01/05/2014. Background. Minimally invasive tooth extraction. Thomas Dietrich Professor of Oral Surgery University of Birmingham, School of Dentistry

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1 Background Remodelling of alveolar bone following extraction Minimally invasive tooth extraction Thomas Dietrich Professor of Oral Surgery University of Birmingham, School of Dentistry 2 weeks 4 weeks 8 weeks Araújo MG, Lindhe J. J Clin Periodontol Feb;32(2): Wah Lay Tan Terry L. T. Wong May C. M. Wong Niklaus P. Lang A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans Authors affi liations: Key words: alveolar bone, dimensional change, extraction, hard tissue, human, removal of Wah Lay Tan, Terry L. T. Wong, May C. M. Wong, teeth, resorption, soft tissue, systematic review Niklaus P. Lang, Implant Dentistry, The University of Hong Kong, Prince Philip Dental Hospital, Implant Dentistry, Hong Kong, China Abstract Background: Removal of teeth results in both horizontal and vertical changes of hard and soft Correspon ding author: Prof. Niklaus P. Lang, DMD, MS, PhD, Dr odont.h. tissue dimensions. The magnitude of these changes is important for decision-making and c. mult. comprehensive treat ment planning, with provisions for possible solutions to expected The University of Hong Kong Faculty of Dentistry Prince Philip Dental Hospital complications during prosthetic rehabilitati on. 34 Hospital Road, Sai Ying Pun Objectives: To review all English dental literature to assess the magnitude of dimensional changes Hong Kong, China of both the hard and soft tissues of the alveolar ridge up to 12 months following tooth extraction Tel.: Fax: in humans. nplang@dial.eunet.ch Methods: An electronic MEDLINE and CENTRAL search complemented by manual searching was conducted to identify randomized controlled clinical trials and prospective cohort studies on hard Confl ict s of interest and soft tissue dimensional changes after tooth extraction. Only studies reporting on undisturbed The authors declare no conflict of interest. post-extraction dimensional changes relative to a fixed reference point over a clearly stated time period were included. Assessment of the identified studiesand data extraction was performed independently by two reviewers. Data collected were reported by descriptive methods. Weighted means and percentages of the dimensional changes over time were calculated where appropriate. Results: The search provided 3954 titles and 238 abstracts. Full text analysis was performed for 104 articles resulting in 20 studies that met the inclusion criteria. In human hard tissue, horizontal Tan et al., Clin. Oral. Impl. Res. 23(Suppl. dimensional 5), 2012, reduction 1 21 (3.79 ± 0.23 mm) was more than vertical reduction (1.24 ± 0.11 mm on buccal, 0.84 ± 0.62 mm on mesial and 0.80 ± 0.71 mm on distal sites) at 6 months. Percentage vertical dimensional change was 11 22% at 6 months. Percentage horizontal dimensional change Horizontal bone loss following extraction Determinants of bone resorption/remodelling? - patient behav ior Saldanha JB, Casati MZ, Neto FH, Sallum EA, Nociti FH Jr. Smoking may affect the alveolar process dimensions and radiographic bone density in maxillary extraction sites: a prospective study in humans. J Oral Maxillofac Surg Sep;64(9): local morphological factors of the extraction site Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. 2004;19 Suppl: Review. - surgical factors (reflection of a flap) Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. Alveolar crest reduction following full and partial thickness flaps. J Periodontol Mar;43(3): Tan et al., Clin. Oral. Impl. Res. 23(Suppl. 5), 2012, post extraction protocols Brägger U, Schild U, Lang NP. Effect of chlorhexidine (0.12%) rinses on periodontal tissue healing after tooth extraction. J Clin Periodontol Jul;21(6):

2 Why minimally invasive? Minimise biological/surgical/technical complications biological normal postoperative morbidity BRONJ/ONJ/ARONJ OAC Bone resorption/remodelling Minimise PDL damage (intentional replantation) Technical/surgical Minimise need for flap surgery Patient satisfaction Basic principle Novel extraction systems Easy X Tract Apex-Control Benex Benex (Zepf/Meisinger) Benex (Zepf/Meisinger) 2

3 Benex 3

4 Prospective study Inclusion criteria Extraction under LA +/- IVS Decayed teeth/roots, not suitable for forceps extraction Exclusion criteria Mobility > I Upper molars Third molars Case Report Form (CRF) Muska et al., Oral Surg Oral Med Oral Pathol Oral Radiol 2013 ; 116: e Benex extraction attempted in 121 roots, 100 (83%) successfully extracted 1 one root excluded (case No. 1) as device could not be positioned due to limited access 2 one root excluded (case No. 128) due to horizontal root fracture after screw insertion 3 only cases were tray was used Technical Details (n=121) Parameter Musca et al., Oral Surg Oral Med Oral Pathol Oral Radiol (2013), in press Success % (n) Failure % (n) Total % (n) Luxation of the root 1 Yes 5 (5) 20 (4) 8 (9) No 95 (95) 80 (16) 92 (111) Axial alignment without tray 1,2 Yes 27 (27) 32 (6) 28 (33) No 73 (73) 68 (13) 72 (86) Tray used 1,2 Yes 75 (75) 68 (13) 74 (88) No 25 (25) 32 (6) 26 (31) Axial alignment with tray 1,2,3 Yes 99 (74) 100 (13) 99 (87) No 1 (1) 0 (0) 1 (1) Screw characteristics 1 Ø1.6, short 79 (79) 50 (10) 74 (89) Ø1.8, short 6 (6) 35 (7) 11 (13) Ø1.6, long 15 (15) 15 (3) 15 (18) Success rate Total: 83 % (92 / 111) Multi-rooted teeth: 43 % (6 / 14 teeth) Single-rooted teeth: 89 % (86 / 97 teeth) Muska et al., Oral Surg Oral Med Oral Pathol Oral Radiol 2013 ; 116: e Learning curve To be continued 323 teeth in 223 patients All molars now excluded p for trend = Muska et al., Oral Surg Oral Med Oral Pathol Oral Radiol 2013 ; 116: e

5 U5 (n=66) U4 (n=38) U3 (n=57) U2 (n=23) U1 (n=29) L1 (n=6) L2 (n=9) L3 (n=19) L4 (n=28) L5 (n=48) Results by toothtype 0% 20% 40% 60% 80% 100% Results 2 significant determinants of extraction failure: multi- vs. single rooted: RR 2.2 (95% CI: 1.3, 4.0), p=0.006 RCT vs. no RCT: RR 2.1 (95% CI: 1.3, 3.6), p=0.003 Benex clinical experience Screw position Factors for success Screw positioning Alignment of pullrope Use of support tray Reasons for failure Anatomical factors undercuts Root divergence Root dimensions Root curvature Screw position Alignment of pullrope 5

6 Support tray Anatomical factors undercuts undercuts undercuts Luxation? 6

7 Case No. 65 Upper premolars Root divergence Root dimensions & curvature Technical complications 1. Screw first 1. Screw first 7

8 2. Remove putty immediately 2. Remove putty immediately 2. Remove putty immediately 3. Use support tray (If in doubt chicken out!) 4. Alignment of pullrope 5. A bit of patience 8

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10 Avoidance of flap surgery? Avoidance of flap surgery? Guesstimated: 44% Actual: 8% Minimisation of surgical trauma? Minimisation of surgical trauma? (Bisphosphonate) 10

11 More options... More options... More options... More options... More options... Extrusion vs. Extraction 10/2012 2/