Elevation extractions, when completed atraumatically and efficiently, are among the most satisfying to me. It’s the feeling of going into a potentially challenging situation with a plan and then only needing to utilize a portion of the plan to accomplish the entire goal that gives me joy. Sometimes it happens because the anatomy was favorable but more often, it’s experience and an advanced armamentarium that resolves the issue at hand.
In this article, I plan to discuss structural and procedural aspects of the Xpanders elevator, my standard extraction process and 2 case studies explaining why these atraumatic elevators from ArtCraft Dental are a crucial part of my surgical kit.
Xpanders™
Xpanders atraumatic elevators are designed to enable clinicians to avoid broken root tips in their practice. Invented by David Fyffe, DDS, these atraumatic elevators are designed to upgrade extractions, making the procedure faster and easier. They’re designed to help avoid the dreaded deep broken root tip mishaps. The Xpanders power comes from the double-action tips. Just a small amount of penetration into the PDL space is all that is needed for maximum lateral tooth movement. With these elevators, users achieve both buccolingual movement and mesiodistal movement. The more movement you can get prior to the use of forceps, the less likely root tips break off, the company says. Xpanders tips allow for a stable 2-point contact between the crest of bone and the neck of the tooth. With simple twisting, one point locks onto the bone, while the other point pushes the tooth laterally, causing buccolingual socket expansion and superior preforceps loosening. These powerful intraligamental elevators are designed to make extractions less stressful.
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The Xpanders at first glance look similar to the 301 surgical elevator you first grabbed in dental school. A bulbous handle extends into a round shank that eventually develops a concave and convex semicircle shape as you approach the tip. Then the details emerge about why they are so special. Most obviously, the Xpanders have a 2-pronged tip instead of a standard shovel shape.
Curved to engage the surface of the root, they are also impregnated and roughened with a proprietary ceramic material that is blown onto the tips during an intense heat treatment process. These tips concentrate force from the large handle to allow quick and focused compression of bone and penetration of the periodontal ligament (PDL) space during a vertical elevation approach.
However, since they are made of relatively thick steel, they will only penetrate about 0.5 mm and are therefore relatively noninvasive. Then, even with minimal rotation forces applied, this instrument will quickly create instability of a root that was otherwise firmly held in its socket.
The handles are made from surgical-grade French stainless steel. They are wide and easy to grip but hollow for lighter weight and correspondingly less wrist fatigue. The interior is confirmed to be airtight during the manufacturing process so they are still safe for standard sterilization protocols. The tips are thick and strong enough to be used in a horizontal elevation motion or direction but that could possibly affect the lifetime of the instrument. In extreme situations, I find that the spread of the tips creates a great 2-point contact where one establishes a purchase point on the ridge and the other provides the upward and outward force needed for expulsion of the remaining root.
The class I lever action that’s typical for an elevator lifting tooth against bone is even more effective with the shape of the Xpanders forceps because of the increased distance between the active points. A typical elevator functions by putting force on the tooth with one edge and then resting with the center of its convex back against the bone. Compared with an equally wide 301, Xpanders achieve almost double the distance of a lever action due to the double-pronged design. Since an average PDL width is under 0.5 mm, there is often very little space to penetrate. Assuming that there is some ferrule remaining at least 2 mm above bone, I choose the Xpanders as my first option for a specialized lifting instrument since it can generate high moment forces between its arms and it grips well with the ceramic coating. If the tooth is equal in height to the bone or below, I prefer using a PDL knife, luxator, or spade elevator to open the space just a little farther using apically directed wedge action and more delicately sever the ligaments before advancing to the Xpanders.
While they are strong enough to withstand rolling wheel-type elevation motions, I don’t rely on the Xpanders for interproximal pressure with molars unless I have sectioned the roots out of concern for breakage of the arms. That being said, I also haven’t witnessed breakage or signs of fatigue in the year that I have been using them. I do find that they are more helpful at removing conical-shaped roots than tripod roots, but that isn’t an issue if you plan to section and separate the roots anyway.
Extraction Steps
My usual protocol for extraction is as follows:
1. Effective anesthesia
2. Periosteal elevation
3. Radicular stability test with 301 or standard elevator
4. Evaluation of ferrule
5. Choice of spade or PDL knife vs Xpanders for luxation
6. Use Xpanders with vertical apically directed force with ¼ reciprocal twisting motion and complete this motion on each of 4 interproximal corners if possible with properly angled instruments.
7. If the root is lifted and mobile enough, secure with a 151 or 150 and remove or if the PDL space is wide enough, reintroduce a standard elevator.
8. Deliver or remove the tooth or root.
9. Curette socket with serrated spoon curette.
10. Place collagen clotting aid or graft if appropriate and close with membrane and sutures.
Oftentimes, I am able to extract teeth with only periosteal and Xpanders elevation, but they are also useful in more difficult cases. To illustrate the effectiveness of the Xpanders and expound on how I use them, below are 2 recent clinical examples.
Case 1
The first case involves a 34-year-old man who was currently taking no medications, was a nonsmoker, and had a midrange caries risk due to past issues with substance abuse (Figures 1-2). He needed extraction of #12 following a chronic apical abscess that led to a large swelling extending to the orbit.
After reducing the swelling with antibiotics and steroids, I saw the patient for the extraction of the tooth and grafting of the site in preparation for a future implant. I anesthetized the site with 3 carpules of Septocaine (Septodont USA) circumferentially and then lifted the surrounding gingiva and periosteum (Figure 3). The goal is always to maintain all walls of the socket, but I am especially careful with bony structures when I am planning to graft. After exposing the tooth-bone interface, I inserted a 301 into the embrasure on the non-
decayed mesial of the tooth to create some minor horizontal force and mobility (Figure 4).
Then I placed the tips of the straight Xpanders into the mesiobuccal corner of the tooth at the PDL line and apically pressed about 30° off the vertical axis of the tooth while doing quarter-turn twists back and forth in a reciprocating fashion. After increasing the mobility and reaching a vertical stopping point, I moved to the mesiolingual corner of the tooth and completed the same motion. The distobuccal corner had significant decay so I gained greater access to the PDL with a spade elevator before engaging with the Xpanders. The distolingual corner wasn’t easily accessible, and I chose not to open more of the Xpanders kit since enough mobility had been gained. I attempted to deliver the tooth with a set of 150 forceps but the coronal portion fractured (Figure 5). I reengaged the straight Xpanders and drove them apically until the root popped up enough to grip with the forceps. I followed through with curettage until the site was devoid of granulation tissue and adequate bleeding had been established with a serrated spoon (Figure 6). All walls were maintained so I filled the site with particulate allograft to the height of the ridge and closed with a membrane and Vicryl sutures. Figure 7 shows the surgical setup.
Figures 8-9 are postoperative images.
Case 2
The second case involves a 39-year-old man with no significant medical history or medications (Figure 10). Tooth #15 had a history of root canal treatment and crown (Figure 11). Hewas seen at a previous appointment by my associate with the crown off and significant recurrent decay was diagnosed on the mesial aspect from a food pack.
The failure of the crown rendered the tooth nonrestorable but it was recemented and the patient was scheduled with me for the extraction. There was no swelling or purulence, so effective anesthesia required only 2 carpules of infiltration with Septocaine. Since the crown attachment was likely compromised due to the decay, I proceeded to periosteal elevation (Figure 12) and then went to my Xpanders set (Figure 13).
I was able to use the “Posterior In” Xpanders to get a good purchase point on the mesiobuccal corner of the mesiobuccal root and worked that angle until the crown popped off (Figure 14). Since there was extensive decay and it was root canal treated, I had expected to section the roots at some point during the procedure and prefer to do this prior to elevation. However, in this situation, I elevated first since I knew the cemented crown would not hold up to pressure. I use a reverse-vent, air-driven surgical handpiece but still like to maintain a periosteal seal as much as possible to prevent pneumonias from debris, air, or water into the fascial planes.
I completed a y-shaped sectioning of the roots with my handpiece and was then able to engage the distobuccal root on its mesiobuccal corner. This quickly created instability, and I removed the distal root with the Xpanders only. The decay on the mesial root caused repeated fracturing upon elevation force and necessitated further osseous reduction. Final removal of the apical portion required root picks. The palatal root was easier to access with the “Posterior Out” Xpanders on the distolingual aspect and the “Posterior In” Xpanders on the mesiolingual and moved buccally enough to allow for removal with a set of 150 forceps. The patient elected not to graft at this location, so hemostasis was confirmed and the patient released. Figures 15-16 are postoperative images.
The first case was atraumatic to surrounding bone, swiftly completed in about 15 minutes, and the site is now moving on its way to ridge regeneration for future restoration. The second case was not so quick and easy but we achieved success through implementation of a good plan with great instruments. I hope this article has provided you with ample reason to try something a little different and to elevate your surgical setup with an Xpanders kit (Figures 17-18). The drawing indicates the proper positioning for use (Figure 19).
