| Abstract|| |
Purpose: The history of dentistry is not short; it started from ancient Egypt to ancient Romans and ancient Greeks. When it comes to extraction, all of them have made their own discoveries and progress. The progress they made also helped dentistry to move ahead in evolution of new extraction technique – the Physics Forceps. We have assessed the viability in using the Physics Forceps for routine dental extraction in our study for a period of 1 year. Materials and Methods: The study was conducted on 241 patients indicated for extraction based on our inclusion criteria using Physics Forceps after obtaining informed consent and University Ethics Committee approval. Tooth fracture, buccal alveolar bone fracture, and soft tissue injury around the tooth to be extracted were studied. Results: In our present study of 241 patients, 57.67% were females and 42.32% were males, out of which 93.77% had no tooth fracture, 3.32% had crown fracture, 1.65% had root fracture, and 1.24% had apex fracture. Further, 85.47% had no buccal alveolar bone fracture and 14.53% had buccal alveolar bone fracture. Using proper technique, 96.26% of patients had no soft tissue damage, and minimal damage was seen in 3.73% of patients. Discussion: Extraction by Physics Forceps is a very good technique of extraction. No or very minimal tooth fracture and soft tissue injury were noted. Though the forceps is costly, it represents a valuable addition to regular armamentarium for a general dentist for routine extraction. Physics Forceps is a dental extractor rather than a forceps.
Keywords: Dental, extraction, hyaluronidase, oral and maxillofacial surgery, Physics Forceps
|How to cite this article:|
Raghu K, Selvakumar S R, Muthukumar R, Thangavelu A, Sathyanarayanan R, Mani M, Balasubramaniam M. Beak and bumper – Physics forceps: Evaluation of new technique in extraction. Indian J Dent Res 2020;31:4-13
|How to cite this URL:|
Raghu K, Selvakumar S R, Muthukumar R, Thangavelu A, Sathyanarayanan R, Mani M, Balasubramaniam M. Beak and bumper – Physics forceps: Evaluation of new technique in extraction. Indian J Dent Res [serial online] 2020 [cited 2021 May 10];31:4-13. Available from: https://www.ijdr.in/text.asp?2020/31/1/4/274108
| Introduction|| |
Technological progression has the best effect in changing the world today. The above statement suits both medical and dental fields. Dentistry has been in existence since humans first felt toothache. The bow drill was the first dental tool used to remove pain in teeth. Everyone has gained their own revelations and experience in extraction progression. The progress they made also helped dentistry to move ahead. The history of dentistry started from ancient Egypt to ancient Greeks and ancient Romans. By the late Middle Ages, the most common solution for tooth decay or toothache was extraction. The old dental key was eventually replaced by forceps in the 20th century.
Serial extraction procedures have been of interest to dentists for many years.
Tooth removal from the alveolus in the alveolar bone is called extraction. Commonly, all tooth extraction instruments are designed using lever and inclined plane principles, by which the dental forceps grasp and leverage the tooth forward and backward, at the pivot point of the tooth in relation to the socket. The socket is expanded and periodontal ligament is separated by combination of this tooth movement.
Over the past decades, atraumatic tooth extractions have been of interest to dentists to maintain adequate bone width for implants. Minimal soft tissue damage and alveolar bone damage is imperative for ideal postextraction implant placement., Forceps, scalpels, elevators, etc., are the common instruments in extraction. Dentists today still use modified versions of the same technique. Historically speaking, humans lacked the right instrumentation to carry out atraumatic painless extractions with minimal postoperative complications. The motivation behind the study is to audit the proficiency of the biomechanical principles utilized as a part of atraumatic extraction of teeth using this new design, the Physics Forceps. A recent innovation, the Physics Forceps has got a new role in extraction technique. As opposed to conventional forceps, Physics Forceps makes just one point contact with the tooth as a unique benefit.
The days of pulling, squeezing, and twisting are now gone forever. Unlike regular conventional oral surgery forceps, Physics Forceps depends on the physics of rotational power, lever, and torque, much like the essential idea of a (non-curve-off) bottle top removal. According to Dr. Richard Golden, inventor of the Physics Forceps, this process preserves the buccal bone, cortical plates, and “virtually eliminates root tip fractures.” The principle objective of the study is to assess the viability of the Physics Forceps for atraumatic extractions by preserving the buccal alveolar bone and less soft tissue damage over a study period of one year.
The Physics Forceps have the epic beak and bumper design that allows atraumatic extraction utilizing just wrist only movement based on first-order lever principle without harming the buccal alveolar bone.
| Materials and Methods|| |
This study was conducted from April 2012 to March 2013 in the Department of Oral and Maxillofacial Surgery, of a Dental College in Tamil Nadu, India. Subjects of the study were selected from patients who underwent extraction during the said period. According to our study norms, 241 patients fell in our extraction criteria which are as follows [Table 1]: all of them were above 18 years in age, and patients with severe tooth damage/trauma, malpositioned/nonfunctioning teeth, failed root canal treated teeth, patients scheduled to undergo radiation or chemotherapy, orthodontic correction were included irrespective of sex and socioeconomic status. Third molar extraction, multiple extraction in same patient, patients below 18 years in age, patients with restricted mouth opening, patients with lesion or infection in the buccal vestibular region, patients with dilacerations, concrescence, or any other root deformities such as supernumerary tooth and mobile tooth with grades II and III were also not included in the study. Prior to the treatment, university Ethical committee (Institutional Human Ethics Committee) approval was taken along with required hematological investigations were done, informed consent obtained and radiographs were taken, if needed.
The following information was supplied relating to ethical approvals (i.e., approving body and any reference numbers). The study was approved by the ethics committee (M18/RMMC/12).
Data were recorded as per the pro forma. The intentions of the study were explained to each and every patient and complete postoperative follow-up after treatment done. Anesthetic agent lignocaine hydrochloride and adrenaline bitartrate injection (LOX 2% adrenaline 1:200,000) was given to all the patients [Figure 1].
|Figure 1: “Physics Forceps” instruments include. (a) Lower universal forceps. (b) Upper front forceps. (c) Upper right forceps. (d) Upper right forceps were used|
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The extraction was done utilizing the following steps [Figure 2].
|Figure 2: Animated images showing steps in extraction using physics forceps|
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Step 1: If needed, moons probe is used to separate the attached gingiva [Figure 2].
Step 2: Beak is placed in palatal or lingual side with the handles opened wide, to set the beak on the solid root surface [Figure 2].
Step 3: At the level of mucogingival junction, bumper is placed perpendicular. Position it securely. No need of squeezing or pulling the handle [Figure 2].
Step 4: Once placed in position, steady rotational force is applied bucally and held in position until it meets with resistance. Pressure increases exponentially allowing for the release of hyaluronic acid to help loosen the attached periodontal ligaments [Figure 2].
Step 5: Physics forceps is done once 1–3 mm tooth movement is achieved [Figure 2].
Step 6: Deliver the tooth with any conventional instrument such as a hemostat or rongeurs [Figure 2]. Once the tooth is extracted, the socket is examined for any excessive bleeding, granulation tissue, bony margins, and soft tissue injuries.
After the extraction, postoperative instructions were given with antibiotics (Cap. amoxycillin 500 mg was prescribed for 5 days) to all the patients and analgesics (Tab. paracetamol 400 mg and ibuprofen 325 mg combination was prescribed for 3 days). If the above-stated combination was not effective, it is changed to Tab. tramadol 50 mg for few patients.
The main outcome was to assess whether the extraction performed was atraumatic, ease in handling of instrument, and intraoperative difficulties to provide less stress to the patient.
Fracture of crown: fracture at the level of CEJ (Y/N)
Root fracture: fracture below the level CEJ (Y/N)
Apex fracture: lower 1/3 of the root fracture (Y/N)
Buccal alveolar bone fracture: Any level of alveolar bone fracture (Y/N)
Soft tissue injury at the extraction site: Any grade of soft tissue injury (Y/N) was assessed in our study. No specific grading were used and only presence or absence of above given criteria were analyzed. [Figure 3] shows maxillary molar extraction case photos: (1) Decayed tooth 26. (2) Placing left upper physics forceps. (3) Immediate postextraction socket, atraumatic site. [Figure 4] shows mandibular molar extraction case photos: (1) Grossly decayed 46. (2) Placing lower universal forceps. (3) Immediate postextraction socket, atraumatic site.
|Figure 3: Maxillary molar extraction case photos: (a) Decayed tooth 26, (b) Placing, left upper physics forceps, (c) Immediate postextraction, socket, atraumatic site|
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|Figure 4: Mandibular molar extraction case photos: (a) Grossly decayed 46, (b) Placing lower universal forceps, (c) Immediate postextraction socket, atraumatic site|
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| Results|| |
In our study, all 241 patients were selected accordingly for eligibility criteria and patient trials commenced from April 2012 and ended in March 2013. In 241 patients, 139 of 241 (57.67%) were males and 102 of 241 (42.32%) were females patients. Sex of the patients was noted just for the record purpose out of which 226 of 241 (93.77%) had no tooth fracture, 8 of 241 (3.32%) had crown fracture, 4 of 241 (1.65%) had root fracture, and 3 of 241 (1.24%) had apex fracture [Table 2]. Using the Physics Forceps correctly, it helps complete difficult extractions quickly and atraumatically, even teeth fracture at the level of CEJ or root canal treated teeth too. Extraction of specific teeth is required in the various presentations of malocclusion. In our journey of extraction, we extracted about 44 teeth with no damage to soft tissue and cortical bone which is required for quick orthodontic correction of the patients. It is not possible to treat all malocclusions without extracting any teeth with minimal damage to the surrounding tissues.
|Table 2: Tooth fracture assessment. Incidences of various levels of tooth fracture using physics forceps|
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By using proper technique, 232 of 241 (96.26%) of patients had no soft tissue damage and minimal damage was seen in 9 of 241 (3.73%) of patients [Table 3]. Postoperatively, the extracted site healed very well with sufficient width for implant in the future for both maxillary and mandibular ridges.
In a given study, Nazarian stated that Physics Forceps have the advantage of efficient class I lever principle, as well as biochemical properties which conserves bone and soft tissue damage.
|Table 3: Soft tissue injury assessment. Soft tissue injury in extraction using physics forceps|
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Among 241 patients, 206 (85.47%) had no buccal alveolar bone fracture and 35 (14.52%) had buccal alveolar bone fracture [Table 4]. No serious harm was observed in any patients other than regular extraction complication due to instrument handling mistakes at the early stage of using Physics Forceps.
|Table 4: Alveolus fracture assessment. Incidences of buccal alveolar bone fracture|
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| Discussion|| |
It is not possible to carry on the study for many years; therefore, we restricted our study limitation once we rectified the trial fractures that happened with initial use of the physics forceps at the study center. The number of traumatic extractions gradually reduced with experience over the study period. Richard Golden in 2004 developed and modified the Physics Forceps with the help of several others doctors. Execution of first-class lever, creep, and the type of force gives mechanical advantage important to make this device more effective and predictive.
Rather than a forceps, Physics Forceps can be called as dental extractor, it utilizing first-class lever mechanics as its name implies. One handle is connected to a “beak” that is positioned in relation to the palatal or lingual root at the level of CEJ and other is attached to “bumper.” The bumper is always placed at the mucogingival junction on the facial aspect of the alveolus, which acts as a fulcrum during the extraction. This basis is used to develop the biomechanics of the Physics Forceps.
Regular dental forceps do not assist the mechanical advantage in extracting the tooth rather to hold or grasp the tooth because it is actually a class 2 lever connected to a hinge. This equals attempting to pull a bottle top off a bottle with pliers, but not using regular bottle cap opener.
Physics forceps does not give crushing weight to the tooth. Rather, the handles (once in position) are pivoted as one unit for a couple of degrees, and afterward the activity is ceased for around 1 minute. The torque produced on the tooth, periodontal ligament, and bone is proportional to the length of the handle to the bumper that is 8 cm and 1 cm distance from forceps beak to the bumper. Accordingly, a power on the handle associated with the bumper will expand the force on the bone, surrounding periodontal ligament, and the tooth by eight times. This also does not fracture the tooth. This is called “Creep” phenomenon. When continuous force is applied to a material, it changes shape. The same phenomenon is used in the design of Physics Forceps creep curve of bone. Creep was initially explained by Reilly.
When creep has extended and debilitated the periodontal ligament and bone, the handle of the extraction device might be gradually turned another couple of degrees for 10 to 30 seconds. This activity adds to the creep rupture of the ligament and generally lifts the tooth a couple of millimeters from the attachment. Now the tooth is free and prepared to be expelled from the attachment utilizing any regular instruments, extraction forceps, or hemostats.
The extraction of a tooth utilizing the Physics Forceps is like the expulsion of a nail from wood utilizing a hammer versus a couple of pincers. The handle acts as a lever, and the beak of the hammers paws fit under the head of a nail. The hammers head acts as a support. A rotational force connected to the hammer handle amplifies the power by the length of the handle, and the nail is raised from the wood. Unlike a nail in wood with parallel sides and rubbing along its full length, a tooth is tapered. Subsequent to being raised a couple of millimeters, the periodontal ligament fibers are broken and the tooth may then be effectively evacuated without extrarotational power.
As we experienced in learning to apply the proper technique in using Physics Forceps, buccal alveolar bone fracture reduced comparatively. A few buccal alveolar fractures occurred at the early state of learning curve and were reduced to nil by the end of the study. It decreases pressure related to extractions and changes the way patients see extractions, making it less stressful for the patient. In a study by Leziy and Perio,
Physics Forceps is the instrument of choice for all unpredictable tooth extractions. Although crown fracture and root fracture cases had been redone by placing palatal or lingual bur cut at the level of CEJ to engage beak in lingual or palatal aspect stated by Richard Golden and extractions were performed with ease causing minimal damage to surrounding hard and soft tissues.
Basic principles of tooth extraction are the physical changes in the expansion of dentoalveolar bone along with the separation of periodontal ligament. The vital part is to understand the biomechanical changes occurring within the tooth and the socket upon using the Physics Forceps. Periodontal ligament is traumatized causing release of hyaluronidase (hyaluronate glycanohydrolase). This enzyme acts as the catalyst in the hydrolysis of hyaluronan (hyaluronic acid), which is the interstitial barrier and cementing extracellular matrix in all human tissue. Once hyaluronidase is released by the chemical breakdown, the tooth will be released from the periodontal attachment to the alveolus and can thus be easily removed from the socket with any instrument (e.g., hemostat or rongeurs)., As a result of our trial experience, Physics Forceps technique is less traumatic to the surrounding tissue, faster, and more efficient than conventional methods.,
| Conclusion|| |
We conclude that extraction using Physics Forceps is very predictable, atraumatic, and has less extraction complications ranging from normal to grossly decayed teeth. Though the cost of the forceps is greater than conventional dental forceps, it is justified from the doctor's point of view. We can highlight the incredible lifestyle benefits that patients can look forward to, after extractions done by Physics Forceps, which gives more comfort and satisfaction to the operators. There is the high possibility of Physics Forceps becoming the first choice of dentists for performing difficult extractions in the future.
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Conflicts of interest
There are no conflicts of interest.
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Indra Gandhi Institute of Dental Science, Pillayarkuppam, Cuddalore EC Road, Puducherry - 607 402
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]