Comparison Of The Clinical Efficacy Of Two different Extraction Techniques In The Removal Of Impacted Maxillary Third Molar

Observation and Results

The measurements and recordings for patient compliance, time taken for the extraction, trauma to surrounding soft tissues, root fracture and tuberosity fraction were made on the scales designed for the purpose. The data recorded was compiled and put to statistical analysis.

Patient Compliance

Mean value of patient compliance on a Visual Analog Scale(VAS) [Table 1].

×

Table 1:

Close

Table 1. Mean value of patient compliance on as recorded on visual analog scale (VAS).

×

Table 2:

Close

Table 2. Measured parameters and mean values for experimental and control group.

Discussion

Discussion In the course of extraction of a tooth, there is expansion of the dento-alveolar bone which surrounds the socket and severing of the periodontal ligament attached to the tooth. Along with these physical changes that occur in the course of extraction, there are more importantly, biochemical changes with in the tooth socket. Periodontal ligament, once severed or traumatized using forceps or elevators results in the release of hyaluronidase locally. Hyaluronidase aids in the catalysis of a chemical called hyaluronic acid, a substantial element of a wide range of human tissues extracellular matrix including the periodontal ligament.

As the periodontal ligament is chemically broken down by hyaluronidase, the tooth slowly gets released in attachment to the alveolus which facilitates east removal using forceps or elevators. The amount of hyaluronidase released per unit time is directly proportionate to the ease of removal of tooth and inversely proportional to trauma caused to the alveolar bone.

Physics Forceps by Golden-Misch works in this principle as it creates with sturdy unslaked pressure on the periodontal ligament, significantly creating a greater release of hyaluronidase in a period of time much shorter than the time required using a traditional third molar forceps or elevators. This is again supported by the fact that the trauma from those techniques are intermittent in nature [5].

Conventional methods of third molar extraction leads to a wide range of complications both intra and post operatively. Luxation of the adjacent tooth when its used as a fulcrum, fracture of the maxillary tuberosity. Complications that occur post-operatively include infections, alveolitis sicca, radix in antro highmori etc. [1], [7-11]. Use of elevators in the extraction of maxillary third molars are very helpful, but its misuse can lead to many complications such as injury to the soft tissues including injury to floor of mouth, tongue, hard and soft palate which is usually caused due to the slipping of elevators during the course of its use [1].

Excessive load or wrongful application of force often leads to the fracture of the bone especially at the angle of the mandible [12- 14]. Extraction of the upper third molar may lead to the fracture of the maxillary tuberosity [3, 4]. Displacement of roots in to the infratemporal fossa, buccal soft tissue, submandibular space, maxillary sinus or inferior dental canal can occur if uncontrolled forces are dissipated. Instrument breakage of the working blade may cause postoperative infection and delay in wound healing [1, 2, 12].

Over time memorandum, many techniques were in practice to minimize complications arising with tooth removal. Over decades extraction in hemophilic patients were done by rubber bands known as rubber band extractions. Orthodontic elastics were used for the atraumatic extraction of teeth in patients treated with bisphosphonate by Regev et al [15]. A comparison (split-mouth) in the use of physical forceps and extraction forceps in orthodontic extraction of maxillary premolars were conducted by Hariharan et at [16] which concluded that a lower visual analogue scale (VAS) score for pain was obtained by the physical forceps in the first post-operative day with no other differences in inflammatory and operative complication and operation time arising between the two groups. A new surgical protocol was introduced by Karl Schumacher with the use of apical instrumentation with focus on occlusal movement of tooth while extraction. This technique helps in preservation of the hard and soft tissues allowing the removal of the most broken-down tooth in a non-flap (closed) technique [17]. Taking in to consideration, all the above-mentioned factors and techniques used over time for the extraction of teeth, a new technique for maxillary 3rd molar extraction has been tried with the use of mandibular cowhorn forceps.

This technique minimizes chances of maxillary tuberosity fracture, slippage of tooth, soft tissue tears along with the requirement of a lower amount of force ensuring that all standard extraction protocols are followed in the course of the procedure.

Minimal chance of occlusal displacement of the adjacent 2nd molar if not adequately supported is a disadvantage of this technique. If the beaks of the lower cowhorn forceps are not in the interdental area of the maxillary third molar or if the force dissipation is incorrect, it may cause the fracture of the distal segment (cusp) of the 2nd molar which we have not encountered in the course of the study. An increased incidence of tuberosity fracture and root fracture were reported in the current study as even <3mm of fractured alveolar bone or its removal with the roots of third molar were an inclusive criterion in the category of fractured maxillary tuberosity and tooth with all forms of root shapes even those with severe dilaceration were extracted and considered a part of the study.

Conclusion

This technique utilizes the use of #217 lower cowhorn forceps for the extraction of maxillary 3rd molars which helps reduce complications arising with the use of conventional forceps technique. This ensures greater patient compliance and ease of acceptance along with minimum trauma and shorter procedure time. This technique however, cannot be used in extraction of tooth with proximal caries or grossly decayed second or third molar.