is planned in the presence
of a thin buccal or lingual plate [31]. In comparison with other conventional techniques for
atraumatic tooth extraction, the SIBS may reduce the surgical time compared to the use of
periotomes. When comparing sonosurgery to piezosurgery, the average heat generated by the
SIBS was close to that by conventional rotary cutting instrument (1.54 to 2.29°C), whereas the
piezoelectric device produced a greater rise in temperature (18.17°C) [32]. Its use is
contraindicated in patients with cardiac pace makers.
196 Mariyam Niyas and Nabeel Nazar

LASERS FOR EXTRACTION

The laser osteotomy for removal of impacted teeth offers non-contact and low-vibration
bone cutting to allow precise bone ablation without any visible, negative, thermal side effects.
Stubinger et al, used Er:YAG lasers for extractions and observed satisfying results, however
the procedures were time consuming and patients were not happy with sound and smell of laser
surgeries [33].

ENDOSCOPICALLY ASSISTED ROOT SPLITTING (EARS)

The endoscopically assisted root splitting (EARS) technique serves as a basic tool for
atraumatic tooth removal. As many other dental specialties make progress in their conservative
approaches, EARS represents a conservative approach, which does follow this trend in oral
surgery. EARS is performed under local anesthesia. The surgeon works in a 9 o`clock position
observing the operation site on a video screen via a Storz Hopkins support endoscope (30
degree view angle, 2.7 mm diameter, Karl Storz Tuttlingen, Germany). The support endoscope
is placed adjacent to the surgical site using the spatula of the support tube for maintenance of
distance. To obtain a precise view of the root anatomy, the crown is removed completely via
transversal separation at the level of the gingiva. Root splitting starts with the identification of
the root canal and subsequent enlargement of the canal at least to the apical third of the root.
Enlargement is assisted by Gates burs and/ or Lindemann straight burs in a low speed surgical
handpiece. Using straight or angulated elevators, a longitudinal split of the root is performed
without damaging the surrounding alveolar bone wall. The fragments are mobilized towards
the center of the alveolus by implosion technique. They are removed subsequently if necessary
under endoscopic control using small Bein elevators or a tissue forceps. If an apical root
fragment is present following splitting, it can easily be identified endoscopically and removed
separately with a Heidbrink elevator or a root forceps. If endoscopic inspection reveals, that a
periapical granuloma or cyst is present, it can be removed under direct vision using small
curettes [34].
In a study by Engelke et al., endoscopically assisted root splitting was applied in 24
consecutive patients collectively 8 central incisors 6 lateral incisors, 5 canines and 5 bicuspids.
Endoscopic observation revealed complete maintenance of the buccal wall at its preoperative
level and control radiographs showed no apical root remnants.
Root sectioning is a valuable aid to remove destructed teeth in the anterior esthetic zone
without damage of the alveolar walls. Endoscopic control is essential for precise identification
and removal of apical root fragments.

CONCLUSION
Atraumatic extraction techniques are becoming more and more popular nowadays.
Technology has made extraction techniques and outpatient oral and maxillofacial surgery very
simple and comfortable, thus benefitting both patients and dentists. Dental practitioners must
make use of these systems, to provide high quality of treatment for their patients in a short
 Atraumatic Extractions 197

duration of time. Atraumatic extraction techniques could well become the standard technique
of extraction.

ETHICAL COMPLIANCE
Source of Funding: This study did not require financial support or any funding.

Disclosure of Interest: The authors declare that they have no conflict of interest.

Informed Consent: Informed consent was obtained from each individual participant
involved in this study.

Statement of Human Rights: This study was conducted in accordance with the 1964
Declaration of Helsinki and its subsequent amendments.

REFERENCES
[1] Al-Khateeb TH. Pain experience after simple tooth extraction. J Oral Maxillofac Surg
2008; 66(5):911–917.
[2] Ring, M. E. Dentistry: An Illustrated History. New York, NY: Harry N. Abrams, 1985.
[3] Howe GL. Some complications of tooth extraction. Ann R Coll Surg Engl 1962; 30:309-
323.
[4] ACS G, Moore PA, Needleman HL, Shusterman S. The incidence of post-extraction pain
and analgesic usage in children. Anesth Prog 1986; 33(3):147–151
[5] Tavarez RR, Dos Reis WL, Rocha AT, Firoozmand LM, Bandeca MC, Tonetto MR,
Malheiros . Atraumatic extraction and immediate implant instillation; the importance of
maintaining the contour of gingival tissues. J Int Oral Health 2013; 5(6):113-118.
[6] Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar bone dimensional changes of post-
extraction sockets in humans: a systematic review. J Clin Periodontol 2009; 36: 1048–
1058.
[7] Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour
changes following single-tooth extraction: a clinical and radiographic 12-month
prospective study. Int J Periodontics Restorative Dent. 2013; 23:313-323.
[8] Saund D, Deitrich T. Minimally invasive tooth extraction: doorknobs and strings
revisited!. Dent Update 2013; 40(4):325-326, 328-330.
[9] P. U Abdul Wahab, Madhulaxmi M, P. Senthil Nathan. Wound Infection After
Therapeutic Tooth Extraction With And Without Antibiotics. Int J Pharm Bio Sci 2013;
4(4): (B) 1277 – 1281.
[10] Misch C, Perez HM. Atraumatic extractions: a biomechanical rationale. Dent Today
2008; 27(8):98, 100-101.
[11] Nazarian A. An efficient approach to full- mouth extractions. Dent Today 2011; 30(8)94-
96
198 Mariyam Niyas and Nabeel Nazar

[12] Dym H, Weiss A. Exodontia: tips and techniques for better outcomes. Dent Clin N Am
2012; 56(1):245-266.
[13] Reilly, D. T., Burstein. A. H. The elastic and ultimate properties of compact bone tissue.
J Biomech., 1975; 8:393-405.
[14] Scull P. Beak and bumper. The Dentist. 2010; 6:56-61.
[15] Madathanapalli S, Surana S, Thakur D, Ramnani P, Kapse S. Physics Forceps vs
Conventional Forceps in Extraction of Maxillary First Molar. International Journal of
Oral Care and Research 2016; 4(1):29-32.
[16] Hariharan S, Narayanan V, Soh CL. Split-mouth comparison of Physics forceps and
extraction forceps in orthodontic extraction of upper premolars. Br J Oral Maxillofac
Surg 2014; 52(10):137-140.
[17] Muska E, Walter C, Knight A, Taneja P, Bulsara Y, Hahn M, Desai M, Dietrich T.
Atraumatic vertical tooth extraction: a proof of principle clinical study of a novel system.
Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116: 303-310.
[18] Tavarez, R. R. D. J., dos Reis, W. L. M., Rocha, A. T., Firoozmand, L. M., Bandéca, M.
C., Tonetto, M. R., Malheiros, A. S. Atraumatic extraction and immediate implant
installation: The importance of maintaining the contour gingival tissues. Journal of
International Oral Health 2013; 5(6):113-8.
[19] Shi-jun K, you-hue Z, Juan Y, dong ye Y, zhi guang Z. Application of Benex extractor
in minimally invasive tooth extraction. China Journal of Oral & Maxillofacial Surgery
2012; 10(4), 328.
[20] Kumar MPS. Newer methods of extraction of teeth. Int J Pharm Bio Sci 2015; 6(3): (B)
679 – 685.
[21] Levitt D. Atraumatic extraction and root retrieval using the periotome: a precursor to
immediate placement of dental implants. Dent Today 2001; 20(11):53–7.
[22] Sharma SD, Vidya B, Alexander M, Deshmukh S. Periotome as an Aid to Atraumatic
Extraction: A Comparative Double Blind Randomized Controlled Trial. J. Maxillofac.
Oral Surg. 2015; 14(3):611–615.
[23] White J, Holtzclaw D, Toscano N. Powertome assisted atraumatic tooth extraction. J
Implant Adv Clin Dent 2009; 1(6):35-44.
[24] Vercellotti T, De Paoli S, Nevins M. The piezoelectric bony window osteotomy and sinus
membrane elevation: Introduction of a new technique for simplification of the sinus
augmentation procedure. Int J Periodontics Restorative Dent 2001; 21: 561–567.
[25] Blus C Vercellotti T, Szmukler-Moncler S. Split-crest and immediate implant placement
with ultra- sonic bone surgery. A 3-year clinical experience with 230 treated sites. Clin
Oral Implants Res 2006; 17:700–707.
[26] Blus C, Szmukler-Moncler S, Salama M, Salama H, Garber D. Sinus bone grafting
procedures using ultrasonic bone surgery: 5-year experience. Int J Periodontics
Restorative Dent 2008; 28:221–229.
[27] Blus C, Szmukler-Moncler S. Relevance of soft tissue cutting with an ultra-sonic sur-
gical device [abstract]. Clin Oral Implants Res 2007; 28:LIII–LIV.
[28] Sortino F, Pedulla E, Masoli V. The piezoelectric and rotatory osteotomy technique in
impacted third molar surgery: comparison of postoperative recovery. J Oral Maxillofac
Surg 2008; 66:2444–8.
[29] Stubinger S, Kuttenberger J, Filippi A. Intraoral piezosurgery: preliminary results of a
new technique. J Oral Maxillofac Surg 2005; 63:1283–7.
 Atraumatic Extractions 199

[30] Eggers G, Klein J, Blank J. Piezosurgery: an ultrasound device for cutting bone and its
use and limitations in maxillofacial surgery. Br J Oral Maxillofac Surg 2004; 42:451–3.
[31] Dimitrios E. V. Papadimitriou, Alessandro Geminiani, Thomas Zahavi, Carlo Ercoli.
Sonosurgery for atraumatic tooth extraction: clinical report. J Prosthet Dent 2012;
108:339- 343.
[32] Heinemann F, Hasan I, Kunert-Keil C Gotz W, Gedrange T, Spassov A. Experimental
and histological investigations of the bone using two different Oscillating Osteotomy
techniques compared with conventional rotary osteotomy. Ann Anat 2012; 194:165-70.
[33] Stubinger S, von Rechenberg V, Zeilhofer HF. Er:YAG laser osteotomy for removal of
impacted teeth: clinical comparison of two techniques. Lasers Surg Med 2007; 39:583–
8.
[34] Araujo, M. G., Lindhe, J. Dimensional ridge alterations following tooth extraction. An
experimental study in the dog. J. Clin. Periodontol., 2005; 32:212-8.
[35] Engelke, W, Beltrán V, Fuentes R, Decco, O. Endoscopically Assisted Root Splitting
(Ears): Method and First Results. Int. J. Odontostomat., 2012; 6(3):313-316.
Copyright of International Journal of Clinical Dentistry is the property of Nova Science
Publishers, Inc. and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.