Original Article

Minimally traumatic extraction techniques in nonrestorable

endodontically treated teeth: A comparative study
ABSTRACT
Aim: The goal of this study was to assess the effectiveness of piezotome as compared to periotome extractions of nonrestorable endodontic
treatment of teeth in terms of operational time, pain control, and postoperative bone loss considering the prosthetic rehabilitation in future.
Materials and Methods: A double‑blind, randomized controlled trial was conducted with 100 patients who wanted single‑rooted teeth to
be extracted (which failed endodontically). The participants have been randomized into two equal groups named as ‑ (i) a periotome group (ii)
and a piezotome group. Duration of the surgery, postoperative pain within 7 days, complications (if any) associated with the extraction process
were performed as a part of clinical assessment. Bone loss has been analyzed 6 months after the surgery radiographically. The data have been
recorded and analyzed using the version 22.0 of the SPSS software package.
Results: All parameters in the periotome category (P < 0.05) were statistically significant except for bone loss and gingival laceration in
comparison to piezotome group. In the piezotome group, a longer time was observed for surgery and delayed pain control was achieved. In our
study, we found statistically significant more marginal bone loss in piezotome group in comparison with periotome group.
Conclusion: The findings of this study indicate that for intraoperative and postoperative comfort periotome could be used as a safer and
cheaper option for atraumatic extractions but piezosurgery may prove as a better choice soon for surgeries in the maxillofacial region to maintain
soft‑tissue integrity.

Keywords: Atraumatic extraction technique, periotome, piezotome

INTRODUCTION preserving gingivae, bone, and other soft and hard tissue
underlying structures for easier prosthetic rehabilitation
Over the past few decades, the scientific literature of
Sneha D. Sharma, Ashish Gupta, Pankaj Bansal,
maxillofacial surgery has enhanced its wings in a wide variety Mohan Alexander1, Vidya B2, Himani Gupta
of areas including neurovascular reconstruction, craniofacial Department of Oral and Maxillofacial Surgery, Sudha Rustagi
surgery, snd distraction osteogenesis. However, in many College of Dental Sciences and Research, Faridabad, Haryana,
countries, the bread and butter of most maxillofacial surgeons 2
Department of Oral and Maxillofacial Surgery, Oxford Dental
appear to be exodontia including routine extractions as well College, Bengaluru, Karnataka, India, 1Department of Oral
as impacted tooth removal. and Maxillofacial Surgery, MAHSA University, Kuala Lumpur,
Malaysia

A complex cascade of biochemical and histologic events Address for correspondence: Dr. Sneha D. Sharma,
ensues during postextraction wound healing that leads to Department of Oral and Maxillofacial Surgery, Sudha Rustagi
College of Dental Sciences and Research, Sector‑89, Kheri More,
physiologic changes in the alveolar bone as well as soft‑tissue
Faridabad ‑ 121 002, Haryana, India.
architecture.[1] The least traumatic the extraction procedure, E‑mail: sharma.sneha2483@gmail.com
the lesser are the alterations in soft and hard tissue. This
Received: 22 January 2021, Revised: 05 May 2021,
led to the introduction of atraumatic techniques of tooth Accepted: 23 May 2021, Published: 20 August 2022
extraction aimed at extracting the tooth or tooth’s root while
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How to cite this article: Sharma SD, Gupta A, Bansal P, Alexander M,

DOI:
Vidya B, Gupta H. Minimally traumatic extraction techniques in nonrestorable
10.4103/njms.njms_309_21 endodontically treated teeth: A comparative study. Natl J Maxillofac Surg
2022;13:S91-6.

© 2022 National Journal of Maxillofacial Surgery | Published by Wolters Kluwer - Medknow S91
 Sharma, et al.: Minimally traumatic extraction techniques in nonrestorable endodontically treated teeth: A comparative study

in future. There are many methods for minimally invasive this clinical trial before enrollment. The computer‑generated
dental extraction techniques available including piezosurgery, randomization method has been used for the random
physics forceps, periotome, benex vertical extractor, and assignment of groups (A piezotome group or B periotome
many more which aids in maintaining adequate bulk of bone group). Therefore, 50 extractions have been made for
that is a prerequisite in intraosseous implant placement. each process. Presurgical planning including radiographic
Periotome has been used in extracting the tooth without evaluation as well as case history was performed for each
causing damage to the osseous structure of endodontically patient. Aseptic tooth extraction was performed under local
treated teeth as well as fractured crown cases maintaining anesthesia (LA) (2% lignocaine with 1:200,000 adrenaline)
the hard‑ and soft‑tissue architecture.[2] and every patient received postextraction antibiotics and
instructions. For Ethical Clearance was obtained from
Moreover, when mentioning extraction with minimal Institutional Ethical Committee- SRCDSR Ethical Committee
damage to surrounding soft tissue, piezosurgery stands with Ref no SRCDSR/ACAD/2020/8496 dated 20.08.2020).
for an innovative technique for osteotomy which uses the
micro‑vibrations of scalpels at an ultrasonic frequency to The Hu‑Friedy periodontal probe was used to measure
enable surgeons to work on the bone with more efficiency preextraction bone level (Peb). For the measurements on
without injuring the surrounding soft tissue integrity.[3] the labial side of the tooth to be removed, three points
were chosen (middle third, distal third, and mesial third).
The proponents of both periotome and piezotome have The marginal height of the bone has been determined by
claimed to reduce soft‑tissue injury and minimizing bone inserting the probe into the gingival sulcus depth, and Peb
loss in the future too. Although many case reports and was measured at every point.
studies have advocated the use of periotome or piezosurgery
individually, not many have studied the use of both periotome In the periotome group, Hu‑Friedy’s periotome was kept in a
and piezotome in endodontically treated teeth which are modified pen grasp and positioned at 20° on the long tooth
more prone to fracture during extraction. axis into gingival sulcus after the clinical examination of the
tooth to be removed. It was used to first detach the cervical
We therefore performed a prospective, double‑blind, and gingival fibers, then proceeded to periodontal ligament
randomized controlled study to test the effectiveness
space several millimeters tangentially to the root surface to
of piezotome as well as periotome in the extraction of
break down the periodontal ligament fibers and the same
endodontically treated teeth that failed to restore.
movement was repeated until 2/3rd distance toward the root
apex was reached and the access was achieved.
MATERIALS AND METHODS
In piezotome group, SATLEC ACTEON piezotome was used.
A prospective, double blind, randomized controlled study was
LC 2 tips were secured to the handpiece and used for all four
conducted with 100 patients (58 women and 42 men) reported
surfaces. The vibrating osteotomy blade tip was inserted in
to the “Department of Oral and Maxillofacial Surgery,” who
wanted single‑rooted teeth to be extracted (which failed
endodontically) [Figures 1, 2 and Diagram 1]. The analysis
was approved by the “Research and Ethics Committee of
the institution.” Each patient received informed permission
and clarification of the goals, effects, and potential risks of

a b c

a b c d
Figure 1: (a) Cone‑beam computed tomography of RC treated tooth (b) Figure 2: (a) Preop cone‑beam computed tomography (b) Using piezotome
using periotome (c) extraction done (c) 6 months postop extraction with piezotome (d) piezotome instrument

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 Sharma, et al.: Minimally traumatic extraction techniques in nonrestorable endodontically treated teeth: A comparative study

between the bone and the root underlying gingivae. The as loss of marginal bone, extraction time, postoperative
blade was advanced in a sweeping movement maintaining pain reduction and bone loss at 6 months were recorded.
the parallelism along the tooth axis and moved toward the Graph 1 and Table 1 reveal that the procedure duration in
apex in small increments of 2–4 mm. piezotome group was substantially longer than that of the
periotome group (P < 0.01). Periotome group pain relief
Periodontal ligament cutting was replicated on all four was substantially higher than piezotome group when an
surfaces for both groups until the root was mobilized entirely. intergroup comparison was made. In three patients, gingival
After that, the extraction of a tooth was aided with tooth lacerations have been noticed – 2 in periotome and 1 in
particular forceps. piezotome group but not of statistical significance as per
the grading score. Mean marginal bone loss immediate
Pain was evaluated with “Visual Analog Scale” before postoperative was assessed with independent samples
LA administration, preoperatively, and postoperatively t‑test which was 0.0832 mm (±0.56 mm) in piezotome
throughout the 7 days. The procedure duration was estimated group and 0.5433 (±0.24 mm) in periotome group. The
from administering LA onwards to completion of the tooth difference between two groups (P < 0.05) was statistically
extraction during the intraoperative process. Complications, important. Bone loss 6 months postoperative was also
if any (bone plate fracture, excessive bleeding, delayed wound assessed using independent samples t‑test. It was assessed
healing, pain beyond 7 days, and dry socket) and gingival in horizontal and vertical parameters with a mean height loss
laceration were assessed immediate postoperatively as well of 4.21 mm (±0.26 mm) and mean buccolingual width loss
as during the 7 days postoperative phase. of 2.85 mm (±1.28) in piezotome group. Mean height loss
was 3.71 (±1.24) mm and mean buccolingual width loss was
After extraction, the distance between the marginal 2.67 (±2.24) mm in periotome group. On analysis, it was not
bone and the gingival has been calculated and known as statistically relevant (P > 0.05), even in the piezotome group
“postextraction bone level” (Pob). It has been determined by the bone loss was more.
positioning the Hu‑Friedy probe at previously selected points
at the edges of the socket. The difference between Pob and Complications such as a dry socket and buccal plate fracture
Peb has been recorded, the marginal bone loss’s amount has were rarely observed and were of no statistical significance
been revealed by the difference in the evaluation of the bone among both the groups, although on the 7th day, moderate
loss during the procedure between these two mean values. pain was more experienced in piezotome patients. To avoid
Furthermore, bone loss was assessed by comparing the bias, all the extractions were performed by operators with
cone‑beam computed tomography obtained preoperatively similar experience and single observer was appointed to
and 6 months postoperatively (considering the nearest assess the clinical and radiographic parameters (keeping the
anatomic landmark). The following parameters have also procedure performed blind). On multiple comparisons, no
been collected sex, age, tooth, Periodontal Disease Index correlation between various variables (surgery length, pain
(PDI), the operator, and mobility grade. The investigators reduction, complications, bone loss) and the grade of tooth
and the patients were blinded to avoid bias. mobility and PDI has been noticed.

Statistical significance was P < 0.05, and data on 100 DISCUSSION

participants were collected from radiographic and clinical
results and assessed with SPSS Version 22.0 (“Statistical The traditional dental extractions involve reflection of a
Package for Social Sciences”). mucoperiosteal flap combined with tooth elevation against
surrounding bone to aid extraction with forceps. Extraction
RESULTS

There were 100 people (58 women and 42 men) registered, 4

people (2 in piezotome and 2 in periotome group) lost since
they have not come for follow‑ups. The finding was based on
the analysis of 96 patients and in both groups, there were
48 patients. They were between 20 and 55 years with a mean
age of 32.47 years.

In this analysis, all teeth removed were single‑rooted teeth

that had failed root canal therapy. Clinical parameters such Graph 1: Different parameters assessed in periotome and piezotome group

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 Sharma, et al.: Minimally traumatic extraction techniques in nonrestorable endodontically treated teeth: A comparative study

Table 1: Different parameter values in both groups

Group N Mean Std Std error mean P value
deviation
Duration of Operation Piezo 50 12.816±7.3938 1.0456 0.0002
Perio 50 5.7801±4.0437 0.5718
Pain reduction in post op Piezo 48 ‑0.7080±2.3069 0.3216 0.002
Perio 48 0.9854±2.754 0.3432
Gingival Laceration Grade Piezo 50 0.1012±0.9035 0.6778 0.08
Perio 50 0.2000±0.64218 0.09035
Marginal Bone loss at surgery Piezo 50 0.08324±0.2432 0.0512 0.007
Perio 50 0.5433±0.2482 0.0476
Bone Loss at post op 6 months width Piezo Width 2.254±4.2133 0.9
Height 2.9133±0.2633
Perio Width 3.6733±2.2415
Height 4.12±2.2280
Mean Horizontal bone Loss Piezo Width 4.2142±2.6711
Perio Height 3.7122±1.2432
Mean Vertical Bone loss Piezo Width 0.0832±0.56
Perio Height 0.5433±0.24

of endodontically treated tooth is primarily because of addressed many preoperative complications including
nonrestorable caries, vertical root fracture, iatrogenic accidental crown, root or alveolar bone fractures which
perforation, endodontic failure, etc. [4] The common often lead to healing complications and extraction time
complications which are observed with such extractions are also increased because of these complications that leads
alveolar osteitis, trismus, postoperative pain, hemorrhage to delayed healing. Specifically considering the exodontia
and wound dehiscence, fracture of cortical plates, or trauma of endodontically treated teeth, they tend to require
to the adjoining soft and hard tissue. Traumatic extraction transalveolar surgery which takes more time and cause
not only causes postoperative complications but also leads more anxiety to the patients. Considering the patient’s
to ridge narrowing and this may further impede successful comfort, postoperative pain, and duration of surgery were
prosthetic placement.[5] considered as important parameters to decide the efficacy
of the atraumatic extraction technique.
Various studies have been advocating different “atraumatic
techniques” of tooth extraction, the most common being the The patient’s comfort is not only determined by postoperative
periotome and piezotome techniques. discomfort but also the time is taken for the surgery.
Piezosurgery required greater time and higher cost of
Periotome is a combination of a mini scalpel and a armamentarium as compared to periotome but all the teeth
miniature elevator and comprises of a very thin metallic extractions were successful with no major complications.
blade and a miniature elevator that repetitively oscillates Similar findings have been quoted by Melek and Noureldin[12]
through gentle wedging movements to the root apex.[6] in their study. This could be due to changing of tips for
Piezotomes, developed by Vercellotti,[7] claim to promote different tooth surfaces too and excess time required for
rapid postoperative wound healing. They use ultrasonic adjacent bone removal. Also, Bortoluzzi et al.[8] mentioned
micro‑vibrations to efficiently sever the bone with minor the association of a longer surgery length with elevated
damage to soft tissue. As far as we know, this is the first postoperative pain which could be a possible reason for
analysis comparing the postoperative soft as well as increased postoperative pain reduction in periotome group as
the hard‑tissue changes when extracting nonrestorable compared to piezotome group. These findings are also similar
endodontic tooth using periotome and piezotome. to our previous study in which the use of periotome reduced
postextraction discomfort as compared to conventional
Concerning the postoperative discomfort, the correlation method.[13] However, on the contrary, piezotome proved to
with duration of surgery has been directly proportional to be a better option in maintaining soft tissue integrity as two
postoperative pain. In addition, postoperative pain has been cases with periotome had Grade 1 gingival laceration (though
cited as the most common complication to exodontia by not of statistical significance), whereas during extraction
“Bortoluzzi et al.,”[8] “Sjogren et al.,”[9] and “Al‑Khateeb”[10] slippage of extraction forceps caused Grade 1 laceration in
in their reports. In their report, Adeyemo et al.[11] also piezotome group.

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 Sharma, et al.: Minimally traumatic extraction techniques in nonrestorable endodontically treated teeth: A comparative study

Enrollment
Assessed for eligibility (n = 100)

Excluded (n = 0)
• Not meeting inclusion criteria (n = 0)
• Declined to participate (n = 0)
• Other reasons (n = 0)

Randomized (n = 100)

Allocation
Allocated to Piezotome group (n = 50 )
• Received allocated Piezotome group (n = 50) Allocated to periotome group (n = 50)
• Did not receive allocated Piezotome • Received allocated periotome group (n = 48)
group (n = 0) • Did not receive periotome group (n = 0)

Follow-Up

Lost to follow-up (n = 2) Lost to follow-up (n = 2)

Discontinued Piezotome group (n = 2) Discontinued periotome group (n = 2)
did not turnup for follow -up did not turnup for follow -up

Analysis

Analysed (n = 48) Analysed (n = 48)

• Excluded from analysis (n = 2) as they did • Excluded from analysis (n = 2) as they did
not turn up for follow up examination not turn up for follow up examination

Diagram 1: CONSORT 2010 Flow Diagram

Comparing the extractions using piezoelectric instruments single‑rooted teeth only, further studies with larger sample
as compared to conventional instruments, Tsai et al.[14] found size including multirooted teeth and bone loss assessment
attachment level more enhanced in piezotome group. On for longer period are recommended. Our study proposes,
the contrary in our study, we found statistically significant using periotome as atraumatic means of extraction for
more marginal bone loss in piezotome group in comparison endodontically treated teeth considering it a more economical
with periotome group. This could be attributed to the fact option with equally effective clinical outcomes and piezotome
periotome helps in extracting teeth without causing harm can be considered as a safe option for surgeries concerning
to osseous housing and maintaining the biological width of the neurovascular bundle in the vicinity of the operating site.
the adjoining gingiva.
CONCLUSION
Every extraction procedure is intended for rehabilitation
procedure in the future and maintenance of height and width The findings of this study propose that for intraoperative
holds significance for prosthetic replacement. and postoperative comfort, periotome can be seen as
safer and cheaper option for atraumatic extractions but
Alveolar ridge resorption following tooth removal results piezosurgery may prove as a better choice soon for surgeries
from a basic bone physiological concept and maximum in the maxillofacial region to maintain soft-tissue integrity.
bone resorption takes place during the first 6 months The immediate bone loss when compared can be helpful
postoperatively.[15] In our study, at 6 months interval more for immediate prosthetic rehabilitation with the use of
bone resorption was observed in piezotome group than in periotome but the results post 6 months present with
periotome group but not of statistical significance. Means of same findings. Further more studies with larger sample size
extraction determines the amount of bone loss. including muti-rooted teeth are suggested for definitive
conclusion.
Furthermore, with some of the limitations of our analysis (we
could not compare this with more than one or two studies as Financial support and sponsorship
it is a new study) and the study was majorly concerned with Nil.
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 Sharma, et al.: Minimally traumatic extraction techniques in nonrestorable endodontically treated teeth: A comparative study

Conflicts of interest variables for postoperative pain after 520 consecutive dental extraction
There are no conflicts of interest. surgeries. Gen Dent 2012;60:58‑63.
9. Sjogren A, Arnrup K, Jensen C, Knutsson I, Huggare J. Pain and fear in
connection to orthodontic extractions of deciduous canines. Int J Paediatr
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