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
oral and maxillofacial surgeons is extraction of
decayed or impacted teeth. According to the Na-
tional Institute of Dental and Craniofacial
Research, 92% of US citizens age 20 to 64 have
had dental caries in their permanent dentition,
with 26% of adults in this age range with current
untreated caries.1 Many patients require one or
more extractions throughout their lifetime because
of impaction, caries, periodontal disease, fracture
of teeth from mastication or previous dental pro-
cedures, and failed root canal therapy. The ideal
principles of exodontia should allow the efficient,
effective, and safe removal of teeth with a primary
focus on minimizing complications and maxi-
mizing comfort for the patient and provider. Failure
to understand the instrumentation and the physics
principles being used can cause prolonged opera-
tive time, iatrogenic injury to the patient, and un-
necessary fatigue and/or injury to the provider.
This article reviews the principles, techniques,
and instrumentation of exodontia, and presents
new instruments being currently marketed for
exodontia.
PREOPERATIVE ASSESSMENT
Before any surgical procedure, a thorough history
and physical examination must be completed.
Although most patients can safely undergo basic
exodontia procedures, medical history and current
medications can allow the surgeon to anticipate
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.
and avoid intraoperative and postoperative com-
plications including bleeding issues, bone and/or
soft tissue healing issues, and the best pain man-
agement strategy for the individual patient. This
assessment also includes forecasting the specific
instrumentation that may be needed for the pro-
cedure. Communication of the need for special
instrumentation or hemostatic agents to the surgi-
cal team maximizes procedural efficiency. The ex-
amination process also includes diagnostic
radiographs of the teeth requiring removal to
confirm necessity of removal and to assess for
possible complications. The radiograph also al-
lows the patient to visualize the teeth that are to
be removed, and to participate in the informed
consent process by seeing the structures that
may be at risk, such as the maxillary sinus cavity,
the inferior alveolar nerve canal, or adjacent
restorations.
The use of cone beam computed tomography
(CBCT) scan by oral and maxillofacial surgeons
has become increasingly popular in the United
States. Although most patients having routine
exodontia do not require CBCT, CBCT may be
indicated when impacted mandibular wisdom
teeth are in close proximity to the inferior alveolar
canal. Matzen and Wenzel2 performed a compre-
oralmaxsurgery.theclinics.com
hensive and well-designed review of the efficacy
of CBCT before mandibular wisdom tooth extrac-
tion. They found a paucity of randomized
controlled trials in their review of more than 300 ar-
ticles, and ultimately concluded that periapical
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
dental extractions includes optimal lighting, suc-
tion, and proper retraction of the soft tissue. A
well-trained assistant is a critical component to
any successful procedure by providing suction,
irrigation, and anticipating instrument needs as
the procedure progresses. The assistant can also
serve as a last line of defense for verification of
correct patient, procedure, allergy profile, consent
completion, and preprocedural sedation require-
ments (eg, NPO status, adult driver). The value of
a formal “time-out” checklist and strict adherence
of the surgical team to the checklist cannot be
understated.
Patient positioning is important for visualization
of the surgical field by the entire surgical team
and for the appropriate posture of the surgeon. Pa-
tient positions that cause unnecessary bending or
twisting of the neck or back can cause significant
disability for the surgeon over time.
Dental elevators come in a wide array of designs
to facilitate luxation of the tooth. However, the
forces applied to the tooth are encompassed by
three principles of physics: (1) a lever, (2) a wedge,
and (3) a wheel. It behooves the oral and maxillofa-
cial surgeon to understand these principles to
maximize the effectiveness of the elevators, while
minimizing excessive or ill-directed force. The
goal of the dental elevators is to luxate the tooth
in a manner that disrupts the periodontal ligament,
thus allowing removal of the tooth with a forceps.
The elevator is used as a wedge when the thin
sharp edge of the instrument is directed parallel
to root surface with apical force. This transects
the periodontal ligament, but also expands the
periradicular bone laterally, and displaces the
tooth coronally.
The elevator is used as a class I lever (fulcrum
located between the source of effort and the
source of resistance) when the tip of the instru-
ment is placed between the bone and the root sur-
face using the crest of the alveolar bone as a
fulcrum (Fig. 1). The longer the lever arm, the
greater the force that is generated by the working
end of the elevator. A stable purchase point on the
tooth is necessary to allow the force to be
adequately applied to the tooth. If the tooth has
Fig. 1. Class I lever.
significant caries, a trough or sectioning of the
tooth may need to be completed to achieve a pur-
chase on stable tooth structure. Another technique
is to create a purchase point on the tooth with a
drill to allow the use of a Crane pick to be used
as a lever.
Finally, the elevator (particularly the Cryer-type
elevators) is used as a wheel and axle. With a Cryer
elevator, the handle acts as an axle, and the work-
ing end of the elevator acts as a wheel to generate
increased force and arc of rotation to elevate a
root. This is primarily used in the mandibular molar
region.
Often, a combination of all three physics princi-
ples are used simultaneously to wedge the
elevator as apical as possible for optimum pur-
chase/fulcrum, then apply lever and rotational
forces to the tooth to quickly and efficiently extract
the tooth. The development of a feel for the correct
application of these forces is critical and must be
carefully and continually reassessed as surgeon
skill develops. With time, one can quickly assess
by feel whether the tooth can be successfully
elevated, or whether the use of a drill would be
most effective.
Dental forceps also have a multitude of designs
to adapt to the specific teeth that they are being
used on. The fundamental principle of the forceps
is as a lever; however, some designs also create a
wedge effect (eg, #23 forceps or forceps with thin
beaks). As with the elevators, prudent use of force
is key to avoiding complications. The lever that is
created by the conventional forceps is that of
two type I levers connected by a hinge.3 In this
configuration, the hinge is acting as the fulcrum
with the handle being the long lever and the beaks
being the short lever.
Perhaps the greatest advance in modern
exodontia is the drill. The modern surgical drill is
a sophisticated instrument that creates high-
speed, high-torque rotation of the bur that can
function in the presence of water and blood and
withstand repeated sterilization cycles. The drill al-
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
where the working tip of the instrument is used to
transect the gingival fibers and crestal periodontal
ligament fibers.6 The instrument is then inclined
mesial and distal and advanced apically. This
sweeping motion transects the periodontal liga-
ment while simultaneously expanding the bone.
The instrument is advanced approximately two-
thirds of the distance to the apex. The procedure
is repeated on the lingual side of the tooth. The
periotome is then removed and forceps is used
to complete the extractions. Sharma and co-
workers6 completed a randomized, double
blinded trial of periotome/forceps versus perios-
teal/forceps extraction of single-rooted teeth.
The study found a significant reduction in opera-
tive time, pain scores, and gingival laceration
with the use of a periotome.6 In the age of implant
dentistry, the periotome may certainly have a role
in preserving bone and gingival architecture. The
concept of directly transecting the fibers as
opposed to tearing the fibers through luxation
and bone expansion is intellectually valid if the
aim is maximizing bone and soft tissue preserva-
tion. A motorized version of the handheld perio-
tome is available that uses a reciprocating
motion. This can theoretically reduce buccal plate
Fig. 4. Luxator periotomes. (Courtesy
of Directa Inc, Newtown, CT.)
fractures by reducing the amount of torque force
that may be inadvertently applied when using the
hand periotomes.7
Piezosurgery
Piezosurgery refers to the use of an ultrasonic
transducer using piezoelectric crystal to convert
oscillating electrical fields applied to the crystal
into mechanical vibration. Fig. 6 shows an
example of a piezoelectric surgical unit. The me-
chanical vibrations produced are in the ultrasonic
frequency (>20 kHz). These vibrations can cause
fragmentation of solid structures and cavitation
of liquid structures to which they are applied. The
frequency of the ultrasonic waves used by the sur-
gical units is specific for hard tissue, which allows
minimal impact on surrounding soft tissue.8 The
ability to avoid mechanical injury of adjacent soft
tissue with this technology is a significant advan-
tage over rotary instruments, particularly in close
proximity to neurovascular structures or sinus
membranes. Advantages also include precise
bone cutting to the depth of 20 to 200 mm depend-
ing on the tip in use and less force required when
performing osteotomies compared with rotary in-
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
includes placement of a pin into the canal of the
tooth followed by placement of the extractor
apparatus (occasionally requiring silicone impres-
sion material on adjacent dentition for stabiliza-
tion). A traction wire is attached from the pin to
the extraction apparatus so that vertical traction
is applied to the tooth. The traction is increased
until extraction is completed successfully. The
system is most successful in single-rooted teeth
and in non–root canal treated teeth.11,12 The
advantage of the system when used successfully
allows for extraction of severely decayed teeth
without having to elevate a flap or remove
buccal/interproximal bone. This is advantageous
in highly esthetic areas where implant restora-
tions are planned. Although likely not a first-line
option, the technology certainly has a role in
maximal preservation of gingival and alveolar
architecture.
SUMMARY
Exodontia is the cornerstone of most oral and
maxillofacial surgery practices. Although each sur-
geon has their routine instruments and techniques,
it is important to occasionally re-evaluate how and
why your “routine” method was established. By
taking the time to reconsider the patient evalua-
tion, instrumentation/staffing, and techniques sur-
rounding exodontia, we can often find subtle ways
to improve the efficiency, comfort, and safety for
ourselves and our patients. We must also always
stay current on new techniques and technologies
that enter the field. The apt surgeon has a thor-
ough understanding of how, why, and when a
certain instrument would be the most effective. It
is hoped this article allows reflection on and intro-
duction to the most current techniques of
exodontia.
DISCLOSURE
The author has nothing to disclose.
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