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British Journal of Oral and Maxillofacial Surgery 52 (2014) e137–e140

Split-mouth comparison of Physics forceps and extraction

forceps in orthodontic extraction of upper premolars
Samyuktha Hariharan ∗,1 , Vinod Narayanan ∗∗ , Chen Loong Soh ∗ ∗ ∗
Department of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, No. 162, Poonamallee High Road, Velappanchavadi,
Chennai- 600 077

Accepted 18 June 2014

Available online 8 July 2014

Abstract

We 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. We 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)) (p = 0.03). There were no other
significant differences between the 2 groups in any other variable studied.
© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Physics forceps; extraction forceps; Atraumatic extraction; Upper premolar extraction; Operative complications; Inflammatory complications

Introduction the gingival sulcus, at a lower level than the bumper.3 This
“beak and bumper” design (Fig. 1) aids extraction without
Both controlled force and finesse are required for a sim- the use of excessive force.
ple tooth extraction.1 There have been various technological Patients who require correction of various presentations
advances in techniques to improve outcomes for patients, and of malocclusion usually need specific teeth extracted, usu-
atraumatic extraction is what we aim for. The Physics forceps ally the first or second upper or lower premolars, because
is a device that uses a first-class lever mechanism for atrau- space is required in the dental arch. These extractions need
matic extraction of a tooth from its socket.2 There are two to be as atraumatic as possible and usually do not require a
handles, one of which is connected to a bumper that functions mucoperiosteal flap to be raised.
as the fulcrum during extraction. It is applied to the bucco- The Physics forceps implements a first-class lever, creep,
labial aspect, usually at the mucogingival junction. The other and the type of force that provides a mechanical advantage,
beak is applied to the palatolingual aspect of the tooth into which makes it more efficient.4 However, we know of no
clinical studies that have compared the use of the Physics
forceps with the universal extraction forceps.
∗ Corresponding author. No. 15, Singaram street, Door no.3, Manaswini

Apts, T.nagar, Chennai- 600 017. Tel.: +09962825989, +914428156883.

∗∗ Corresponding author. Tel.: +09381041945.
∗∗∗ Corresponding author. Tel.: +09940690089.
Patients, material, and methods
E-mail addresses: [email protected] (S. Hariharan),
[email protected] (V. Narayanan), [email protected]
(C.L. Soh). Twenty-seven patients took part in this single-blind, split-
1 Tel.: 04426801580 mouth clinical trial. They had been referred to the Department
http://dx.doi.org/10.1016/j.bjoms.2014.06.013
0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
e138 S. Hariharan et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) e137–e140

postoperatively. The presence of any redness, drainage of

pus, swelling, and pain were considered to be infection. Pain
scores were recorded on the first, third, and seventh postop-
erative days using a visual analogue scale (VAS) with 0 being
no pain and 10 indicating the worst possible pain. Operating
time was recorded using a stop watch from the beginning of
extraction after the local anaesthetic had been injected to the
completion of the extraction.
The primary outcome variables were operative (removal
of the root or fractured alveolus) and inflammatory compli-
Figure 1. Design of the physics forceps.
cations (dry socket, delayed healing, pain, and postoperative
infection). The secondary outcome variable was duration of
operation. The ndependent t test and chi square test were used
of Oral and Maxillofacial Surgery, Saveetha Dental College, to assess the significance of differences, as appropriate. The
for extraction of bilateral upper premolars for orthodontic t test was used in the assessment of differences in operating
reasons. All were fully informed about the research, and the time and pain scores, and the chi square test in the differences
patients or their parents gave their written consent. in incidence of incomplete removal of a root, fractured alveo-
Inclusion criteria were: the patients required extraction of lus, dry socket, delayed healing, and postoperative infection.
upper premolars for orthodontic reasons; they were available Probabilities of less than 0.05 were accepted as significant.
for assessment up to 7 days postoperatively, and their ages The statistical analyses were made with the help of SPSS
ranged from 10-25 years. Medically compromised patients, (version 17.0, SPSS Inc., Chicago, IL, USA).
those with periodontally weak teeth, and those whose pre-
molars were affected by dental caries, were excluded.
The sample size was calculated using the results from the Results
pilot study on 10 upper premolar teeth (n = 5 patients) by
means of the independent t test using G Power (version 3.1), The mean (SD) age was 16 (4) years, range 11-23, of which
assuming an ␣-error and ␤-error of 0.05. The pilot study 15 were female and 12 male.
resulted in a total sample size of 54 teeth (27 premolars in One patient had a fracture of the buccal root above the mid-
the Physics forceps group, and 27 in the universal extraction dle third when the universal extraction forceps was used, and
forceps group). Physics forceps was used in one quadrant and this root was removed with root forceps. There was therefore
the universal extraction forceps in the other. Randomisation no significant difference between the 2 groups.
was by tossing of a coin. There were no complaints of fractured alveolus, dry
After the procedures had been explained to the patient, socket, delayed healing, or postoperative infection.
the teeth were anaesthetised using lignocaine 2% plus The VAS for pain differed between the groups as the sock-
epinephrine 1:200000 units as Xylocaine1.8 ml local anaes- ets from which the teeth had been removed by the Physics
thetic solution. Both the upper premolars were extracted as forceps had significantly less pain on the first postoperative
atraumatically as possible using the Physics forceps in one day than the other group (t (df) = 52, p = 0.03). The VAS for
quadrant and the universal extraction forceps in the other. All pain on postoperative days 3 and 7, were similar in the 2
extractions were by the same operator. Operating time was groups as all patients scored 0 on each occasion. The mean
noted from the beginning of the extraction after the injec- (SD) pain score in the Physics group on day 1 was 0.6 (0.6),
tion of local anaesthetic to the completion of extraction. The compared with 1.04 (0.9) for the other group.
socket was compressed manually and a gauze roll placed The mean (SD) operating time using Physics forceps was
within, and the patient was asked to bite on it for 45 minutes. 29.4 (27.3) seconds and with the universal extraction for-
Operative and inflammatory complications were evaluated by ceps 43.5 (49.5) seconds. This difference was not significant
a staff member who was unaware of which forceps had been (t (df) = 52, p = 0.204).
used. Postoperative instructions were given after adequate
haemostasis had been ensured.
Operative complications such as incomplete removal or Discussion
fracture of the root were assessed by an evaluator who was
not aware of which forceps had been used. A simple yes/no Various instruments and techniques have been developed to
format was used for the assessment. aid atraumatic tooth extraction. Techniques such as powered
Inflammatory complications such as the presence of a periotomes,1,4,5 piezosurgery,6,7 lasers,8 Physics forceps,1–4
dry socket, delayed healing, pain, or postoperative infection orthodontic extrusion of the third molar,9 and the Benex ver-
were also evaluated on the first, third, and seventh post- tical extraction system,10 are being widely used and reported.
operative days. Healing was considered to be delayed if The Physics forceps, which works on the mechanism of a
there was incomplete soft tissue coverage within 21 days first-class lever, is used by rotation of the wrist rather than a
 S. Hariharan et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) e137–e140 e139

squeezing movement. The handles are rotated as a single unit A pilot study of 5 patients (10 teeth) was done before
for a few degrees, and then stopped for almost a minute.1 The this study to find out what size of sample would be required
length of the forceps handle to the bumper is 8 cm and the for the main study. The sample size was 54, and each
torque force that is generated on the tooth, periodontal liga- group comprised 27 teeth. To our knowledge this is the first
ment, and bone is related to this, divided by the distance from comparative clinical trial that has compared the Physics
the bumper to the beak of the forceps (1 cm). The force that forceps with conventional forceps. An abstract was presented
is applied on the handle attached to the bumper will there- at the International Association of Dental Research in 2010
fore increase the force on the tooth, periodontal ligament, and that compared the Physics forceps with the conventional
bone by about 8 times. The force applied by the bumper on forceps in ?? patients (Long S et al. A comparison of the
to the gingiva and bone is over a larger surface area and is a conventional forces to the Physics forceps. Paper presented
compressive force, so the tooth and alveolus do not fracture. at the International Association of Dental Research, 2010)
Once the tooth is subluxated, it can be delivered with the help and the authors reported that the mean operating time was
of conventional forceps or a rongeur.1,2 less using Physics forceps (120.5 seconds) than with the uni-
According to Dym and Weiss1 there is no need to versal extraction forceps (188.6 seconds). The incidence of
raise a mucoperiosteal flap or use an elevator before fractures of the bony plate fractures was 22% in the Physics
attempting extraction with the Physics forceps. This is a forceps group compared with 25% in the conventional
major advantage, particularly in cases that require atraumatic forceps group. However, the outcome data were not clear.
extraction. We found that the mean operative time using the Physics
We chose a split-mouth study design because it has fewer forceps for extraction of upper premolars was 21.4 (27.3)
chances of bias, as so many variables (such as nutritional seconds and 43.5 (49.5) seconds for the universal extraction
status, oral hygiene, and quality of bone) are the same on forceps. These results are comparable with those of Long et
both sides, and the patient’s compliance was constant. There al, but they did not standardise the teeth.
was no operator bias as the same surgeon operated on both Other studies that have mentioned the Physics forceps
sides of each patient and so used both forceps. have been review studies, and we know of no other compar-
The only significant difference between the groups was ative clinical studies, so there is a need for more prospective
pain on the first postoperative day(p = 0.03). The design of studies with larger numbers.
the Physics forceps allows the tooth to be delivered atrau-
matically, unlike the conventional forceps. This might reduce Conflict of interest
trauma at the surgical site and therefore pain, particularly in
the early postoperative period. We have no conflicts of interest.
There was no difference in the incidence of operative
and inflammatory complications between the 2 groups. One Ethics statement and confirmation of patients’
patient in the universal forceps group had a fracture of the permission
tooth at the middle third of the root, which was retrieved
with root forceps. This patient had no particular pain post- All patients or their parents gave signed informed consent.
operatively and healed uneventfully. No patient developed The study was cleared by the Institutional Scientific Review
postoperative infection or delayed healing, which is in agree- Board and Institutional Human Ethics Committee of our
ment with studies that reported only minimal complication hospital, and followed the principles of the Declaration of
after uncomplicated extractions.11 Patients’ compliance with Helsinki.
postoperative care and drug regimens may also play a
part.11,12
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