P r i n c i p l e s of E x o d o n t i a

William Stuart McKenzie, DMD, MD

KEYWORDS
 Exodontia  Elevators  Dental forceps  Dental extractions

KEY POINTS
 Exodontia services comprise the largest portion of clinical practice for most oral and maxillofacial
surgeons in the United States.
 This article is an overview of the principles of exodontia including the physics principles underlying
the appropriate use of dental elevators and forceps.
 New instruments including periotomes, piezosurgery, Physics Forceps, and vertical extraction sys-
tems are also introduced and reviewed.

The most common procedure performed by most and avoid intraoperative and postoperative com-
oral and maxillofacial surgeons is extraction of plications including bleeding issues, bone and/or
decayed or impacted teeth. According to the Na- soft tissue healing issues, and the best pain man-
tional Institute of Dental and Craniofacial agement strategy for the individual patient. This
Research, 92% of US citizens age 20 to 64 have assessment also includes forecasting the specific
had dental caries in their permanent dentition, instrumentation that may be needed for the pro-
with 26% of adults in this age range with current cedure. Communication of the need for special
untreated caries.1 Many patients require one or instrumentation or hemostatic agents to the surgi-
more extractions throughout their lifetime because cal team maximizes procedural efficiency. The ex-
of impaction, caries, periodontal disease, fracture amination process also includes diagnostic
of teeth from mastication or previous dental pro- radiographs of the teeth requiring removal to
cedures, and failed root canal therapy. The ideal confirm necessity of removal and to assess for
principles of exodontia should allow the efficient, possible complications. The radiograph also al-
effective, and safe removal of teeth with a primary lows the patient to visualize the teeth that are to
focus on minimizing complications and maxi- be removed, and to participate in the informed
mizing comfort for the patient and provider. Failure consent process by seeing the structures that
to understand the instrumentation and the physics may be at risk, such as the maxillary sinus cavity,
principles being used can cause prolonged opera- the inferior alveolar nerve canal, or adjacent
tive time, iatrogenic injury to the patient, and un- restorations.
necessary fatigue and/or injury to the provider. The use of cone beam computed tomography
This article reviews the principles, techniques, (CBCT) scan by oral and maxillofacial surgeons
and instrumentation of exodontia, and presents has become increasingly popular in the United
new instruments being currently marketed for States. Although most patients having routine
exodontia. exodontia do not require CBCT, CBCT may be
indicated when impacted mandibular wisdom
teeth are in close proximity to the inferior alveolar
PREOPERATIVE ASSESSMENT
canal. Matzen and Wenzel2 performed a compre-
oralmaxsurgery.theclinics.com

Before any surgical procedure, a thorough history hensive and well-designed review of the efficacy
and physical examination must be completed. of CBCT before mandibular wisdom tooth extrac-
Although most patients can safely undergo basic tion. They found a paucity of randomized
exodontia procedures, medical history and current controlled trials in their review of more than 300 ar-
medications can allow the surgeon to anticipate ticles, and ultimately concluded that periapical

Mid-State Oral Surgery and Implant Center, 445 Henslee Drive, Dickson, TN 37055, USA
E-mail address: mckenzieomfs@gmail.com

Oral Maxillofacial Surg Clin N Am 32 (2020) 511–517

https://doi.org/10.1016/j.coms.2020.06.001
1042-3699/20/Ó 2020 Elsevier Inc. All rights reserved.
512 McKenzie

and panoramic imaging is sufficient for most pa-

tients undergoing wisdom tooth removal. Howev-
er, they did find that CBCT may be indicated if
traditional imaging suggested high risk of inferior
alveolar nerve proximity, and that the CBCT would
change clinical decision making, such as perform-
ing coronectomy instead of extraction.2

INSTRUMENTATION/STAFFING
The instrumentation necessary for successful Fig. 1. Class I lever.
dental extractions includes optimal lighting, suc-
tion, and proper retraction of the soft tissue. A
well-trained assistant is a critical component to significant caries, a trough or sectioning of the
any successful procedure by providing suction, tooth may need to be completed to achieve a pur-
irrigation, and anticipating instrument needs as chase on stable tooth structure. Another technique
the procedure progresses. The assistant can also is to create a purchase point on the tooth with a
serve as a last line of defense for verification of drill to allow the use of a Crane pick to be used
correct patient, procedure, allergy profile, consent as a lever.
completion, and preprocedural sedation require- Finally, the elevator (particularly the Cryer-type
ments (eg, NPO status, adult driver). The value of elevators) is used as a wheel and axle. With a Cryer
a formal “time-out” checklist and strict adherence elevator, the handle acts as an axle, and the work-
of the surgical team to the checklist cannot be ing end of the elevator acts as a wheel to generate
understated. increased force and arc of rotation to elevate a
Patient positioning is important for visualization root. This is primarily used in the mandibular molar
of the surgical field by the entire surgical team region.
and for the appropriate posture of the surgeon. Pa- Often, a combination of all three physics princi-
tient positions that cause unnecessary bending or ples are used simultaneously to wedge the
twisting of the neck or back can cause significant elevator as apical as possible for optimum pur-
disability for the surgeon over time. chase/fulcrum, then apply lever and rotational
Dental elevators come in a wide array of designs forces to the tooth to quickly and efficiently extract
to facilitate luxation of the tooth. However, the the tooth. The development of a feel for the correct
forces applied to the tooth are encompassed by application of these forces is critical and must be
three principles of physics: (1) a lever, (2) a wedge, carefully and continually reassessed as surgeon
and (3) a wheel. It behooves the oral and maxillofa- skill develops. With time, one can quickly assess
cial surgeon to understand these principles to by feel whether the tooth can be successfully
maximize the effectiveness of the elevators, while elevated, or whether the use of a drill would be
minimizing excessive or ill-directed force. The most effective.
goal of the dental elevators is to luxate the tooth Dental forceps also have a multitude of designs
in a manner that disrupts the periodontal ligament, to adapt to the specific teeth that they are being
thus allowing removal of the tooth with a forceps. used on. The fundamental principle of the forceps
The elevator is used as a wedge when the thin is as a lever; however, some designs also create a
sharp edge of the instrument is directed parallel wedge effect (eg, #23 forceps or forceps with thin
to root surface with apical force. This transects beaks). As with the elevators, prudent use of force
the periodontal ligament, but also expands the is key to avoiding complications. The lever that is
periradicular bone laterally, and displaces the created by the conventional forceps is that of
tooth coronally. two type I levers connected by a hinge.3 In this
The elevator is used as a class I lever (fulcrum configuration, the hinge is acting as the fulcrum
located between the source of effort and the with the handle being the long lever and the beaks
source of resistance) when the tip of the instru- being the short lever.
ment is placed between the bone and the root sur- Perhaps the greatest advance in modern
face using the crest of the alveolar bone as a exodontia is the drill. The modern surgical drill is
fulcrum (Fig. 1). The longer the lever arm, the a sophisticated instrument that creates high-
greater the force that is generated by the working speed, high-torque rotation of the bur that can
end of the elevator. A stable purchase point on the function in the presence of water and blood and
tooth is necessary to allow the force to be withstand repeated sterilization cycles. The drill al-
adequately applied to the tooth. If the tooth has lows for efficient removal of cortical bone and
 Principles of Exodontia 513

sectioning of teeth. The liberal use of irrigation to

minimize overheating and subsequent necrosis
of surrounding bone is critical. Adequate lighting,
retraction, and suctioning is important to avoid iat-
rogenic injury to adjacent tissues. The impact of
the surgical drill on the efficiency of office-based
exodontia cannot be understated and is an invalu-
able surgical tool. The use of the drill allows signif-
icant mechanical advantage by allowing apical
position of the elevators, increased purchase,
and dividing of multirooted teeth.

NOVEL INSTRUMENTATION/EXTRACTION
TECHNIQUES
Advances in materials, technology, and innovative
design have produced interesting new instruments
for exodontia. Here we review some of the new Fig. 2. Physics Forceps instrument. (Courtesy of Gold-
products that have been marketed. enDent/Directa Inc, Roseville, MI.)

Physics Forceps
The Physics Forceps (GoldenDent, Roseville, MI) operative time and immediate postoperative mar-
uses a class I lever by placing a bumper in the ginal bone and soft tissue loss with the Physics
buccal vestibule and a thin beak on the lingual Forceps. Hariharan and coworkers5 found advan-
aspect of the tooth. Constant pressure is then tages with the Physics Forceps over conventional
applied for several minutes to the tooth, which el- forceps with regards to pain scores.
evates the root from the socket 1 to 3 mm. Per the
manufacturer, the combination of the lever arm Periotomes
combined with release of hyaluronidase within
Advances in material physical properties have
the periodontal ligament space causes release of
allowed for the creation of extremely thin and
the periodontal ligament. The tooth can then be
sharp instruments, such as the Luxator (Directa
removed with rongeur or other tooth forceps. The
Inc, Newtown, CT) style periotome (Fig. 4). The
manufacturer claims that the forceps provides
extremely thin edge can be inserted between the
atraumatic extractions that minimize root or alve-
root surface and the alveolar bone directly trans-
olar bone fractures and preserves surrounding
ecting the periodontal ligament while simulta-
bone. Fig. 2 shows the instrument design, and
neously acting as a wedge (Fig. 5). Even though
Fig. 3 shows how the forceps is positioned to
less force is used than a traditional elevator, the
create a class I lever. El-Kenawy and Ahmed3
resistance to instrument fatigue and fracture is
compared the Physics Forceps with conventional
an achievement in material science. The perio-
forceps with regard to incidence of root, crown,
tome is most effective on single-rooted teeth
and buccal plate fracture. The authors found a sig-
nificant reduction in incidence of crown and root
fracture with the Physics Forceps.3 The design of
the Physics Forceps replaces the buccal beak on
a traditional forceps with a rubber bumper that
seats against the soft tissue deep in the vestibule.
This creates a significant mechanical advantage
with the class I lever analogous to using the claw
of a hammer to remove a nail from a board. The
manufacturer intends for the forceps to be used
with gentle constant pressure applied over several
minutes in contrast to traditional forceps, where
squeezing and rotation are often used. Patel and
colleagues4 used a split-mouth prospective meth-
odology to compare the Physics Forceps with
conventional forceps for orthodontic extractions. Fig. 3. Physics Forceps being used for extraction.
The study found a significant reduction in (Courtesy of GoldenDent/Directa Inc, Roseville, MI.)
514 McKenzie

Fig. 4. Luxator periotomes. (Courtesy

of Directa Inc, Newtown, CT.)

where the working tip of the instrument is used to fractures by reducing the amount of torque force
transect the gingival fibers and crestal periodontal that may be inadvertently applied when using the
ligament fibers.6 The instrument is then inclined hand periotomes.7
mesial and distal and advanced apically. This
sweeping motion transects the periodontal liga- Piezosurgery
ment while simultaneously expanding the bone. Piezosurgery refers to the use of an ultrasonic
The instrument is advanced approximately two- transducer using piezoelectric crystal to convert
thirds of the distance to the apex. The procedure oscillating electrical fields applied to the crystal
is repeated on the lingual side of the tooth. The into mechanical vibration. Fig. 6 shows an
periotome is then removed and forceps is used example of a piezoelectric surgical unit. The me-
to complete the extractions. Sharma and co- chanical vibrations produced are in the ultrasonic
workers6 completed a randomized, double frequency (>20 kHz). These vibrations can cause
blinded trial of periotome/forceps versus perios- fragmentation of solid structures and cavitation
teal/forceps extraction of single-rooted teeth. of liquid structures to which they are applied. The
The study found a significant reduction in opera- frequency of the ultrasonic waves used by the sur-
tive time, pain scores, and gingival laceration gical units is specific for hard tissue, which allows
with the use of a periotome.6 In the age of implant minimal impact on surrounding soft tissue.8 The
dentistry, the periotome may certainly have a role ability to avoid mechanical injury of adjacent soft
in preserving bone and gingival architecture. The tissue with this technology is a significant advan-
concept of directly transecting the fibers as tage over rotary instruments, particularly in close
opposed to tearing the fibers through luxation proximity to neurovascular structures or sinus
and bone expansion is intellectually valid if the membranes. Advantages also include precise
aim is maximizing bone and soft tissue preserva- bone cutting to the depth of 20 to 200 mm depend-
tion. A motorized version of the handheld perio- ing on the tip in use and less force required when
tome is available that uses a reciprocating performing osteotomies compared with rotary in-
motion. This can theoretically reduce buccal plate struments. Piezoelectric surgery has two unique

Fig. 5. Luxator periotomes being used

for extraction. (Courtesy of Directa
Inc, Newtown, CT.)
 Principles of Exodontia 515

microcoagulation of the vessels caused by the

shockwaves from implosion of bubbles (cavitation
effect).9 This leads to increased visibility while
operating. The second unique property of piezo-
surgery is release of oxygen molecules while cut-
ting, which is antiseptic and promotes healing of
the area.9 This not only reduces discomfort but im-
proves healing and preserves bone if implant
placement is indicated. The piezosurgery blades
also allow for precise osteotomies, which can
improve bone preservation (Fig. 7). The limitation
of piezosurgery is increased time to complete
osteotomies compared with rotary drills. In a re-
view of the literature, Al-Moraissi and coworkers10
found statistically significant reduction in swelling,
pain, and trismus, but a significant increase in the
operative time compared with rotary drills.
Fig. 6. Piezoelectric surgery unit. (Courtesy of mec-
tron s.p.a., Italy.) Vertical Extraction System
There have been several studies on a vertical
properties because of how the energy is trans- tooth extraction system (Benex, Lucerne,
ferred to the bone. The first is minimal bleeding Switzerland).11,12 Fig. 8 shows the Benex device.
while operating, which is caused by The earliest was by Muska and colleagues11 who

Fig. 7. Piezoelectric inserts/blades in a

variety of configurations for clinical
use. (Courtesy of mectron s.p.a., Italy.)
516 McKenzie

Fig. 8. Benex device. (Courtesy of Benex, Lucerne, Switzerland.)

demonstrated the principle of this system, which DISCLOSURE

includes placement of a pin into the canal of the
tooth followed by placement of the extractor The author has nothing to disclose.
apparatus (occasionally requiring silicone impres-
sion material on adjacent dentition for stabiliza- REFERENCES
tion). A traction wire is attached from the pin to
the extraction apparatus so that vertical traction 1. Dental caries (tooth decay) in adults (age 20 to 64).
is applied to the tooth. The traction is increased In: National Institute of Dental and Craniofacial
until extraction is completed successfully. The Research. 2018. Available at: https://www.nidcr.nih.
system is most successful in single-rooted teeth gov/research/data-statistics/dental-caries/adults.
and in non–root canal treated teeth.11,12 The Accessed February 29, 2020.
advantage of the system when used successfully 2. Matzen LH, Wenzel A. Efficacy of CBCT for
allows for extraction of severely decayed teeth assessment of impacted mandibular third molars:
without having to elevate a flap or remove a review-based on a hierarchical model of evi-
buccal/interproximal bone. This is advantageous dence. Dentomaxillofac Radiol 2015;44(1):
in highly esthetic areas where implant restora- 20140189.
tions are planned. Although likely not a first-line 3. El-Kenawy M, Ahmed W. Comparison between
option, the technology certainly has a role in physics and conventional forceps in simple dental
maximal preservation of gingival and alveolar extraction. J Maxillofac Oral Surg 2015;14(4):
architecture. 949–55.
4. Patel HS, Managutti AM, Menat S, et al. Comparative
SUMMARY evaluation of efficacy of Physics Forceps versus
conventional forceps in orthodontic extractions: a
Exodontia is the cornerstone of most oral and prospective randomized split mouth study. J Clin Di-
maxillofacial surgery practices. Although each sur- agn Res 2016;10(7):ZC41–5.
geon has their routine instruments and techniques, 5. Hariharan S, Narayanan V, Soh CL. Split-mouth
it is important to occasionally re-evaluate how and comparison of Physics Forceps and extraction
why your “routine” method was established. By forceps in orthodontic extraction of upper premo-
taking the time to reconsider the patient evalua- lars. Br J Oral Maxillofac Surg 2014;52(10):
tion, instrumentation/staffing, and techniques sur- e137–40.
rounding exodontia, we can often find subtle ways 6. Sharma S, Vidya B, Alexander M, et al. Periotome as
to improve the efficiency, comfort, and safety for an aid to atraumatic extraction: a comparative dou-
ourselves and our patients. We must also always ble blind randomized controlled trial. J Maxillofac
stay current on new techniques and technologies Oral Surg 2015;14(3):611–5.
that enter the field. The apt surgeon has a thor- 7. Jain S, Oswal R, Purohit B, et al. Technological ad-
ough understanding of how, why, and when a vances in extraction techniques and outpatient oral
certain instrument would be the most effective. It surgery. Int J Prev Clin Dental Res 2017;4(4):295–9.
is hoped this article allows reflection on and intro- 8. Rahnama M, Czupka11o L, Czajkowski L, et al. The
duction to the most current techniques of use of piezosurgery as an alternative method of
exodontia. minimally invasive surgery in the authors’
 Principles of Exodontia 517

experience. Wideochir Inne Tech Maloinwazyjne systematic review and meta analysis. Int J Oral Max-
2013;8(4):321–6. illofac Surg 2016;45(3):383–91.
9. Schlee M, Steigmann M, Bratu E, et al. Piezosur- 11. Muska E, Walter C, Knight A, et al. Atraumatic verti-
gery: basics and possibilities. Implant Dent 2006; cal tooth extraction: a proof of principle clinical study
15(4):334–40. of a novel system. Oral Surg Oral Med Oral Path
10. Al-Moraissi EA, Elmansi YA, Al-Sharaee YA, et al. Oral Rad 2013;116(5):e303–10.
Does the piezoelectric surgical technique produce 12. Hong B, Bulsara Y, Gorecki P, et al. Minimally inva-
fewer postoperative sequelae after lower third molar sive vertical versus conventional tooth extraction.
surgery than conventional rotary instruments? A J Am Dent Assoc 2018;149(8):688–95.