APPLICATION OF PHYSICS FORCEPS FOR EXTRACTION OF …repository-tnmgrmu.ac.in/9911/1/240302318narasimman.pdf · 2018-10-24 · transalveolar extraction in 87% of mutilated teeth. Hence

APPLICATION OF PHYSICS FORCEPS FOR

EXTRACTION OF MUTILATED TOOTH TO

AVOID TRANSALVEOLAR EXTRACTION

METHOD-A PROSPECTIVE STUDY

Dissertation Submitted to

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY

In partial fulfillment for the Degree of

MASTER OF DENTAL SURGERY

BRANCH III

ORAL AND MAXILLOFACIAL SURGERY

MAY 2018

ACKNOWLEDGEMENT

First of all, I thank GOD for his love, grace, mercy and wisdom which formed

the foundation of my life and all my work.

I wish to thank my mother Mrs.Mekala for the sacrifices she made and

for giving me a great foundation in my life and for being the most wonderful

mother . I thank my uncles Mr.Malarvannan, Mr.Swaminathan, Mr.Suriya

Devan, Mr.Rajendran for being the pillars of my life and showering me love

and encouragement.I sincerely thank Mr.Ezhavazhgan, Mr.Pannerselvam,

Mr.Jothimani for believing in me & supporting me unconditionally.I thank

my grandparents Mr.Azhagu sivanandan and Mrs.Mayavathi for praying

and supporting me in all my works.

With deep satisfaction and immense pleasure, I present this work

undertaken as a Post Graduate student specializing in Oral and Maxillofacial

Surgery at Ragas Dental College and Hospital. I would like to acknowledge

my working on this dissertation which has been wonderful and enriching

learning experience.

I convey my heartfelt gratitude and my sincere thanks to my Head of

the department and my guide Professor Dr M Veerabahu, Department of

Oral and Maxillofacial Surgery, Ragas Dental College and Hospital, Chennai

for his exceptional guidance, tremendous encouragement, well timed

suggestions, concern and motivation providing me with his immense patience

in brightening years of my postgraduate program. I have been fortunate to

study under his guidance and support. I thank you very much sir for guiding

me in my thesis work and I am indebted towards you forever for all

consideration you have shown towards me. Your presence in the department

creates an aura and motivates me to reach heights. I would cherish these

memories throughout my life.

I would like to extend my heartfelt gratitude to Professor Dr N S

Azhagarasan, Principal, Ragas Dental College and Hospital for allowing us

to use the scientific literature and research facilitates of the college and for

providing the platform to meet such wonderful academicians and people.

I owe enormous gratitude to my guide Professor Dr Malini Jayaraj for

her invaluable guidance and support throughout my course. She has always

been a source of provoking new thoughts in me. Her loving and caring nature

lightened the burden of many hardships. I shall forever remain thankful to her

for her valuable guidance and input throughout the making of this

dissertation. It was an enriching experience to have spent three years of my

life under her guidance.

I wish to convey my heartfelt thanks to Professor Dr B Vikraman, a

great teacher who has always been a source of inspiration. His way of looking

at things three dimensionally has always given a touch of perfection. His

subtle humour and comments have been thoroughly enjoyed throughout my

post graduate life.

I would also thank my Professor Dr J A Nathan for everlasting

inspiration, constant encouragement, constructive criticism and valuable

suggestion conferred upon me throughout my postgraduate period.

I am greatly indebted to Dr Radhika Krishnan Anaesthesiologist, for

imparting and sharing her vast experience in the field of medicine. I thank her

for her valuable suggestion and constant encouragement through my

postgraduate course.

I am grateful and sincerely thankful to Dr D. Shankar, Dr Sathya

Bama, Dr Saneemand Dr Satish Readers, for their vehement personal

interest, wish and never-ending willingness to render generous help to me

throughout my dissertation and post graduate with valuable advice.

I thank Dr Seema Alice Mathew, Dr James Bhagat, Dr Naren

Kumar, Dr K.M. Harish Senior lecturers for their guidance, scholarly

suggestion and whole-hearted support throughout my postgraduate course.

I thank Dr Venkatesh, Dr Raghu Department of surgical oncology

Cancer Institute Adayar, Chennai, , for their vehement, valuable guidance and

encouragement during my peripheral postings.

.

I sincerely thank my batch mates, Dr Meeran Sharif, Dr Senthil, Dr

SharnuSiviah , Dr Nambi Nayagi and Dr Nirmal for their support,

constructive criticism at every step and selfless co - operation during my

dissertation. I wish them a successful career ahead.

I would like to thank my dear friends Dr Prasanth eager, Dr Sam

prasanth,Dr.Nivetha,Mashshariff,ArunBalaji,Elakkuvan,Sindhupriya,

Arulraj,Amudhan, Sathiyaseelan for inspiring and encouraging me during

my postgraduate period. My heartfelt thanks to my dear friends, without them

my time wouldn’t have been enjoyable.

I offer my sincere thanks to my senior’s, Dr Narayana murthy,

Dr Nirmal tony, Dr Sriraman, Dr Vivek, My Juniors Dr Manoj kumar,

Dr Stephen, Dr Ajith, Dr Arun, Dr Deepan, Dr Kishok, Dr Diana, Dr Alka,

Dr Veera Raghavan, Dr Aravindh sai for their encouragement and support

during the course.

I sincerely thank Mr Thavamani, for helping in editing and printing of

my thesis. I would also thank Sis.Deepa, Sis.Laila,Sis. Leema, Sis.Mala for

helping me throughout my post graduate period.

I would like to dedicate this dissertation to lovable ones Dhayan AB,

Kunthavi priya and my mother who always wish for me to reach great heights

and achieve greater goals in my life.

ABSTRACT

AIM

The aim of this study is to evaluate the possibility of avoiding a

trans-alveolar method of extraction for mutilated tooth using physics forceps.

MATERIALS AND METHODS

In this prospective clinical study, a total of 30 patients seeking

transalveolar method of extraction were taken as study group. Out of 30

patients, complete success of extraction with physics forceps (Atraumatic

extraction) was selected as one group and failure to extract tooth with physics

forceps (Traumatic extraction) was selected as another group. Clinical

outcomes in form of operative time taken, gingival laceration, intra-operative

patient comfort, postoperative pain and healing were recorded and compared.

RESULTS

Statistically significant reduction in the operating time, marginal bone

loss, soft tissue loss, post-operative evaluvation of parameters including pain

,healing status and other complications were lesser in physics forceps

( Atraumatic extraction) when compared to transalveolar method of extraction

.

CONCLUSION

In our study, we would like to conclude that we could avoid

transalveolar extraction in 87% of mutilated teeth. Hence from the findings of

our study, we advocate that the use of physics forceps would reduce the rate

of transalveolar extraction in mutilated teeth. Further it provides a smoother,

uneventful post-operative healing in patients who require extraction of

mutilated teeth. We would like to highlight, inspite of the higher cost of

instrument and a steep learning curve, it would be commonly employed in

future to perform atraumatic extraction of mutilated tooth. In majority of cases

employment of transalveolar method can be avoided by proper usage of

physics forceps in mutilated tooth.

KEYWORDS; Physics forceps, Atraumatic extraction, Transalveolar

extraction, Post-operarative pain, Post-operative healing.

CONTENTS

S.No TITLE PAGE

NO

1. INTRODUCTION 1

2. AIMS AND OBJECTIVE 7

4. REVIEW OF LITERATURE 8

5. MATERIALS AND METHODS 19

6. RESULTS 32

7 TABLES AND GRAPHS 35

7 DISCUSSION 55

8 SUMMARY AND CONCLUSION 63

9 BIBLIOGRAPHY 66

10 ANNEXURES -

LIST OF TABLES

TABLE

NO

TITLE

1. DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO GENDER

2. DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO AGE

3. DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO THE

INDICATION FOR EXTRACTION


METHOD OF EXTRACTION


GINGIVAL CONDITION AT THE TIME OF EXTRACTION


TIME TAKEN TO COMPLETE THE PROCEDURE

7.

DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO THE

STATUS OF ALVEOLAR BONE (SOCKET INTACT) AT THE

TIME OF EXTRACTION

8.

DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO THE

STATUS OF POST-OPERATIVE COMPLICATIONS REVIEWED

ON DAY 3, DAY5,DAY 7 FROM THE DAY OF EXTRACTION


STATUS OF POST-OPERATIVE PAIN RECORDED FOR

PATIENTS WHO UNDERWENT EXTRACTION USING PHYSICS

FORCEPS(VAS SCALE) REVIEWED ON DAY 3, DAY5,DAY 7

FROM THE DAY OF EXTRACTION


STATUS OF POST-OPERATIVE PAIN RECORDED FOR

PATIENTS WHO UNDERWENT EXTRACTION WITH TRANS-

ALVEOLAR METHOD(VAS SCALE) REVIEWED ON DAY 3,

DAY5,DAY 7 FROM THE DAY OF EXTRACTION

11 DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO THE

HEALING CONDITION RECORDED FOR PATIENTS WHO

UNDERWENT EXTRACTION USING PHYSICS FORCEPS

(LANDRY ET AL) REVIEWED ON DAY 3, DAY5,DAY 7 FROM

THE DAY OF EXTRACTION


HEALING CONDITION RECORDED FOR PATIENTS WHO

UNDERWENT EXTRACTION WITH TRANSALVEOLAR

METHOD (LANDRY ET AL) REVIEWED ON DAY 3, DAY5,DAY

7 FROM THE DAY OF EXTRACTION

Introduction

Introduction

1

INTRODUCTION

An extraction of tooth is considered as a very traumatic procedure by

any layman due to the horrifying experiences associated with the tooth

extraction in the past. Even in this current era; despite modern methods of

anaesthesia, removal of tooth is the most dreaded procedure in majority of

patients.

The history of dental extraction forceps goes back to the time of

Aristotle (384 to 322 BC) wherein Aristotle described the mechanics of

extraction forceps. This was documented 100 years before by Archimedes

who studied and discussed the principle of the lever. A tool called a pelican

(as it resembled a large-beaked bird ) was developed in the 14th century, and

was put in use to extract teeth untill the 18th century. The modern tooth

extraction forceps became popular in the early 20th century. Until the early

1900s, travelling dentists performed extractions at town fairs, where musicians

were instructed to play loud enough to cover the cries of pain of those unlocky

patients who had their teeth extracted.

An ideal tooth extraction is defined as the painless removal of the

whole tooth, or tooth-root with minimal trauma to the investing tissues, so that

the wound heals uneventfully and no postoperative prosthetic problem is

created.

Introduction

2

The three mechanical principles of extraction are: - 1.Expansion of the

bony socket to permit the removal of its contained tooth. This is achieved by

using the tooth as the dilating instrument, and is the most important factor in

„forceps extraction‟. In order to ensure access, it is recommended that

sufficient tooth structure be clinically available to be firmly grasped by the

forceps blades. The root pattern of the tooth must be such that it permits

dilatation of the socket sufficiently to facilitate the complete dislocation of the

tooth from its socket. The socket can be dilated only if the alveolar bone is

sufficiently elastic to permit such expansion. If the root pattern or consistency

of the investing bone is such that the dilation of the socket is impracticable,

then the trans-alveolar method of extraction, with or without the division of

the roots of multi-rooted teeth, must be employed 2. The use of a lever and

fulcrum to force a tooth or root out of the socket along the path of least

resistance 3.The insertion of a wedge or wedges between the tooth-root and

the bony socket wall, thus causing the tooth to rise in its socket.

Various possible complication in tooth extraction includes failure to

secure anaesthesia, failure to remove the tooth with either forceps or elevators;

fracture of crown or roots of tooth being extracted; fracture of alveolar bone,

maxillary tuberosity, adjacent or opposing tooth;fracture of mandible;

displacement of a root into the soft tissues, into the maxillary antrum;

excessive haemorrhage during tooth removal or on completion of the

extraction or postoperatively; damage to gums, lips, inferior alveolar nerve or

Introduction

3

its branches, lingual nerve, tongue and floor of mouth; postoperative pain may

be due to damage to hard and soft tissues, dry socket; postoperative swelling

due to oedema, haematoma formation, infection, trismus, creation of oro-

antral communication.

Delayed wound healing is one of the most common problem that can

occur after tooth extraction .It may be attributed to traumatic extraction which

causes great damage to the gingival tissue.. Gingival pain, swelling,

inflammation are the common problems that the patients usually encounter the

day after extraction. Clinically, traumatic damage to the dentoalveolar housing

during extraction can result in significant ridge deformities upon healing

Dar Es Salaam41

in his study found out that the frequency of post

extraction complications was low , and was mainly due to, infected sockets ,

followed by bleeding sockets and retained roots . In addition to the above

mentioned complications, he mentioned eight complications suffered by

patients, which includes necrotising fasciitis , herpes zoster, ludwig's angina,

infections of the submandibular , parapharyngeal , masticator and

submasseteric spaces ,and reaction to local anaesthesia (2ml of 2 per cent

lignocaine hydrochloride.

Transalveolar extraction method is the surgical technique which is

employed for recovering roots that were fractured during routine extraction of

teeth which could not be extracted by the routine closed methods for a

variety of reasons. This method involves the reflection of a full thickness

Introduction

4

muco-periosteal flap, cutting of the bone obstructing the removal of the tooth

and if required sectioning of the roots and then removal. Postoperative

complications commonly include haemorrhage ,pain ,swelling.

Hence “Atraumatic dental extraction“ have gained prominence and

may ultimately become the standard technique for tooth removal which

preserves bone, gingival architecture and aids in preservation of the socket for

future implant or immediate dental implant placement.

One of the tool and technique that have been proposed for minimally

invasive tooth removal was by using “ PHYSICS FORCEPS”. Various other

advanced technique include powertome, proximators, periotomes and benex

extractor

The Physics Forceps (ADDLEYTM

) (Fig 1-8) is an atraumatic

extraction system that provides a simple, predictable and unconventional

method of extracting teeth regardless of a practitioner‟s extraction experience,

or the condition of the tooth, while providing a positive patient experience.

The Physics Forceps operate as an elevator, rather than forceps, using

first-class lever mechanics. One handle is connected to a "bumper" (Fig 9),

which acts as the fulcrum, that is placed deep in the vestibule. The other

handle is connected to the "beak," which is positioned most often on the

lingual or palatal root of the tooth into the gingival sulcus. No aspect of the

instrument grasps the crown and there is no advanced elevation needed. Once

the instrument is properly placed, the handles are rotated a few degrees with

Introduction

5

only wrist movement in a slow, steady and controlled manner — no

squeezing.

The Physics Forceps are effective in most cases, including grossly

decayed or broken down teeth, endodontically treated teeth, fractured or

fragile teeth, curved or long rooted molars and cuspids, or any tooth that

would historically be challenging with conventional instrumentation. The

Physics Forceps is ideal for an implantologist who aims to preserve the

surrounding bone and tissue in preparation for placement of dental implants.

The Physics Forceps applies a constant and steady load on the tooth,

allowing "creep" to build, releasing hyaluronic acid, resulting in the

breakdown of the periodontal ligaments. This forceps works in shorter time

period than conventional methods that employ intermittent, rocking or brute

strength types of forces.

The principles of biomechanics are the basis for the development of

the physics forceps. This instrument was developed by Golden in 2004 and

has been modified with the help of several doctors. Implementation of a first-

class lever, creep, and the type of force provides the mechanical advantages

necessary to make this dental extraction devices more efficient.

The extraction of a tooth using Physics Forceps is similar to the

removal of a nail from wood using a hammer verses a pair of pliers

(Fig 12,15). The handle of the hammer is a lever, and the beak of the

Introduction

6

hammer‟s claw fit under the head of a nail. The hammer‟s head acts as a

fulcrum. A rotational force applied to the hammer handle magnifies the force

by the length of the handle, and the nail is elevated from the wood. Unlike a

nail in wood with parallel sides and friction along its full length, a tooth is

tapered. After being elevated a few millimeters, the periodontal ligament

fibres are broken and the tooth may then be easily removed without additional

rotational force.


trans-alveolar method for extraction of mutilated tooth using physics forceps.

Aims and Objectives

AIMS & OBJECTIVES

7

AIMS AND OBJECTIVES


trans-alveolar method for extraction of mutilated tooth using physics forceps.

Review of Literature


8

REVIEW OF LITERATURE

Dr.Soumen Mandal, Dr. Sunil Kr. Gupta, Dr. Ankur Mittal,

Dr. Ritesh Garg (2015)13

evaluated efficacy of physics forcep in non-surgical

mandibular multirooted tooth extractions.They compared outcome variables

(laceration, cortical plate fracture, post-operative pain and complication) in

patients being treated for their multirooted tooth extraction with the physics

forcep and the conventional forcep and organised a double blind, randomized

controlled trial in which p value came to be statistically significant in support

following parameter for physics forcep. (p value Laceration of gingival tissue

0.032, cortical plate fracture 0.001, post-operative pain 0.035 and average time

taken for extraction was 2.33 with a standard deviation of ±1.588) .This study

concluded that physics forceps can be used as a helpful aid in atraumatic

extraction of mandibular tooth, in addition to decreasing patient’s post-

operative discomfort it also maintain the socket integrity by preventing any

damage to the soft tissue and hard tissue architecture and thus making

placement of future prosthesis easier.

Timothy Kosinski,DDS,MAGD (2012)25

in his study stated that the

patient who underwent extraction with physics forceps were satisfied with

simplicity of procedure and its atraumatic nature.


9

Harsh S Patel,Anil M Managutti,Shailesh Menat,Arvind

Agarwal,Dishan Shah,Jigar Patel (2016)20

in their study compared the

efficacy of physics forceps with conventional forceps in terms of operating

time, prevention of marginal bone loss & soft tissue loss, postoperative pain

and postoperative complications following bilateral premolar extractions for

orthodontic purpose. They found mild swelling on 1st postoperative day in

2.38% (1 case) of extraction done by physics forceps and 4.76% (2 cases)

extractions done by physics forceps. Tooth fracture (irrespective of crown and

root fracture) was noted in 6% of total extractions which was equal in both

physics forceps and conventional forceps groups (3% each). Buccal cortical

fracture was noted in 4.76% of total extractions done by conventional forceps

and no cortical fracture in extractions done by conventional forceps. This

study suggested that physics forceps was more efficient in reducing operating

time and prevention of marginal bone loss & soft tissue loss when compared

to conventional forceps in orthodontically indicated premolar extractions.

Khaled K. Abou-ayasha, Sherif S. Ayyad, Riham M. Eldibany

(2016)24

designed a study to clinically and radiologically evaluate immediate

implant placement into fresh extraction sockets of maxillary anterior teeth

following extraction by physics forceps. This study was conducted on ten

adult patients of both sexes with age ranged between 20-40 years, having

maxillary anterior teeth indicated for extraction and immediate implant


10

rehabilitation. Patients were divided into two groups; each group contained

5 patients (a study group and a control group), in the study group, teeth

extraction was performed using the maxillary anterior physics forceps while in

the control group extraction was performed using the maxillary anterior

conventional forceps. Clinical evaluations were done in the immediate post-

operative period, after one week, after 1, 3 and 6 months. Radiographic

evaluations were done after 1, 3 and 6 months. Clinical results revealed that

there were statistically significant (p=0.016) results obtained in each group

separately throughout the evaluation period. This study concluded that

immediate implant placement following tooth extraction using Physics

forceps showed superior results in the immediate post-operative phase alone.

N.J. Perkins, H.M. Perez, C.E. Misch, R. Golden. St. Helen’s

(2010)39

in their study stated that as with any new technique there is a learning

curve for operators in making the transition from conventional forceps to

Physics Forceps, especially the effective use of wrist movement. Physics

Forceps represent an important addition to the armamentarium for atraumatic

exodontia.


11

Soumen Mandal, Shriparna Biswas Mandal,Vaibav

Kamal,Avanindra Kumar,Kamna Gorka,Avanish Kumar (2015)13

in

their study evaluated and determined the efficacy of the physics forceps in

nonsurgical mandibular single-rooted tooth extraction.The comparision

between the mean time taken for the extraction of a single-rooted tooth with a

physics forceps and a conventional forceps, which was 1.868 minutes with

physics forceps with a standard deviation of 1.503 minutes whereas with a

conventional forceps the mean time was 2.584 minutes with a standard

deviation of 1.831 minutes.23 out of 25 subjects reported no laceration with

the use of physics forceps whereas 8 out of 25 subjects reported laceration

with the use of conventional extraction forceps. This study concluded that

the extraction using the physics forceps were predictable in time commitment,

faster ,less traumatic physically and pshychologically to the patient

Sathish Madathanapalli, Sanidhya Surana,Deepak Thakur, Pooja

Ramnani, Sheetal Kapse (2016)29

conducted a study to compare the efficacy

of physics forceps vs conventional forceps for the extraction of the right and

left maxillary 1 st molars. They compared the physics forceps with the

conventional forceps for the removal of maxillary 1 st molars in 30 patients

under the following parameters time taken, post operative pain on the

3rd

,5th,7

th day, incidence of crown/root/buccal plate fracture during extraction.

There was a significant difference pertaining to the time taken (p=0.006) and


12

pain on the 3 rd postoperative day (p=0.031).On comparing all parameters

,they found out that the utility of this physics forceps is better in comparison to

the conventional forceps.

Marco Cicciù, Ennio Bramanti, Fabrizio Signorino, Alessandra

Cicciù and Francesco Sortino (2013)11

in their article analysed all the

applied movements when extracting healthy upper and lower jaw premolars

for orthodontic purposes. The results of the study demonstrated how the

strength, needed for performing the first upper premolar extraction is 25 times

higher than the lower jaw. This confirmed that tooth extraction of multi-root

teeth will result in a very difficult surgical operation. The rocking movement

recorded high values of +199 Nmm while the twisting recorded maximum

values of +8,69 Nmm. This data showed how the strength needed for double

rooted teeth extraction is not proportional to the strength needed for single

ones.This study concluded complications of tooth extraction are connected to

an incorrect force application


13

Egon Muska, DDS, Clemens Walter, DMD, Alan Knight, BDS,

Pankaj Taneja, BDS, Yogesh Bulsara,Michael Hahn, BDS, Mayur Desai,

and Thomas Dietrich, MD, DMD, MPH (2013)35

study conducted to

evaluate the applicability and limitations of a novel atraumatic extraction

system. The present study demonstrated a high success rate for the atraumatic

extraction of severely decayed teeth not suitable for forceps extraction with

the use of a novel vertical extraction system. Ninety-eight out of 111 teeth

were successfully extracted with the device, indicating an overall success rate

of 83%. The success rate was higher in single-rooted teeth (89%), whereas

fewer than one-half (43%) of multirooted teeth were successfully extracted.

The results of this proof of principle study suggest 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.

Harry Dym, DDS, Adam Weiss, DDS (2012)14

their article reviewed

and highlighted exodontia tips as well as new techniques to make simple and

complex exodontia more predictable and efficient with improved patient

outcomes. This article summarized that dentist requires some practice before

achieving complete mastery in the use of the physics forceps because the

technique is significantly different from what is used for conventional forceps


14

extractions; however, once comfortable, the clinician will marvel at the ease

and the little force required to remove even difficult teeth.

Rudys Rodolfo De Jesus Tavarez, Washigton Luís Machado dos

Reis, Adrycila Teixeira Rocha, Leily Macedo Firoozmand, Matheus

Coêlho Bandéca, Mateus Rodrigues Tonetto, Adriana Santos Malheiros

(2013) 52

presented a clinical case where the extraction was performed using

atraumatic extractor with implant placement and immediate provisionalization

in a maxillary lateral incisor.The clinical case described in this paper

demonstrates a sequence of clinical atraumatic extraction, and then the

Immediate installation provisionalization. It was concluded that when

carefully indicated and planned, this technique can provide an immediate

result promising with maintaining the tooth gingival contour.

Mohamed H. El-Kenawy • Wael Mohamed Said Ahmed (2015)28

conducted a study to evaluate the efficacy of physics forceps versus

conventional forceps in simple dental extraction . The incidence of crown,

root, and buccal bone plate fractures decreased while using physics forceps

when compared to the conventional forceps. In physics forceps group(100

cases): crown fracture occurred in three cases (3 %), buccal bone fracture

occurred in three cases (3 %), and root fracture occurred in 14 roots (8.5 %),


15

while in conventional forceps group(100 cases): crown fracture occurred in 10

cases (10 %), buccal bone fracture occurred in seven cases (7 %), and root

fracture occurred in 27 roots(16.6 %).This study suggested that the physics

forceps and its associated beak and bumper technique is clinically valuable in

atraumatic tooth removal and in preserving the buccal bone plate, which is

mainly critical for implant dentistry.

Sonune Avinash M., Borle Rajiv M., JadhavAnendd A. (2017)47

conducted a study to evaluate the efficacy between the conventional

extraction forceps and physics forceps in orthodontic extraction of maxillary

premolars. In this study, mean time taken for extraction by conventional

forceps(19.42 sec) was found to be significantly lesser as compared to

physics forceps (33.64 sec) and there was buccal cortical plate fractures in 12

patients while using the conventional extraction forceps and no buccal plate

fracture with use of physics forceps group. This study suggested that physics

forceps have certain advantages over conventional method of extraction in

multi rooted, decayed tooth but there are no such obvious results found to

indicate consideration of physics forceps over conventional forceps for

orthodontic extraction in routine practice.


16

Yong-Hoon Choi*, Ji-Hyun Bae (2011)10

in their study stated

atraumatic safe extraction (ASE) can be regarded as a reproducible,

predictable method of extraction for Intentional Replantation. A Physics

Forceps was used for extraction and the success rate of ASE was assessed.

Ninety-six premolars and molars were treated by Intentional Replantation. The

complete success rate (no crown and root fracture) was 93% (n = 89); the

limited success rates because of partial root tip fracture and partial osteotomy

were 2% (n = 2) and 5% (n = 5), respectively. The clinical and overall success

rates of ASE were 95% and 100%, respectively; no failure was observed. This

study concluded that the ASE method should be considered as reliable

extraction method for safe and successful Intentional Replantation; it is

expected to contribute greatly to save natural teeth. However, long-term

observation of its prognosis is required.

Samyuktha Hariharan, Vinod Narayanan, Chen Loong Soh

(2014)19

compared outcome variables (operative complications, inflammatory

complications, and operating time) in patients being treated by orthodontic

extraction of upper premolars with the Physics forceps or the universal

extraction forceps. They organised a single blind, split mouth clinical trial to

compare the outcomes of the 2 groups (n=54 premolars). The Physics forceps

group had lower mean (SD) visual analogue scores (VAS) for pain (0.59

(0.57)) on the first postoperative day than the other group (1.04 (0.85))


17

(p=0.03). There were no other significant differences between the 2 groups in

any other variable studied. The authors reported that the mean operating time

was less using Physics forceps (120.5seconds) than with the universal

extraction forceps (188.6seconds). The incidence of fractures of the bony plate

fractures was 22% in the Physics forceps group compared with 25% in the

conventional forceps group and found that the mean operative time using the

Physics forceps for extraction of upper premolars was 21.4 (27.3) seconds and

43.5 (49.5) seconds for the universal extraction forceps

Charles A. Babbush, DDS, MScD (2007)6 in their article reviewed

the mechanisms involved in traditionally extracting teeth, and discusses a

technological breakthrough that enables non molar intact teeth to be extracted

mechanically and atraumatically. This article summarized “The Easy X-Trac

System” represents a revolution in exodontia. Instead of pulling and twisting

the tooth root to be extracted, the surgeon secures a screw within the root, then

uses a simple mechanical device to lift the screw and root atraumatically.

Carl E.Misch, DDS MDS; Helena M.Perez, DDS (2008)33

in their

article reviewed the biomechanics of a periotome, an elevator, and extraction

forceps. Those methods will be compared to the biomechanical principles used

in the atraumatic extraction of teeth utilizing a new forceps design. They


18

summarized the mechanical advantages available to extract the teeth were

primarily applied to hold the crown of the tooth, rather than aiding in its

extraction. An extraction device (physics forceps) has been developed to apply

a biomechanical rationale to the extraction process of a tooth using a class 1

lever, creep, and shear components of force.

Materials and Method

Materials and Methods

19

MATERIALS AND METHODS

This study was conducted at Department of Oral and Maxillofacial

Surgery, Ragas Dental college and Hospital, Uthandi. A total of 30 patients

who required tooth extraction were included in this clinical study. A clearance

for performing the study was obtained from the institutional ethical

committee, and each patient was given a brief description of the intended

procedure with follow period and was required to sign an informed consent

sheet.

The recorded Data included age, sex, chief complaint, medical and

dental history, clinical findings, radiographic findings, duration of procedure,

The following parameters was evaluvated, ie PAIN-(VAS) ,GINGIVAL

INDEX- (Landry et al) on 3rd

,5th,7

th post-operative day.

INCLUSION CRITERIA

Ellis class III,IV,V,VI,VII,VIII,IX

Grossly decayed tooth

Fracture of teeth below alveolar crest

Root canal treated tooth


20

EXCLUSION CRITERIA

• Ellis class I fracture

• Ellis class II fracture

• Severely malpositioned teeth

• Tooth with Grade II, Grade III mobility

• Teeth with true pocket

• Teeth with clinical attachment loss

• Medically compromised patients

• Patients not willing for extraction

ARMAMENTARIUM USED

• 2% lignocaine with1:80,0000 adrenalin

• Molt no 9 periosteal elevator

• William’s probe

• Maxillary physics forceps

• Mandibular physics forceps

• Gauze

• Suture material ( if needed )


21

SURGICAL TECHNIQUE DURING EMPLOYMENT OF PHYSICS

FORCEPS

• Tooth to be extracted is anaesthetised with Local Anaesthesia

(2% Lignocaine with 1:80,000 adrenalin )

• Lingual and buccal gingival attachment is separated from the tooth

using mucoperiosteal elevator (Molt No.9)

• Forceps handles are opened widely, beak is set into the depth of the

lingual or palatal sulcus on solid root surface. Secure purchase point on

solid root surface is critical to successfully rolling out the tooth.

• The bumper (which is covered by plastic or rubber to avoid trauma to

the buccal soft tissues) is set perpendicular to the tooth at about the

level of the mucogingival junction.

• Position was held securely without squeezing the handles.

• A steady and slow rotational force is applied in the direction of the

bumper without squeezing the handles or moving the arm.

• As the periodontal ligament disengages, the tooth literally “pop”

(Fig 12,15).

• After that releasing pop, the tooth is easily delivered with a

conventional instrument.


22

• All the patients were prescribed following medications: Cap.

Amoxicillin 500mg (TID)-3days,Tab.Metrogyl 400mg (TID)-

3days,Tab. Diclofenec Sodium 50mg (BD)-3 days, Tab. Ranitidine

150mg (BD)-3days

EVALUATION CRITERIA

Tooth delivered using

PHYSICS FORCEPS OPEN METHOD

Trauma to the gingiva (mucosal tear)

YES NO

Fracture of alveolar bone (socket intact)

YES NO

Time taken for procedure ----


23

HEALING INDEX -LANDRY ET AL

Very poor

-tissue colour: greater than or equal to 50% of gingiva red

-response to palpation: bleeding

-granulation tissue: present

- incision margin: not epithelialised, with loss of epithelium

beyond incision margin

- suppuration present

Poor

-tissue colour: greater than or equal to 50% of gingiva red

-response to palpation: bleeding

-granulation tissue: present

-incision margin: not epithelialised with connective tissue

exposed

Good

-tissue colour: greater than or equal to and less than 50% of

gingiva red

-response to palpation: no bleeding

-granulation tissue: none


24

-incision margin: no connective tissue exposed

Very good

-tissue colour: less than 25%of gingiva red




Excellent

-tissue colour: all tissues pink




DAY-3

POST-OP Healing index (Landry et al )

Very Poor

Poor

Good

Very Good

Excellent


25

POST-OP PAIN (VAS)

DAY-5


Very Poor

Poor

Good

Very Good

Excellent


26

POST-OP PAIN (VAS)

DAY -7


Very Poor

Poor

Good

Very Good

Excellent


27

POST-OP PAIN (VAS)


28

CASE HISTORY

OP NO

DATE

NAME

AGE/SEX

OCCUPATION

WEIGHT

RELIGION

PHONE NO

ADDRESS

CHIEF COMPLAINT

HISTORY OF PRESENTING ILLNESS


29

PAST MEDICAL HISTORY

PAST DENTAL HISTORY

PERSONAL HISTORY

EXTRA-ORAL EXAMINATION

FACE -

LIPS -

TEMPOROMANDIBULAR JOINT –

LYMPH NODES –


30

INTRA-ORAL EXAMINATION

INVESTIGATIONS

DIAGNOSIS

TREATMENT PLAN

SURGICAL NOTES


31

PROCEDURE

STARTING TIME –

FINISHING TIME –

TIME TAKEN FOR PROCEDURE -

TOOTH DELIVERED USING

PHYSICS FORCEPS

OPEN METHOD

TRAUMA TO THE GINGIVA (MUCOSAL TEAR )

YES

NO

TRAUMA TO GINGIVA :PRESENT/ABSENT

Figures

Figures

INSTRUMENTATION

Fig 1.Right maxillary posterior physics forceps

Fig 2.Instrument code for Right maxillary posterior physics forceps

Figures

Fig 3.Left maxillary posterior physics forceps

Fig 4.Instrument code for Left maxillary posterior physics forceps

Figures

Fig 5.Maxillary anterior physics forceps

Fig.6.Instrument code for Maxillary anterior physics forceps

Figures

Fig 7.Mandibular universal physics forceps

Fig 8.Instrument code for Mandibular universal physics forceps

Figures

Fig 9. Bumper –which act as a fulcrum

Fig 10. Stop watch used to record time taken to complete the procedure

Figures

CASE I

Fig 11.Pre-operative IOPA

Fig 12.Intra-operative application of physics forceps

Fig 13.Post-operative extraction site

Figures

CASE II

Fig 14.Pre-operative IOPA

Fig 15. Intra-operative application of physics forceps

Fig 16.Post-operative extracted socket

Results

Results

32

RESULTS

The present prospective, clinical study was conducted to evaluvate the

possibility of avoiding a trans-alveolar method for extraction of mutilated

tooth using physics forceps. In our study, 30 patients who required extraction

of mutilated tooth was taken into the study design. All those 30 patients

reported to the outpatient Department, Department of oral and maxillofacial

surgery, Ragas Dental College, Uthandi, Chennai for tooth extraction.

All 30 patients were examined and assessed with radiographs

(Fig 11,14) .Out of 30 patients, (Table,Graph 1) 26 were male and 4 were

female in ratio of 6.5:1 . The mean (SD) age who underwent extraction using

physics forceps was 37.92 years(Table 13), range 21-65, of which 9 were

female and 17 male whereas who underwent transalveolar extraction was

28.25 years(Table 13) ,range from 21-65 of which 2 were female and 2 male.

Out of 30 patients,26 patients underwent extraction using physics

forceps and 4 patients underwent transalveolar method of extraction (Table 4).

All 4 patients with transalveolar method (Table,Graph 3) had grossly decayed

with root canal treated few years back.

On day of extraction; operating time, patient comfort, gingival trauma

were assessed for made for both the group of patients who underwent

extraction with physics forceps and transalveolar method of extraction.

Results

33

Postoperative healing was recorded with HEALING INDEX-LANDRY ET

AL and postoperative pain was recorded on VAS SCALE .Both were

recorded on 3rd ,5th,7

th post-op day.

EXTRACTION TIME: Operating time was recorded using a stop

watch (Fig 10) from the beginning of extraction after the local anaesthetic had

been injected to the completion of the extraction. Time taken to extract a tooth

can be considered as a time period from engaging a tooth by forceps to

completely removing it out of socket. Out of 26 subjects who underwent

extraction using physiscs forceps, (Table,Graph 6) 18 reported extraction

below 5mins;8 reported between 5-10 mins; and none reported more than 10

min. Out of 4 subjects who underwent transalveolar extraction reported

extraction time more than 10 min. The operating time was shorter when the

patient underwent extraction using Physics forceps than for the transalveolar

extraction and there was statistically significant difference in the operating

time between two groups(p<0.001)

PATIENT COMFORT: All 26 patients had good comfort during

extraction with physics forceps while 4 patients had mild discomfort with

transalveolar extraction, there was statistically significant difference in the

patient comfort between two groups (p<0.001)(Table 13)

TRAUMA TO GINGIVA: Trauma to gingiva was noted in 3 patient

with transalveolar extraction and with physics forceps none was noted

Results

34

(Table,Graph 5), there was statistically significant difference in the gingival

trauma between two groups (p<0.014)(Table 13)

PAIN SCORE: Postoperative pain measured on VAS scale was

recorded on 3rd, 5th,7

th post-op day. Out of 26 patients (Table 9), only 7

reported with pain on 3rd

day with physics forceps. On follow up on 5th

day,

only 1 reported with pain and on 7th

day none reported with pain. Mean VAS

score within group (physics forceps) was 0.001(Table 15). Out of 4 patients

who underwent transalveolar extraction, (Table 10) 3 reported with pain on

3rd day. On follow up on 5th day 2 reported with pain and on 7

th day none

reported with pain. Mean VAS score within group (transalveolar extraction)

was 0.082(Table 15).Mean VAS Score (Table 15) on 3rd post-op day with

physics forceps and transalveolar extraction were 0.002 and on 5th day 0.039

.There was statistically significant reduction in the pain score in physics

forceps group postoperatively.

HEALING SCORE: All 26 patients who underwent extraction using

physics forceps had good healing postoperatively and hence mean healing

score were p<0.001.While all 4 patients who underwent transalveolar

extraction had poor healing on 3rd

day post-op, and 3 had poor healing on 5th

day post-op and on 7th day all 4 had good gingival healing. Hence mean

healing score with transalveolar extraction were p<0. 039.There was

statistically significant difference between two groups in the gingival healing

postoperatively(p<0.001) (Table 14)

Tables and Graphs

Tables and Graphs

35

TABLE1: DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO

GENDER

TABLE2: DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO

AGE

AGE TOTAL NO PERCENTAGE%

18-28

10 33.3%

29-38

9 30%

39-49

7 23.3%

50 ABOVE

4 13.3%

GENDER TOTAL NO PERCENTAGE %

MALE 19 63.4%

FEMALE 11 36.7%

Tables and Graphs

36

TABLE 3: DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO

THE INDICATION FOR EXTRACTION

INDICATION FOR

EXTRACTION

TOTAL NO PERCENTAGE%

GROSSLY DECAYED 20 66.7%

FRACTURED TOOTH 3 10%

ROOT CANAL TREATED

TOOTH

4 13.3%

FRACTURE OF TOOTH

BELOW ALVEOLAR

CREST

3 10%


THE METHOD OF EXTRACTION

TOOTH DELIVERED TOTAL NO PERCENTAGE%

PHYSICS FORCEPS 26 86.7%

OPEN METHOD 4 13.3%

Tables and Graphs

37


THE GINGIVAL CONDITION AT THE TIME OF EXTRACTION

TRAUMA TO

GINGIVA


YES 3 10%

NO 27 90%


THE TIME TAKEN TO COMPLETE THE PROCEDURE

TIME TAKEN FOR

PROCEDURE


0-5 MIN 18 60%

5-10 MIN 8 26.7%

ABOVE 10 MIN 4 13.3%

Tables and Graphs

38


THE STATUS OF ALVEOLAR BONE (SOCKET INTACT) AT THE

TIME OF EXTRACTION

CONDITION OF

ALVEOLAR BONE

(SOCKET INTACT)


YES 27 90%

NO 3 10%


THE STATUS OF POST-OPERATIVE COMPLICATION REVIEWED

ON DAY 3, DAY5, DAY 7 FROM THE DAY OF EXTRACTION

POST-OP COMPLICATION

METHOD OF

EXTRACTION

DAY 3 (NO) DAY 5(NO) DAY 7(NO)

PHYSICS

FORCEPS

3 2 0

OPEN METHOD 2 0 0

Tables and Graphs

39


THE STATUS OF POST-OPERATIVE PAIN RECORDED FOR

PATIENTS WHO UNDERWENT EXTRACTION USING PHYSICS

FORCEPS (VAS SCALE) REVIEWED ON DAY 3, DAY5,DAY 7


POST-OP PAIN-VAS

ANALOGUE

PAIN PERCENTAGE%

DAY 3 7 27%

DAY 5 1 3.9%

DAY 7 0 0%

TABLE 10: DISTRIBUTION OF STUDY SUBJECTS ACCORDING

TO THE STATUS OF POST-OPERATIVE PAIN RECORDED FOR

PATIENTS WHO UNDERWENT EXTRACTION WITH TRANS-

ALVEOLAR METHOD(VAS SCALE) REVIEWED ON DAY 3,

DAY5,DAY 7 FROM THE DAY OF EXTRACTION

POST-OP PAIN-VAS

ANALOGUE

PAIN PERCENTAGE%

DAY 3 3 75%

DAY 5 2 50%

DAY 7 0 0%

Tables and Graphs

40


TO THE HEALING CONDITION RECORDED FOR PATIENTS WHO

UNDERWENT EXTRACTION USING PHYSICS FORCEPS

(LANDRY ET AL) REVIEWED ON DAY 3, DAY5,DAY 7 FROM THE

DAY OF EXTRACTION

POST-OP HEALING DAY 3 DAY 5 DAY 7

VERY POOR 0 0 0

POOR 0 0 0

GOOD 26 0 0

VERY GOOD

0 26 0

EXCELLENT 0 0 26

Tables and Graphs

41


TO THE HEALING CONDITION RECORDED FOR PATIENTS WHO

UNDERWENT EXTRACTION WITH TRANSALVEOLAR METHOD

(LANDRY ET AL) REVIEWED ON DAY 3, DAY5,DAY 7 FROM THE

DAY OF EXTRACTION

POST-OP HEALING DAY 3 DAY 5 DAY 7

VERY POOR 0 0 0

POOR 4 3 0

GOOD 0 1 0

VERY GOOD

0 0 4

EXCELLENT 0 0 0

Tables and Graphs

42

STATISTICS:

Inferential statistics was used for comparision between the two groups

(Physics forceps and Transalveolar method of extraction).Chi square and

Mann-Whitney for intergroup comparision; . Kruskal Wallis for within group

comparision; Friedman Test was done for within group comparision at

different time intervals

Table 13; Descriptives:Distribution and comparision of study group

characteristics at base line.

*Kruskal Wallis

ǂ Mann-Whitney

Type of

procedure

Total

Subjects

Mean

Age (yrs)

Sex Time taken Patient

comfort

Gingival Trauma

Male Female 0-5

min

5-10

min

>10

min

Yes No Yes No

Physics

forcep

26 37.92 ±

14.3

17 9 18 8 - 26 - - 26

Trans-

alveolar

4 28.25 ±

6.02

2 2 - - 4 - 4 3 1

p Value* <0.001* <0.001ǂ 0.014ǂ

Tables and Graphs

43

Table 14; Healing Index:Distribution and comparision of characteristics

of study groups at different time intervals.

*Chi Square

ǂFriedman Test

Time Physics Forceps Transalveolar

Very Poor

Poor Good Very

Good

Excellent Very Poor

Poor Good Very Good

Excellent P value

3rd

DAY

- - 19 7 - - 4 - - - <0.001

5th

DAY

- - 6 15 5 - 3 1 - - <0.001

7th

DAY

- - - 13 13 - - 4 - - <0.001

P

Valueǂ <0.001 0.039

Tables and Graphs

44

Table 15; Pain Index: Distribution and comparison of characteristics of

study groups at different time intervals

Time Physics Forceps Transalveolar P

Value*

No Pain

Mild Moderate Severe No Pain Mild Moderate Severe

3rd

DAY

19 6 - 1 1 1 2 - .002

5th

DAY

25 1 - - 2 2 - - .039

7th

DAY

26 - - - 4 - - - -

P

Valueǂ

0.001 0.082

*Chi Square

ǂFriedman Test

Tables and Graphs

45

0

2

4

6

8

10

12

14

16

18

20

MALE(19) FEMALE(11)

GRAPH 1: DISTRIBUTION OF STUDY

SUBJECTS ACCORDING TO GENDER

MALE(19) FEMALE(11)

0

2

4

6

8

10

12

14

18-28 29-38 39-49 50 ABOVE


SUBJECTS ACCORDING TO AGE

18-28 29-38 39-49 50 ABOVE

Tables and Graphs

46

0

5

10

15

20

25

GROSSLY DECAYED (20) FRACTURED TOOTH (3) ROOT CANAL TREATED TOOTH (4)

FRACTURE OF TOOTH BELOW ALVEOLAR CREST

(3)

GRAPH 3: DISTRIBUTION OF STUDY SUBJECTS

ACCORDING TO THE INDICATION FOR

EXTRACTION

GROSSLY DECAYED (20)

FRACTURED TOOTH (3)

ROOT CANAL TREATED TOOTH (4)

FRACTURE OF TOOTH BELOW ALVEOLAR CREST (3)

Tables and Graphs

47

0

5

10

15

20

25

30


SUBJECTS ACCORDING TO THE METHOD

OF EXTRACTION

PHYSICS FORCEPS (26) OPEN METHOD (4)

Tables and Graphs

48

0

10

20

30

40

50

60

70

80

90

100

TRAUMA TO GINGIVA - YES (3) TRAUMA TO GINGIVA - NO (27)


SUBJECTS ACCORDING TO THE GINGIVAL

CONDITION AT THE TIME OF EXTRACTION

TRAUMA TO GINGIVA - YES (3) TRAUMA TO GINGIVA - NO (27)

0

2

4

6

8

10

12

14

16

18

20

0-5 MIN (18) 5-10 MIN (8) ABOVE 10 MIN (4)


ACCORDING TO THE TIME TAKEN TO

COMPLETE THE PROCEDURE

0-5 MIN (18) 5-10 MIN (8) ABOVE 10 MIN (4)

Tables and Graphs

49

0

5

10

15

20

25

30

SOCKET INTACT YES (27) SOCKET INTACT NO (3)


ACCORDING TO THE CONDITION OF ALVEOLAR

BONE(SOCKET INTACT) AT THE TIME OF

EXTRACTION

SOCKET INTACT YES (27) SOCKET INTACT NO (3)

Tables and Graphs

50

0

0.5

1

1.5

2

2.5

3

3.5

PHYSICS FORCEPS OPEN METHOD


ACCORDING TO THE CONDITION OF POST-

OPERATIVE COMPLICATION REVIEWED ON DAY

3, DAY5,DAY 7 FROM THE DAY OF EXTRACTION

DAY 3 (NO) DAY 5(NO) DAY 7(NO)

Tables and Graphs

51

0

1

2

3

4

5

6

7

8

DAY 3 (7) DAY 5 (1) DAY 7 (0)


ACCORDING TO THE CONDITION OF POST-

OPERATIVE PAIN RECORDED FOR PATIENTS

WHO UNDERWENT EXTRACTION USING

PHYSICS FORCEPS(VAS SCALE) REVIEWED ON

DAY 3, DAY5,DAY 7 FROM THE DAY OF

EXTRACTION

DAY 3 (7) DAY 5 (1) DAY 7 (0)

Tables and Graphs

52

0

0.5

1

1.5

2

2.5

3

3.5

DAY 3 (3) DAY 5 (2) DAY 7 (0)


SUBJECTS ACCORDING TO THE CONDITION

OF POST-OPERATIVE PAIN RECORDED FOR

PATIENTS WHO UNDERWENT EXTRACTION

WITH TRANSALVEOLAR METHOD(VAS

SCALE) REVIEWED ON DAY 3, DAY5,DAY 7


DAY 3 (3) DAY 5 (2) DAY 7 (0)

Tables and Graphs

53

0

5

10

15

20

25

30

VERY POOR POOR GOOD VERY GOOD EXCELLENT


ACCORDING TO THE HEALING CONDITION

RECORDED FOR PATIENTS WHO UNDERWENT

EXTRACTION USING PHYSICS FORCEPS

(LANDRY ET AL) REVIEWED ON DAY 3, DAY5,DAY


DAY 3 DAY 5 DAY 7

Tables and Graphs

54

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

DAY 1 DAY 2 DAY 3


ACCORDING TO THE HEALING CONDITION

RECORDED FOR PATIENTS WHO UNDERWENT

EXTRACTION WITH TRANSALVEOLAR METHOD

(LANDRY ET AL) REVIEWED ON DAY 3, DAY5,DAY


VERY POOR POOR GOOD VERY GOOD EXCELLENT

Discussion

Discussion

55

DISCUSSION

Tooth extraction requires controlled force and fineness for atraumatic

extractions. Various instruments and techniques have been described to aid

atraumatic tooth extraction. The advantage of physics forceps over

conventional forceps and all other extraction techniques is related to their

unique design that can employ a powerful mechanical advantage by

employing an efficient first-class lever. Unlike the conventional forceps

extraction technique, in physics forceps the buccal portion of the beak is a

plastic covered bumper which is placed apically in the vestibule and work by

rotation of the wrist rather than a squeezing movement.

In physics forceps the length of the forceps handle to the bumper is 8

cm and the distance from the bumper to beak is 1 cm so the torque force that is

generated on the tooth, periodontal ligament, and bone is equal to length of

handle (8cm) divided by the distance from the bumper to the beak of the

forceps (1cm), so the force that is applied on the handle attached to the

bumper will therefore increase the force on the tooth, periodontal ligament,

and bone by about 8 times. The force applied by the bumper onto the gingiva

and bone is distributed over a larger surface area and is a compressive force,

so the tooth and alveolus do not fracture. Once the tooth is subluxated it can be

delivered with the help of conventional forceps or a rongeur (19)

.

According to Dym and Weiss14

, there is no need to raise a

mucoperiosteal flap or use an elevator before attempting extraction with the

Discussion

56

Physics forceps. This is a major advantage, particularly in cases that require

atraumatic extraction. Yong-Hoon Choi10

stated that Atraumatic safe

extraction (ASE) should be considered as reliable extraction method for safe

and successful intentional replantation (IR) and added that even multirooted

molars can be extracted safely without fracture using the physics forceps.

According to khaled K24

, physics forceps applied a constant and steady

pressure with the wrist only, that helps to decrease the incidence of buccal

bone fracture. In addition the bumper applies a compressive force at the buccal

bone as it was positioned on the buccal alveolar ridge, resulting in holding and

supporting the bone in its place. This result was in agreement with the result of

Kosinski25

who stated that the buccal movement applied by physics forceps

was slow and generally insufficient to fracture the buccal bone plate and

concluded that immediate implant placement following tooth extraction using

Physics forceps showed superior results in the immediate post-operative phase

only.

The application of the Physics Forceps involves 6 stages: (1)

Separation of the gingival attachment from the tooth (e.g. using a periosteal

elevator, Molt No 9); (2) Placement of the ‘beak’ onto a secure palatal/lingual

application point (root surface); (3) Placement of the ‘bumper’ (with single-

use plastic sleeve attached) onto the buccal aspect of the alveolus at the level

of the mucogingival junction (this acts as a fulcrum; braces and protects the

buccal plate); (4) Application of a steady slow rotational force (facilitates

creep in the periodontium) using only wrist movement for 30–40 seconds;

Discussion

57

(5) Occlusal elevation of the tooth a few millimetres from its socket;

(6) delivery of the tooth using a haemostat/rongeurs/conventional forceps.

Time taken to extract a tooth can be considered as a time period from

engaging a tooth by forceps to completely removing it out of socket . In our

study(Table,Graph 13) it was found that the time required to extract using

physics forceps was significantly lesser as compared to that of conventional

forceps (p<0.001). It is in accordance with Mandal S et al 30

., in their

comparative study also reported the same results with mean extraction time of

139.8 sec using physics forceps and 236 sec using conventional

forcepsWhereas S Hariharan et al 19

., in their study did not find significant

difference in time taken, with mean extraction time using physics forceps 29.4

sec and conventional forceps 43.5 sec

In our study, all 26 patients had good comfort with physics forceps

while with transalveolar extraction all patients had even postoperative

discomfort which is in accordance with Dr. Soumen Mandal 13

which stated

that all the transalveolar extraction complication not only cause post-op

discomfort to the patient but also lead to difficulty in immediate implant

placement. Trauma to gingiva is the common complication that arise due to

traumatic extraction which gives pain and discomfort to the patient

postoperatively hence atraumatic extraction do not cause any damage to

gingiva.

In our study (Table,Graph 5)., Trauma to gingiva was noted in 1 patient

with transalveolar extraction and 3 patients with transalveolar and physics

Discussion

58

forceps extraction noted none(p<0.014). Design of physics forceps is such that

forces are applied on buccal gingiva through bumper, which can contribute to

crushing injury. Bleeding is always associated with trauma. After tooth

extraction the bleeding is usually occurs due to trauma to the investing tissues.

During dental extractions, barring systemic causes, bleeding usually occurs

following shearing of PDL ligaments, microfractures of cortical plates, antral

perforations, presence of granulation tissue and rarely from apical / nutrient

foramen.

Physics forceps have certain advantages over conventional method of

extraction in multi rooted, decayed tooth. , Saumen mandel13

in his study

found more gingival laceration with the application of conventional forceps.

Sonune Avinash M46

in his study concluded that Gingival laceration can be

avoided by careful retraction immaterial of forceps used. Bleeding with

physics forceps was less owing to less soft and hard tissue trauma during

extraction. Harsh S Patel(20)

in his study found significant difference of

mean changes in pre extraction and post extraction gingival level using

physics forceps and conventional forceps which suggested that physics forceps

was comparatively less traumatic to the gingival tissues when compared to

conventional forceps. Mandal S et al 30

, compared the gingival tissue status

following extraction using physics forceps and conventional forceps by

clinically examining for the presence or absence of laceration on marginal

gingiva. They found gingival laceration in 16.6% in physics forceps group and

Discussion

59

52.38% in conventional forceps group and concluded physics forceps can

performs extractions less traumatically than conventional forceps.

Pain is purely a subjective symptom. It can vary from person to person

and in same person at different times. Postoperative pain due to traumatized

hard tissues may be from bruising of bone during instrumentation or from

allowing a bur to overheat during bone removal. Avoidance of these errors of

technique and attention to the smoothing of sharp bone-edges and socket toilet

eliminate this pain. Soft tissues may be damaged in several ways. An incision

which passes through only one layer of the gingiva may lead to the mucous

layer being separated from the periosteum, with the formation of a ragged flap

which heals slowly. If a flap is too small, much traumatic retraction may be

required to secure access, and if the soft tissues are not properly protected they

may become entangled with a bur. All these errors of technique and their

sequelae are preventable.

Postoperative pain measured on VAS scale was recorded on 3rd

, 5th

,

and 7th

post-op day. Out of 26 patients, only 7 reported with pain on 3rd day

with physics forceps. On follow up on 5th day only 1 reported with pain and on

7th day none reported with pain. Mean VAS score (Table 15) within group

(physics foceps) was 0.001.Out of 4 patients who underwent transalveolar

extraction,3 reported with pain on 3rd day. On follow up on 5 th day 2

reported with pain and on 7 th day none reported with pain. Mean VAS

score(Table 15) within group (transalveolar extraction) was 0.082.Mean VAS

Discussion

60

Score on 3rd

post-op day with physics forceps and transalveolar extraction

were 0.002(Table 15)and on 7 th day 0.039(Table 15) .Any other

complications were also recorded on 3rd post op day. Postoperative pain in

extractions done by physics forceps and conventional forceps using Visual

Analogue Scale (VAS) was also measured by Harsh S Patel 20

in his study

and his results suggested that there was no statistically significant difference in

VAS score on 1st and 3rd postoperative days between two groups however

lower mean VAS score was noted in the physics forceps group which may be

attributed to comparatively less traumatic extractions done by physics forceps.

The results are at par with the conclusions of S Hariharan et al 19

., who found

significantly lesser postoperative pain in physics forceps group on first

postoperative day when compared to conventional forceps. Satish

Madathanapalli et al 29

noted statistically significant difference on 3rd day

while there was no difference seen on the 5th and 7th

post-operative day.

Sonune Avinash M 47

in his study measured postoperative pain on VAS scale

recorded from day 0 to day 7. On evaluation pain was observed in

conventional till day 3 and in physics forceps group till day 4 after which pain

was subsided in both the groups. Mean VAS score on 1st post op day using

conventional forceps and physics forceps were 1.56 and 1.68 respectively.

Mean VAS score on 3rd post op day using conventional forceps and physics

forceps were 0.62 and 0.68 respectively. However, the difference in pain score

using either forceps were not statistically significant(p=0.52,0.87) (47)

. In our

study, there was statistically significant difference in the pain score both

Discussion

61

within groups(p=0.001,0.082) and between two groups(p=0.002,0.039)

postoperatively(Table 15).

If the soft tissues were not handled carefully during an extraction

traumatic oedema may delay healing. The use of blunt instruments, the

excessive retraction of badly designed flaps, or a bur becoming entangled in

the soft tissues predispose to this condition. Postoperative healing measured

with HEALING INDEX-LANDRY ET AL and postoperative pain measured

on VAS SCALE .Both were recorded on 3rd

,5th,7

th post-op day. In our

study,all 26 patients who underwent extraction using physics forceps had good

healing postoperatively and hence mean healing score were p<0.001.While all

4 patients who underwent transalveolar extraction had poor healing on 3 rd

day postop, and 3 had poor healing on 5 th day postop and on 7 th day all 4

had good gingival healing. Hence mean healing score with transalveolar

extraction were p<0.039(Table 14). Healing of soft tissue wound is an

orchestrated event. Sonune Avinash M 47

in his study stated that healing is

influenced by number of local and systemic factors and noted that there were

no statistically significant differences in soft tissue healing in both physics

forceps and conventional forceps groups on 7th, 14th and 21stpost operative

day. In our study, there was statistically significant difference between two

groups in the gingival healing postoperatively(p<0.001)

In our study, none of the patients who underwent extraction

with physiscs forceps had buccal cortical bone fracture and 4 patients who

Discussion

62

underwent transalveolar extraction had crestal bone loss as it involves bone

guttering to remove tooth. Out of 4 patients who underwent transalveolar

extraction, 3 were root canal treated and were tried to be extracted using

physics forceps but was unsuccessful. This could be owing to the fact that the

root canal treated teeth weakens over time and making it brittle thus posing

major challenge for the physics forceps to extract it . All 26 patients who

underwent extraction with physics forceps had good comfort while 4 patients

with transalveolar extraction had discomfort with excessive bleeding as they

had gingival laceration. All the above mentioned patients with transalveolar

extraction received simple interrupted suturing (3-0 silk) and postoperative

instructions were given. Sutures were removed on 7 th postop day.

Summary and Conclusion


63

SUMMARY AND CONCLUSION

In this prospective clinical study, we evaluated possibility of avoiding

transalveolar extraction in mutilated tooth by employing physics forceps.

Physics forceps have certain advantage over conventional method of

extraction in multi rooted, decayed tooth. Statistically significant findings

were observed in time taken for extraction, patient comfort, gingival

laceration, soft tissue healing and post-operative pain between two groups.

Hence atraumatic extraction can be achieved with the physics forceps. It can

also be used for immediate implant placement, intentional replantatation,

orthodontic extraction as it maintain the socket integrity by preventing any

disturbance to the soft tissue and hard tissue architecture and thus making

future prosthetic management easier.

ADVANTAGE OF OUR STUDY

1. Single operator study.

2. Traumatic extraction can be avoided with the use of physics forceps

3. Post-operative complications after extraction can be minimised

4. Operating time with the use physics forceps is less

5. Post-operative extraction pain is minimized and healing is uneventful

with the use of physics forceps

6. Procedure is done in atraumatic manner with minimal manipulation of

hard and soft tissue, thus facilitating implant placement.


64

DISADVANTAGE OF OUR STUDY

1. Physics forceps application mostly fails for root canal treated tooth,

teeth with multirooted or diverged root.

2. The cost of a physics forceps is high when compared to conventional

forceps hence the usage of physics forceps in routine clinical practice

is less viable.

3. Learning curve is steep even for an experienced practitioner

CONCLUSION

In our study, we would like to conclude that we could avoid

transalveolar extraction in 87% of mutilated teeth. Hence from the findings of

our study, we advocate that the use of physics forceps would reduce the rate of

transalveolar extraction in mutilated teeth. Further it provides a smoother,

uneventful post-operative healing in patients who require extraction of

mutilated teeth. We would like to highlight, inspite of the higher cost of

instrument and a steep learning curve, it would be commonly employed in

future to perform atraumatic extraction of mutilated tooth. In majority of cases

employment of transalveolar method can be avoided by proper usage of

physics forceps in mutilated tooth.

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Annexures

Annexures

Annexure – I

Annexures

Annexure – II

CONSENT FORM

I ____________________ Age___Residing at ______________ ______

__________ have been informed that my tooth is severely mutilated and

the chances of tooth fracture is high when conventional intra-alveolar method

of extraction is performed using conventional forceps.I have been informed

about the possibility of removing my offending teeth with novel instrument

called “PHYSICS FORCEPS”.I have also been informed in the eventuality of

not being able to remove the offending teeth using physics forceps,

conventional trans-alveolar method is performed to remove the offending

tooth

Signature of the investigator Signature of the participant

Date:

Signature of the witness

Place:

Annexures

Annexure – III

APPLICATION OF PHYSICS FORCEPS FOR EXTRACTION OF …repository-tnmgrmu.ac.in/9911/1/240302318narasimman.pdf · 2018-10-24 · transalveolar extraction in 87% of mutilated teeth. Hence

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