Efficacy of the Atraumatic Physics Forceps Over Conventional Extraction Forceps in Extraction of Tooth-Does it Offer an Alternative in All Types of Extraction or Only can be Used in Few Selected Types of Extraction: A Comparative Study.

We conducted this study to evaluate the efficacy of physics forceps in dental extractions as compared with conventional forceps and as well as to evaluate its atraumatic point of view. Materials and
Methods: A total of 200 healthy adult patients were included in the study who reported for dental extractions, divided into two groups each containing 100 patients. The patients were randomly allocated into either group by lottery method.
Results: Operating time in the physics forceps group was found to be significantly reduced as well as lesser incidence of dry socket was noted which was statistically significant on the 2nd day postoperatively. However, incidence of root fracture, buccal plate fracture, and gingival lacerations were not found to be statistically significant but their occurrence was less in the physics forceps group as compared with the conventional forceps group.
Conclusion: To conclude, we can say that extractions done by physics forceps results in significant reduction in unnecessary trauma as well as stress to both the operator and patient. The forceps is an atraumatic extraction system which is a boon for the profession, thereby reducing ridge deformities and preparing the patients for future prosthesis. Copyright:

INTRODUCTION

Dentist performs a variety of procedures such as exodontia, root canal treatment, and implants to name a few, out of which, exodontia is the first surgical procedure that a dentist performs than any other procedures. The varied indications for tooth extractions are grossly carious tooth, severe periodontal disease, orthodontics, pre-prosthetic reasons, preradiation extraction, as well as various other reasons.[1]

The forces on both the facial and lingual portion of the tooth are applied equally associated with an additional force generated by the clinician's arm and wrist movement resulting in elevation of the tooth out of the socket. These forces cause unnecessary loss of tissue, fracture of facial plate of bone, root fracture, and postoperative pain, that over a period of time results in significant ridge deformities making the placement of implants and future prosthesis difficult.[23]

Various techniques and instruments were introduced over the last decade for performing atraumatic dental extractions such as powered periotomes, piezosurgery, lasers, Physics forceps, orthodontic extrusion of the third molar, and the Benex vertical extraction system.[14]

The Physics Forceps was developed and designed by Dr. Richard Golden in 2004. The forceps is a dental elevator rather than a forceps which works like a modified first class lever distributing stress without the squeezing, grasping, twisting, and pulling force which provides greater mechanical advantage, hence making it more efficient.[1256]

MATERIALS AND METHODS

A prospective single blind, randomized controlled trial was conducted in the Department of Oral and Maxillofacial Surgery from November 2016 to September 2018. The patients who met the inclusion and exclusion criteria were selected. Inclusion criteria included systemically healthy adult patients between 18 and 60 years of both genders, patients with teeth having 3 mm or more of intact tooth structure above the gingival margin and having atleast buccal/lingual plate intact, failed root canal treated tooth, Prosthetic reasons, and Orthodontic reason. Exclusion criteria included patients with uncontrolled systemic disease, abnormal root morphology, periodontally compromised tooth, pregnancy, and lactating mother.

The total sample size of the study was 200 patients divided into two groups of 100 each and samples were randomly allocated into groups by the lottery method.

Preoperative assessment included detailed case history and radiographic examination (OPG or IOPA of the tooth indicated for extraction). Postoperative assessment included pain, swelling, incidence of dry socket, and soft tissue lacerations. Pain was evaluated postoperatively on 1st, 2nd, and 3rd day using 10-point visual analogue scale. Incidence of dry socket and swelling was evaluated postoperatively on 1st, 2nd, and 3rd days. Soft tissue laceration was evaluated on the day of treatment immediately after extraction.

RESULTS

This study included 200 patients, 92 males and 108 females with mean age of 31.6 ± 10.60 years. The mean age in physics forceps group is 31.49 ± 10.62 whereas in conventional forceps, the mean is 31.83 ± 10.63.

Extraction time

The mean time taken for extraction using Physics forceps was 2.08 (±1.08) min while that with conventional forceps were 3.50 (±1.17) min. When subjected to independent t-test, this difference was found statistically significant with P = 0.004 <0.05 [Table 1].

Table 1

Comparison of time taken for extraction among the two groups in study population

Abbreviation	Time intervals	Experimental		Control		P
		Mean	SD	Mean	SD
T1	POST-OP DAY 1	2.08	1.02	3.51	1.17	0.004*

The experimental group reported significantly less time for extraction as compared with control group (P = 0.004 <0.05).

Crown and root fracture

Fracture of the crown occurred in 3 (3%) cases in physics forceps group and in 5 (5%) cases in conventional forceps groups and root fracture occurred in 2 (2%) cases in physics forceps group and in 6 (6%) cases in conventional forceps group [Table 2].

Table 2

Distribution of root fracture among the groups

	Groups		Total
	Control	Experimental
Root fracture
absent
n	91	95	186
%	91.0%	95.0%	93.0%
Crown fractue
n	5	3	8
%	5.0%	3.0%	6.0%
Root fracture
n	6	2	8
%	6.0%	2.0%	4.0%
Total
n	100	100	200
%	100.0%	100.0%	100.0%
P	0.350

Bony plate fracture

Fracture of the buccal cortical plate occurred in 4 (4%) cases in physics forceps group and in 6 (6%) cases in conventional forceps group [Table 3].

Table 3

Distribution of Bony plate fracture among the groups

	Groups		Total
	Control	Experimental
Present
n	6	4	8
%	6.0%	4.0%	4.0%
Absent
n	94	96	192
%	94.0%	96.0%	96.0%
Total
n	100	100	200
%	100.0%	100.0%	100.0%
P	0.640

Pain score

Mean VAS score on 1st post-op day using physics forceps and conventional forceps were 1.86 ± 0.70 and 1.70 ± 0.66, respectively. Mean VAS score on 2nd post-op day were 1.49 ± 0.77 and 1.31 ± 0.65 whereas on 3rd post-op day, mean VAS score were 0.65 ± 1.04 and 0.52 ± 0.81. No statistically significant difference among both the groups was found at various intervals when subjected to independent t test [Table 4].

Table 4

Comparison of Mean and standard deviation of VAS SCORES in study population at different time intervals (INTER GROUP)

Abbreviation	Time intervals	Experimental		Control		P
		Mean	SD	Mean	SD
T1	POST-OP DAY 1	1.86	0.70	1.70	0.66	0.097
T2	POST-OP DAY 2	1.49	0.77	1.31	0.65	0.705
T3	POST-OP DAY 3	0.65	1.04	0.52	0.81	0.325

Soft tissue lacerations

The presence of soft tissue lacerations was found in 8 (8%) cases in physics forceps group and in 11 (11%) cases in conventional forceps group. When subjected to chi square test test, this difference was found not to be statistically significant among both the groups [Table 5].

Table 5

Distribution of soft tissue lacerations among the groups

	Groups		Total
	Control	Experimental
Soft tissue lacerations
Present
n	11	8	19
%	11.0%	8.0%	9.5%
Absent
n	89	92	181
%	89.0%	92.0%	90.5%
Total
n	100	100	200
%	100.0%	100.0%	100.0%
P	0.315

Chi Square Test, *Significance of relationship at P<0.05

Swelling

The Distribution of Swelling was compared with postoperative 1st, 2nd, and 3rd day, and this difference was not found to be statistically significant among both the groups.

Dry socket

At postoperative 1st day, dry socket was seen in 8 (8%) cases in control group and in 4 (4%) cases in physics forceps group which was not statistically significant.

At postoperative 2nd day, dry socket was seen in 12 (12%) cases in control group and in 4 (4%) cases in physics forceps group which was statistically significant when subjected to chi square test (P = 0.033 <0.05) [Table 6].

Table 6

Distribution of dry socket among the groups at postoperative day 2

	Groups		Total
	Control	Experimental
Dry socket - day 2
Present
n	12	4	16
%	12.0%	4.0%	8.0%
Absent
n	88	96	184
%	88.0%	96.0%	92.0%
Total
n	100	100	200
%	100.0%	100.0%	100.0%
P	0.033*

The Distribution of Dry socket was compared using Chi SQUARE TEST and this difference was found to be statistically significant among both the groups. Significant higher incidence of dry socket was seen in control group subjects (P = 0.033).

DISCUSSION

In this study, it was found that the time required to extract using physics forceps was significantly lesser as compared to that of conventional forceps which is in accordance with Mandal et al.,[4] Patel HS et al.,[7] Madathanapalli et al.,[8] Avinash et al.,[9] Lingaraj Balihallimathm et al.,[10] and Soliman et al.,[11] whereas Hariharan et al.[12] did not find any significant difference in time taken for extractions, using either physics or conventional forceps in their study [Table 1].

The reason for reduced operating time maybe due to the fact that physics forceps applies a constant pressure which triggers a biochemical reaction in the periodontal ligament resulting in a faster and increased release of hyaluronidase enzyme as a result of which the tooth breaks loose from its attachment to periodontal fibers to the alveolus and can be removed out of the socket.[231314]

There was no statistically significant difference in VAS score on 1st, 2nd, and 3rd postoperative days between two groups [Table 1]. This is in accordance with Patel HS et al.,[7] Avinash S et al.,[9] and Soliman et al.,[11] whereas Madathanapalli et al.[8] in their study found statistically significant difference in VAS score on 3rd day in the physics forceps groups. However, no significant difference was reported in the mean pain scores on 5th and 7th day between the two groups.

This study also did not find any significant difference in the incidence of buccal plate fracture among both the groups. This is in accordance with Patel et al.,[7] Avinash S et al.,[9] Madathanapalli et al.,[8] Basheer et al.,[15] Soliman et al.,[11] and Kosinski.[3] In physics forceps group, fracture is seen in 4% cases whereas in conventional forceps group, it is 6%. Although not statistically significant, the incidence is less. The reason which was cited for decreased facial plate fracture is due to the compressive force applied by the bumper of the physics forceps to the gums and bone and is over a greater surface area that also permits the lingual plate to expand more and hence the facial plate is prevented from fracture.[131416]

In this study, gingival lacerations were seen in 11% cases in conventional forceps group and in 8% cases in physics forceps group which is not statistically significant. This is in accordance with study conducted by Madathanapalli et al.,[8] Sonune AM et al.,[9] and Basheer S,[15] whereas Mandal et al.[4] and Lingaraj Balihallimathm et al.[10] reported significant difference in gingival lacerations in conventional forceps groups then in physics forceps group. However, few studies have reported significant gingival lacerations in the initial cases in the physics forceps group. This may be attributed to the fact that the operator is not familiar with its use in the initial period of its use; however, once the operator is familiar with its use, the incidence is markedly reduced.

CONCLUSION

The learning curve for physics forceps is different from the conventional forceps as the technique of delivering the tooth from the socket is different. Unlike the conventional forceps, the physics forceps is new in the market, and as a result, few dental professionals are familiar with its use and it is also not used for teaching in dental schools. However, once the operator is familiar with its design and technique, such as movement of the wrist and direction of application of force, the process of extraction is simple.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.