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I am a graduate of University of Detroit Mercy School of Dentistry in Detroit, Michigan, and earned my Master’s degree and specialty certificate in periodontics from the University of Minnesota School of...
What can you tell us about your background?
I grew up in a small town where my dad, Dr. Johnny Capes, was a general dentist. What I remember best about that was spending time in his office and seeing him making people better. The other was the fact...
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Dr. Paula Scull describes the unique “beak & bumper” features of Physics Forceps® and the atraumatic extraction technique
Tooth extraction is probably the oldest aspect of dentistry known to man. The history of dental extractions dates back to the days of Aristotle (384 to 322 BC) who described the mechanics of extraction forceps, including the advantages of “two levers acting contrary...having a single fulcrum.” Abulkasim, an Arab surgeon from Spain, illustrated a number of double-ended extraction forceps in his 11th Century Treatise on Medicine and Surgery. Prior to this, primitive societies were extracting teeth with a chisel-shaped piece of wood held against the tooth and pounded with a mallet. Earlier still, Chinese tooth-pullers used their fingers. These Oriental dentists developed the necessary strength in their fingers for this task by spending hours pulling nails out of planks. Therefore, you would not expect any significant innovations in this most basic of dental techniques to be introduced as late as the 21st Century. But this is what has happened with the development of Physics Forceps® (Golden|Misch).
Most dentists are very capable of extracting teeth, but few enjoy the experience, often only extracting the very easiest of teeth and referring the more challenging ones to a colleague, who can be “responsible” if anything “goes wrong;” thereby reducing their exposure to the unpleasant complications of tooth extraction, the “snapping” sound of a fractured root in the apical third, or having to remove bone in a site they may have intended for an implant or other such restoration. These unexpected events do not necessarily jeopardize the treatment plan, but they do require time. Likewise, virtually no patients like having “teeth pulled.”
Conventional extraction proceduresConventional exodontia involves separating the periodontal attachment, using an elevator to rupture the periodontal ligament (PDL) and expand the alveolar bone, and forceps to grasp and “pull out” the tooth. Two equal forces applied through the beaks of the forceps combined with a third force, movement of the operator’s arm and wrist, cause further compression and expansion of the alveolar bone, ultimately resulting in the release of the tooth from its socket. “Snapped roots” and broken bone are the result of too much force being applied to often already-compromised dental structures, exceeding the capacity of thebone and/or tooth to withstand it.
This “pulling” technique also invites unnecessary trauma, including broken roots and bone, inflammation, and postoperative pain, loss of tissue, and stress for both the patient and dental team.
However, if the operator could utilize just two opposing forces, and these two forces eliminated the need for the third force (the clinician’s arm), the risk of fracturing the dental structures would be dramatically reduced. There would also be significantly less discomfort for the patient. This is the principle of a first-class lever, and it is the essence of the “new” Physics Forceps® concept.The Physics Forceps® conceptThe Physics Forceps® have a revolutionary “beak & bumper” design that enables the operator to extract teeth using wrist movement only.
They act like a simple, first-class lever. One force is applied with the beak on the lingual aspect of the tooth or root. The second force is applied via the “bumper,” which is placed on the alveolar ridge at the approximate location of the mucogingival junction. The handles of the Physics Forceps® are not squeezed, just held, with a gentle but steady rotational force applied through a small amount of wrist movement only (Figure 9 illustrates the suggested hand positions for using the lower universal and upper Physics Forceps®). This limited amount of wrist movement is achieved by simply moving the wrist by about 3 to 4 degrees and then maintaining this position to apply the steady gentle pressure for about 30 to 40 seconds. This application of a steady but moderate force builds up internal force or “creep,” which allows the bone to slowly expand and the PDL to release. The operator will soon feel the tooth disengage from the socket (or “pop”) and notice it rise occlusally from the socket by 1 to 2 mm. The operator can then remove the Physics Forceps® and lift out the tooth using either his/her fingers alone or another appropriate instrument.
The gingival attachment still needs to be separated prior to extraction with the Physics Forceps®. However, all maxillary teeth (including molars) can be extracted without sectioning; lower molars occasionally need sectioning to ensure a more predictable extraction. Sometimes it is also advisable to drill a small trench on the lingual surface of the tooth or root in order to engage the beak more securely on solid root surface.
With this technique, less is more, and the most challenging part of the transition from the use of conventional forceps to the Physics Forceps® is overcoming the habit of using too much force by either squeezing the forceps or using the arm. Fortunately, the manufacturer supplies an excellent DVD with the product, which explains the new technique in great detail. Once you have watched it a couple of times, you will have no problem developing the technique and enjoying the benefits that result.
The benefits of the Physics Forceps® include:
The Physics Forceps® are supplied in a set of four patterns comprising a Universal Lower, Upper Anterior, Upper Right, and Upper Left Posterior versions. When I first bought my set, I was a bit skeptical, but once I had mastered the technique, I found them so easy to use—they have made the whole extraction procedure much quicker and more pleasant for both me and my patients.Clinical caseA 30-year-old, fit, healthy, but apprehensive woman was referred to my practice for removal of a lower left first molar (Figures 1 and 2).
The tooth had been root-filled, but continued to give acute symptoms of pain. After a full discussion of all the options, it was decided to remove the tooth and plan a single, screw-retained implant restoration after 3 months of healing.
The patient was warned about the risks associated with removing the tooth, including possible tooth/root fracture and the consequent need for a flap and bone removal.
Under local anesthetic, the Physics Forceps® were applied with the buccal bumper pressed against the alveolar ridge at the approximate location of the mucogingival junction and the lingual blade engaging the lingual surface of the roots (Figure 3). A gentle, but steady rotational force was applied through a small amount of wrist movement only. This limited amount of wrist movement was achieved by simply lowering my wrist by about 3 to 4 degrees and then maintaining this position to apply the steady, gentle pressure. After 2 minutes, the tooth was seen to “pop” and move up and out of its socket (Figure 4).
The tooth was removed intact (Figure 5), despite the large, splayed, bulbous roots that were very brittle due to the previous root treatment. In addition, the socket was left entirely intact with complete preservation of the interdental and buccal bone (Figure 6). The socket was then sutured to support the blood clot and allow approximation of the soft tissues (Figure 7).
The patient tolerated the procedure very well, and despite her anxiety, found the gentle rotation with light pressure quite acceptable and not at all unpleasant.The patient healed with no complications (Figure 8) and will have the implant placed after bone healing has occurred.Tips for success
Reprinted with permission from The Dentist 2010(March);59-61.
Paula Scull qualified in dentistry from UCH London in 1989. She has a Fellowship in dental surgery, is on the Specialist list for Oral Surgery, and has an MSC from Guys, London, in Implant Dentistry.
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