Evaluation of the effect of a pneumatic dental elevator on tooth extraction

Evaluation of the effect of a pneumatic dental elevator on tooth extraction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of the effect of a pneumatic dental elevator on tooth extraction Xiancheng Feng, Yiyuan Tian, Qingjie Du, Keyi Wang, Ruiqi Chen, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4740115/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Pneumatic tooth elevators are newly developed surgical instruments that utilize compressed air to drive a small, oscillating tip that can gently loosen the tooth from its socket. However, the effect of pneumatic tooth elevators in veterinary clinical practice is not yet clear. In this study, 6 dogs were used as experimental animals. and maxillary first premolars and mandibular first molars were extracted using traditional (control group) and pneumatic dental elevators (experimental group). Physiological parameters, extraction time, intraoperative complications, hematological examination, and tissue healing were compared to investigate the effect of pneumatic dental elevators. The results showed that compared to the control group, the experimental group had a smaller increase in heart rate and respiratory rate, and the time required to extract the mandibular first molar was less. The incidence of complications in the control group was 25% (3/12), while there were no complications in the experimental group. Additionally, all cases in the control group had defects in the mandibular alveolar bone, while only 2/3 of the cases in the experimental group had defects, and the degree of defect was less than that of the control group. The white blood cell count and C-reactive protein (CRP) concentration in the experimental group were significantly lower than those in the control group. The early wound healing score (EHS), soft tissue healing index, and trabecular area in the experimental group were all significantly greater than those in the control group. The above results indicate that using pneumatic dental elevators reduces the degree of pain during the surgical process, takes less time, causes less damage to periodontal tissues, reduces the severity of postoperative inflammation, and promotes better tissue healing. This study provides a theoretical basis and technical reference for the clinical application of the new type of pneumatic dental elevator, promoting its wider application. pneumatic tooth elevator traditional tooth elevator tooth extraction molar tissue healing. Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION The periodontal tissues around the tooth root, such as the periodontal ligament, gingiva, and alveolar bone, firmly anchor the teeth to the alveolar bone, maintaining their stability ( 1 ). During tooth extraction, it is necessary to sever the periodontal ligament and push the root away from the adjacent alveolar bone to enlarge the space between the tooth root and surrounding alveolar bone, thereby increasing the mobility of the tooth within the socket and making it easier to be extracted ( 2 , 3 ). The ideal extraction can be defined as the painless removal of the entire tooth or root, with minimal trauma to the periodontal tissues, stable wound healing, and no postoperative repair issues ( 4 ). The correct selection and application of standard extraction instruments can minimize trauma to both soft and hard tissues and complications associated with tooth extraction ( 5 ), as well as shorten the duration of the extraction and reduce the pain. Dental elevators are essential instruments in exodontia, used to separate teeth from periodontal tissues ( 6 ). Traditional dental elevators apply the mechanical principles of wedges, levers, and axles. Lever forces exert significant pressure on tooth roots and alveolar bone, loosening and tearing the periodontal ligament to dislocate the tooth, inevitably causing significant trauma in the process ( 4 ). Additionally, using traditional dental elevators for tooth extraction relies mainly on the physical force applied by the operator, which can be particularly time-consuming and laborious for the removal of difficult teeth. Pneumatic dental elevators are a newly developed surgical instrument that uses gas pressure to drive the elevator, of which the tip repeatedly vibrates and compresses within the pneumatic cylinder, wedging the narrow and sharp blade between the teeth and alveolar bone to separate the roots from surrounding tissues, increasing the gap between the teeth and alveolar bone. Theoretically, using pneumatic dental elevators for tooth extractions is more labor-saving compared to traditional dental elevators, and eliminates the damage to the fulcrum. Additionally, pneumatic dental elevators are better suited for the extraction of more challenging teeth, offering convenience for the operator. However, there is currently a lack of in-depth research on the effect of pneumatic dental elevators. This study used dogs as experimental animals to compare the use of traditional and pneumatic dental elevators for tooth extraction. The study examined the physiological parameters, extraction time, incidence of intraoperative complications, hematological examination, and postoperative tissue healing in both groups, investigating the effectiveness of pneumatic dental elevators to provide a theoretical basis and technical reference for the clinical use of pneumatic dental elevators, aiding in its better promotion and usage in the future. MATERIALS AND METHOD Animals The experiment was approved by the Ethics Committee on the Use and Care of Animals at Northwest A&F University. All of the dogs were reared, obtained, and housed in accordance with our institute’s laboratory animal requirements. The dogs were kept in cages in a feeding room with purification equipment at a temperature of 18–25°C, humidity of 40–60%, airflow value of 0.13–0.18 m/s, ventilation rate of 10–20 times per hour, light normal, and noise below 60 dB. Six experimental dogs, weighing between 5 and 10 kg and aged between 2 and 4 years were selected and numbered 1–6. They were all fed the same diet and given water, as well as immunized and dewormed. The experimental dogs were acclimated for one week before the experiment. The animals were fasted and deprived of water for 6 h before anesthesia. General anesthesia was induced with propofol (Jiabo Pharmaceutical, Qingyuan, China) and maintained with isoflurane (Ringpu, Tianjin, China) in oxygen. The physiological parameters (heart rate, mean arterial pressure, blood oxygen saturation, and respiratory rate) of the experimental animals in a stable state (three stages of anesthesia without any operation) and during the extraction were recorded by the monitor (Mindray, Shenzhen, China). Prior to the surgery, the teeth were cleaned and polished, followed by rinsing with a diluted (0.12%) chlorhexidine gluconate solution (Lircon, Dezhou, China). After surgery, the animals were deprived of water for 6 h and food for 1 d. Exodontia using the traditional dental elevator The mandibular first molars and maxillary first premolars of dogs numbered 1 to 3, were extracted using traditional dental elevators (Kruuse, Shanghai, China), designated as the control group. The surgical steps were as follows: ( 1 ) cutting dental crown: maxillary first premolars are single-rooted teeth and do not require sectioning; mandibular first molars are double-rooted teeth, and need to be sectioned into two single-rooted parts from the root bifurcation towards the crown direction using a high-speed dental drill (Kruuse, Shanghai, China); ( 2 ) loosening teeth: the blade of the elevator was wedged into the periodontal space, and the elevator handle was rotated using adjacent teeth or surrounding bone tissue as a fulcrum, to relax and break the periodontal ligament. The elevator was used to move around the tooth, repeating the above steps to loosen the tooth; ( 3 ) tooth extraction: when the tooth was sufficiently loose, the neck of the tooth was grasped and gently twisted with extraction forceps (RWD, Shenzhen, China), followed by tooth extraction. The time taken for each tooth to be completely extracted was recorded; ( 4 ) closure of the extraction socket: the wound was debrided and a pedicle mucogingival flap was created on the buccal side to suture without tension. Exodontia using pneumatic dental elevator The mandibular first molars and maxillary first premolars of dogs numbered 4–6, were extracted using the pneumatic dental elevator (Runyue, Shijiazhuang, China), designated as the experimental group. The cutting crown, tooth extraction, and socket closure operations were the same as the traditional dental elevator. The methods of using the dental elevator varied, as follows: the handle was held using the pen-holding technique, and the blade was inserted into the periodontal space. The machine was turned on, and after the blade entered approximately 2 mm into the periodontal space, the angle of the blade was adjusted. The machine was turned on again, allowing the blade to penetrate deeper into the periodontal space and widen it, cutting or tearing the periodontal ligament. The above steps were repeated at multiple points to loosen the tooth. The time taken for each tooth to be completely extracted was recorded. Incidence of intraoperative complications The types and incidence of intraoperative and postoperative complications were recorded. Minor intraoperative complications included root fractures, gingival tears, minor alveolar bone fractures, and root displacements; more serious intraoperative complications included jaw fractures, severe bleeding, significant tooth displacement, and damage to adjacent tissues. Imaging examinations Before and after the surgery, X-ray films of the surgical site were taken by a digital radiography system (Eighteeth, Changzhou, China) to observe the bone defect of the extraction socket. Hematological tests Venous blood was collected from the dogs prior to the surgery and 24 h after tooth extraction for blood routine tests (Mindray, Shenzhen, China) and serum CRP concentration assays. The changes in these results were calculated in comparison to the preoperative blood routine test results. Soft tissue healing assessment The soft tissue healing was evaluated using the EHS at 24 h postoperatively ( 7 ) and Landry's healing index at 7 d postoperatively ( 8 ), with higher scores indicating a greater degree of healing. Bone tissue recovery evaluation Tissue samples from the surgical sites in the upper and lower jaws were collected at 90 d and 120 d postoperatively. The samples were fixed in 4% paraformaldehyde for 48 h, rinsed in water for 2 h, and dehydrated in 70%, 80%, and 90% gradient alcohol for 5 d. The samples were then made transparent by soaking in n-butanol for 3 d, followed by soaking in absolute ethanol twice, and then in xylene for 3 d. The samples were embedded in hydroxyethyl methacrylate embedding medium for 5–10 days. The embedded samples were sectioned continuously using a hard tissue microtome, with section thicknesses of approximately 100 µm. The sections were then polished to a thickness of 70–80 µm using a hard tissue grinder. Finally, the tissue sections were stained with hematoxylin-eosin (H&E) and toluidine blue, to observe the overall tissue repair and bone formation, respectively. The sections were examined and photographed using a fluorescence stereomicroscope and an automatic upright microscope. Three technical replicates (repeat measurements of the samples from the same animal) were performed for each sample. The captured images of the sections were processed using ImageJ to measure and calculate the percentage of trabecular bone area relative to the total area. Statistical Analysis Experiments were repeated at least 3 times. All data were analyzed with GraphPad Prism version 8.0.0 (GraphPad Software), and presented as mean ± standard error of the mean. Independent samples t-test was used for statistical analysis between two groups, where P < 0.05 indicated a significant difference and P < 0.01 indicated a highly significant difference. RESULTS Intraoperative physiological parameters The heart rate, respiratory rate, mean arterial pressure (MAP), and blood oxygen saturation of animals at three stages of anesthesia without any operation and when using tooth extraction during the experiment were recorded, and the changes in each indicator were calculated. The change in heart rate and the increase in respiratory rate of the experimental group animals was significantly lower than that of the control group (Fig. 1 A and B, P < 0.05 and P < 0.01, respectively), and there was no significant difference in the changes in MAP and blood oxygen saturation between the two groups (Fig. 1 C and D). Tooth extraction time When removing the mandibular first molar, the experimental group took significantly less time than the control group (Fig. 1 E, P < 0.05); when removing the maxillary first premolar, there was no significant difference in the duration of tooth extraction between the two groups. Incidence of intraoperative complications In the control group, there was a case of root fracture and two cases of severe soft tissue damage during the operation (Fig. 2 A), all involving the mandibular first molar and surrounding tissues; preoperative and postoperative X-ray examination results showed no alveolar bone fracture, jaw bone fracture, or adjacent tissue damage in both groups (data not shown). The incidence of complications during the operation in the control group was 25% (3/12), while no complications were observed in the experimental group. In addition, postoperative mandibular alveolar bone defects were present in all subjects of the control group, while only 2/3 of the teeth in the experimental group exhibited such defects (Fig. 2 B). Moreover, the extent of the defects in the experiment group was smaller compared to the control group (Fig. 2 B). Hematological examination As shown in Fig. 3 , postoperative white blood cell counts significantly increased in both groups (Fig. 3 A, P < 0.05), with the experimental group significantly lower than the control group (Fig. 3 A, P < 0.05); postoperative neutrophil counts in both groups were significantly higher than before surgery but not significantly different (Fig. 3 B, P < 0.05). There were no significant changes in the counts of monocytes, eosinophils, basophils, and platelets in either group postoperatively (data not shown). The postoperative serum CRP concentrations of both groups exceeded the normal range, with the experimental group significantly lower than the control group (Fig. 3 C, P < 0.05). Postoperative soft tissue recovery Postoperative soft tissue healing was assessed using EHS 24 h after surgery, as shown in Table 1 . There was no significant difference in maxillary EHS scores between the two groups; however, the mandibular EHS scores in the experimental group were significantly higher than those in the control group (Table 1 , P < 0.05). At 7 d postoperatively, the healing index of the experimental group was significantly higher than that of the control group (Fig. 4 A, P < 0.01). Table 1 Postoperative soft tissue healing evaluation (24 h) Maxillary surgical site Mandibular surgical site Control group 7.67 ± 3.88 3.00 ± 1.26 Experimental group 8.50 ± 1.97 5.67 ± 2.34 P value > 0.05 < 0.05 Postoperative bone tissue healing At 30 d, 60 d, and 90 d postoperatively, there were no significant differences in the ratio of postoperative to preoperative alveolar bone height between the control group and the experimental group (Table 2 ). Table 2 The ratio of postoperative to preoperative alveolar bone height 30 d 60 d 90 d Control group 0.92 ± 0.05 0.90 ± 0.09 0.98 ± 0.12 Experimental group 0.92 ± 0.04 0.92 ± 0.09 0.99 ± 0.14 P value > 0.05 > 0.05 > 0.05 As shown in Fig. 4 B, at 90 days postoperatively, H&E stained sections showed that trabeculae (black triangle) were observed in both groups, which were thin and interconnected in a mesh-like pattern; moreover, toluidine blue stained sections showed that both groups had osteoblasts (black arrow) on the surface of the bone trabeculae, with no signs of inflammatory infiltration in either group. At 120 days postoperatively, the H&E stained sections showed that the trabeculae (black triangle) in both groups were thicker than at 90 days postoperatively; toluidine blue stained sections showed a decrease in the number of osteoblasts (black arrow) on the surface of trabeculae in both groups compared to 90 days postoperatively, with no inflammatory infiltration was observed in either group. Figure 4 C presented the quantitative analysis of the trabecular area percentage in the sections at 90 and 120 days postoperatively, revealing a significantly higher percentage in the experimental group compared to the control group (Fig. 4 C, P < 0.05). DISCUSSION Surgery can cause certain damages to animals, including intraoperative and postoperative pain ( 9 ). Increased heart rate, respiratory rate, blood oxygen saturation, and blood pressure, are usually considered indicators of pain perception, therefore monitoring these changes in clinical practice can be used to assess pain levels. This study monitored the above indicators of animals during the surgical process and calculated the changes. The results showed that when using the pneumatic dental elevator for tooth extraction, the increase in heart rate and respiratory rate of animals was significantly lower than when using the traditional dental elevator. This indicates that compared to traditional dental elevators, the use of pneumatic dental elevators for tooth extraction results in lower pain perception in animals. In addition, the time taken to extract the mandibular first molar using the pneumatic dental elevator was significantly shorter than using the traditional dental elevator, and the incidence of intraoperative complications was significantly reduced. With the reduction in surgical time, the time of anesthesia also decreased, which to some extent reduces the anesthesia risk of surgery ( 10 ). Therefore, using the pneumatic dental elevator not only significantly improves the efficiency of tooth extraction, but also increases safety. Dental surgery complications are relatively common, with minor intraoperative complications including crown/root fracture, soft tissue injury, minor alveolar bone fracture, and root displacement; more serious intraoperative complications include mandibular fracture, severe bleeding, severe tooth displacement, and damage to adjacent tissues ( 11 ). The extent of soft tissue damage can be assessed visually, while the degree of bone tissue damage requires evaluation through imaging studies. Taking an oral X-ray before tooth extraction can help clinicians understand the overall condition of the tooth roots and periodontal tissues, and formulate an appropriate surgical plan ( 12 ). Taking an oral X-ray after tooth extraction can determine whether the tooth has been completely removed, and can determine whether the surgery has caused damage to the periodontal hard tissues and adjacent teeth as well as the severity of the damage by comparing it with the preoperative X-ray. In this study, the incidence of complications during the operation in the control group was 25% (3/12), while no complications were observed in the experimental group. Furthermore, postoperative mandibular alveolar bone defects were present in all subjects of the control group, whereas only 2/3 of the subjects in the experimental group exhibited such defects, with the extent of the defects smaller than the control group. Therefore, using a pneumatic dental elevator can cause less damage to teeth. When the white blood cell count, neutrophil ocunt and serum CRP concentration increases and exceeds the normal reference range, it may indicate infection or inflammation ( 13 , 14 ). Research by Michelsen et al. showed that serum CRP concentration can sensitively measure the differences in surgical injury severity ( 15 ). The results of the blood routine tests showed that both groups had significantly elevated white blood cell count and neutrophil count after surgery, with the postoperative neutrophil count in the experimental group significantly lower than that in the control group. Both groups had postoperative serum CRP concentrations exceeding the normal range (> 10 mg/L). The postoperative serum CRP concentration in the control group was greater than 40 mg/L, indicating moderate systemic inflammation ( 16 ), and significantly higher than that in the experimental group, suggesting that the degree of intraoperative damage in the experimental group was lower than that in the control group. These results indicate that both groups had acute inflammation after surgery, but the inflammatory response in the experimental group is milder. Following injury, gingival epithelial cells exhibit robust regenerative capacity, with migration towards the injured site commencing within hours. By the 7th day, these cells mature, culminating in the formation of a new stratum corneum ( 17 ). The EHS has been specifically designed to evaluate the initial stages of healing in gingival tissues following dental procedures within 24 hours. This method takes into account three key parameters: clinical signs of re-epithelialization (CSR), clinical signs of hemostasis (CSH), and clinical signs of inflammation (CSI) ( 7 ). CSR evaluates the extent to which the wound edges approximate, CSH assesses the absence of bleeding and fibrin exudate, and CSI examines the degree of redness indicating inflammation. A higher combined score indicates better healing progress ( 7 ). By the 7th day post-extraction, epithelial cells mature, forming a new stratum corneum, which is then evaluated using the healing index developed by Landry et al ( 18 ). This index incorporates parameters such as tissue color reflecting gum swelling, bleeding on probing, presence of granulation tissue, margin of epithelialization, and any signs of pus, providing a comprehensive assessment of soft tissue healing at this stage. A higher score also signifies improved healing. This experiment evaluated the degree of soft tissue healing at 24 h and 7 days postoperatively, with the experimental group scoring significantly higher than the control group, indicating better soft tissue healing in the experimental group. After tooth extraction, there is a noticeable resorption of the alveolar bone, with the width of the bone showing a more significant loss than the height, and the buccal plate resorbing more markedly than the lingual plate ( 19 ). The ratio of alveolar bone height after tooth extraction compared to before extraction is an important clinical indicator. It reflects the impact of the extraction on the alveolar bone structure and the healing condition of the alveolar bone post-extraction. If the ratio is close to 1, it indicates that the alveolar bone has been well preserved during the extraction process or that the healing process is going well. In this study, it was found that there was no significant difference in the ratio of postoperative to preoperative alveolar bone height between the control group and the experimental group. Observations of osteoblasts, bone trabeculae formation, and the histological structure of bone tissue can be used to assess the degree of bone tissue healing. Morphological observation of the surgical site tissues at 90 and 120 days postoperatively revealed a greater number of osteoblasts on the bone trabecular surfaces in both groups. Osteoblasts, fibroblasts, endothelial cells, and other cells secrete various growth factors that stimulate the migration of mesenchymal stem cells, osteoblast proliferation and differentiation, as well as bone matrix synthesis, promoting bone remodeling ( 20 , 21 ). Compared to the control group, the experimental group showed more new bone formation, suggesting better bone healing in the experimental group. CONCLUSION Using pneumatic dental elevators for tooth extraction reduces the degree of pain during the surgical process, takes less time, causes less damage to periodontal tissues, reduces the severity of postoperative inflammation, and promotes better tissue healing. Declarations CONFLICT OF INTEREST There are no conflicts of interest. FUNDING This work was supported by Northwest A&F University Doctoral Research Startup Fund (Yangling, Shaanxi, China; grant no. 2452024063). Author Contribution XF and YT wrote the main manuscript text and prepared Figs. 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Periodontal ligament stem cells in the periodontitis niche: inseparable interactions and mechanisms. J Leukoc Biol. 2021 Sep;110(3):565-576. eng. Epub 2021/05/28. doi:10.1002/jlb.4mr0421-750r. Cited in: Pubmed; PMID 34043832. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4740115","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":328064937,"identity":"569a66f0-4439-4f35-a923-d7863a9766b1","order_by":0,"name":"Xiancheng Feng","email":"","orcid":"","institution":"Northwest A\u0026F University","correspondingAuthor":false,"prefix":"","firstName":"Xiancheng","middleName":"","lastName":"Feng","suffix":""},{"id":328064938,"identity":"208d0964-6b13-4f51-831e-156c90fd78e8","order_by":1,"name":"Yiyuan Tian","email":"","orcid":"","institution":"Northwest A\u0026F University","correspondingAuthor":false,"prefix":"","firstName":"Yiyuan","middleName":"","lastName":"Tian","suffix":""},{"id":328064939,"identity":"fc1ceebb-1662-4a11-8ec1-7788775536e0","order_by":2,"name":"Qingjie Du","email":"","orcid":"","institution":"Northwest A\u0026F University","correspondingAuthor":false,"prefix":"","firstName":"Qingjie","middleName":"","lastName":"Du","suffix":""},{"id":328064940,"identity":"16fc7f48-a0db-451d-9c54-096bb628a933","order_by":3,"name":"Keyi Wang","email":"","orcid":"","institution":"Northwest A\u0026F University","correspondingAuthor":false,"prefix":"","firstName":"Keyi","middleName":"","lastName":"Wang","suffix":""},{"id":328064941,"identity":"e4d5d1c6-0ce7-4861-b27c-d8561376bf82","order_by":4,"name":"Ruiqi Chen","email":"","orcid":"","institution":"Northwest A\u0026F University","correspondingAuthor":false,"prefix":"","firstName":"Ruiqi","middleName":"","lastName":"Chen","suffix":""},{"id":328064942,"identity":"9612d94c-7aa2-4efd-9bce-1f5eb007c613","order_by":5,"name":"Juanjuan Du","email":"","orcid":"","institution":"Northwest A\u0026F University","correspondingAuthor":false,"prefix":"","firstName":"Juanjuan","middleName":"","lastName":"Du","suffix":""},{"id":328064943,"identity":"174d3a8c-65ad-4fc5-ae03-607660c49344","order_by":6,"name":"Pengxiu Dai","email":"","orcid":"","institution":"Northwest A\u0026F University","correspondingAuthor":false,"prefix":"","firstName":"Pengxiu","middleName":"","lastName":"Dai","suffix":""},{"id":328064944,"identity":"e5b1a52a-dc94-4a99-9beb-61b69058d4cc","order_by":7,"name":"Xinke Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIie3RIQ7CMBSA4TZNOlMyW5IFrrCEA3CV1oAiQVZMdIF0AvAIDoEDXJslVcUjN4VBDIdkYCHbcIj+ul/a9wqAz/eXYaArkZBxlqYFE0knAs3W2UFM8kVcONuJoLyn0CimU9Uvl6gdDLcTlhOH+QFwJbjEIMxWrJHAtdVmJyJ+kkZd+DEC1J33jQQFmdS3+hZp0po4DGI6ayYYBVLXs3CZQzXnCrUTEiht3uNbqEAnQoll7yX313BBmbOkdZZ6Y6Pq9ZXh8FreHyIZhNmmmXy+9LfjPp/P5/vaExdgUZztEOl6AAAAAElFTkSuQmCC","orcid":"","institution":"Northwest A\u0026F University","correspondingAuthor":true,"prefix":"","firstName":"Xinke","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-07-15 01:09:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4740115/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4740115/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62632279,"identity":"a0669757-c399-4bab-8dae-d52713d6bb70","added_by":"auto","created_at":"2024-08-16 16:10:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":116932,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe changes in intraoperative physiological indices and time of teeth\u003c/strong\u003e \u003cstrong\u003eextraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Heart rate difference before and during tooth extraction. (B) Respiratory rate difference before and during tooth extraction. (C) MAP difference before and during tooth extraction. (D) Arterial oxygen saturation difference before and during tooth extraction. (E) Time taken for tooth extraction.All data are expressed as means ± SEM. * indicates \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05, and** indicates \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01. CG: control group; EG: experimental group; MFP: maxillary first premolar; MFM: mandibular first molar.\u003c/p\u003e","description":"","filename":"Picture1.png","url":"https://assets-eu.researchsquare.com/files/rs-4740115/v1/dcdb49e03899aff98006f0d6.png"},{"id":62632281,"identity":"48517aca-2c61-4da4-bbe5-19b94a91e078","added_by":"auto","created_at":"2024-08-16 16:10:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1515492,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoperative complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Complications in CG. a. Fracture of the tooth (white arrow); b. Gingival tear (white arrow); c. Gingival tear (white arrow). (B) Preoperative and postoperative X-ray films. The first row is the preoperative dental X-rays of the control group, and the second row is the postoperative dental X-rays of the control group; the third row is the preoperative dental X-rays of the experimental group, and the fourth row is the postoperative dental X-rays of the experimental group. CG: control group; EG: experimental group.\u003c/p\u003e","description":"","filename":"Picture2.png","url":"https://assets-eu.researchsquare.com/files/rs-4740115/v1/52e3378b695a98b12385748f.png"},{"id":62632280,"identity":"79e7e284-5d56-45b9-9aae-19b5d5d329d5","added_by":"auto","created_at":"2024-08-16 16:10:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":76996,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHematological examination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) White blood cell count before and after tooth extraction. (B) Neutrophil count before and after tooth extraction. (C) Serum CRP concentration before and after tooth extraction. All data are expressed as means ± SEM. * indicates a significant difference between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05). # indicates a significant difference between postoperative and preoperative data in the same group. CG: control group; EG: experimental group.\u003c/p\u003e","description":"","filename":"Picture3.png","url":"https://assets-eu.researchsquare.com/files/rs-4740115/v1/c0e81f6d5465c6ffac4c5c2a.png"},{"id":62632286,"identity":"b4eec32f-1ac1-4ab4-b65e-6f1b9616d468","added_by":"auto","created_at":"2024-08-16 16:10:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":793346,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSoft and hard tissue recovery evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Assessment of soft tissue healing at 7 days postoperatively. (B) Bone tissue section staining. (C) Quantification of the bone trabecular area in panel B. All data are expressed as means ± SEM. * indicates a significant difference between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05), and ** indicates a highly significant difference between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.01). CG: control group; EG: experimental group. Trabeculae (black triangle); Osteoblast (black arrow).\u003c/p\u003e","description":"","filename":"Picture4.png","url":"https://assets-eu.researchsquare.com/files/rs-4740115/v1/a3013f3d62d0cdaf3b7330ae.png"},{"id":71712629,"identity":"63bd5755-e782-4c6c-b938-ed504598862c","added_by":"auto","created_at":"2024-12-18 02:46:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3851085,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4740115/v1/eb1bd4ba-ed77-433b-8be2-5b7126692b18.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of the effect of a pneumatic dental elevator on tooth extraction","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe periodontal tissues around the tooth root, such as the periodontal ligament, gingiva, and alveolar bone, firmly anchor the teeth to the alveolar bone, maintaining their stability (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). During tooth extraction, it is necessary to sever the periodontal ligament and push the root away from the adjacent alveolar bone to enlarge the space between the tooth root and surrounding alveolar bone, thereby increasing the mobility of the tooth within the socket and making it easier to be extracted (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The ideal extraction can be defined as the painless removal of the entire tooth or root, with minimal trauma to the periodontal tissues, stable wound healing, and no postoperative repair issues (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The correct selection and application of standard extraction instruments can minimize trauma to both soft and hard tissues and complications associated with tooth extraction (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), as well as shorten the duration of the extraction and reduce the pain.\u003c/p\u003e \u003cp\u003eDental elevators are essential instruments in exodontia, used to separate teeth from periodontal tissues (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Traditional dental elevators apply the mechanical principles of wedges, levers, and axles. Lever forces exert significant pressure on tooth roots and alveolar bone, loosening and tearing the periodontal ligament to dislocate the tooth, inevitably causing significant trauma in the process (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, using traditional dental elevators for tooth extraction relies mainly on the physical force applied by the operator, which can be particularly time-consuming and laborious for the removal of difficult teeth. Pneumatic dental elevators are a newly developed surgical instrument that uses gas pressure to drive the elevator, of which the tip repeatedly vibrates and compresses within the pneumatic cylinder, wedging the narrow and sharp blade between the teeth and alveolar bone to separate the roots from surrounding tissues, increasing the gap between the teeth and alveolar bone. Theoretically, using pneumatic dental elevators for tooth extractions is more labor-saving compared to traditional dental elevators, and eliminates the damage to the fulcrum. Additionally, pneumatic dental elevators are better suited for the extraction of more challenging teeth, offering convenience for the operator. However, there is currently a lack of in-depth research on the effect of pneumatic dental elevators. This study used dogs as experimental animals to compare the use of traditional and pneumatic dental elevators for tooth extraction. The study examined the physiological parameters, extraction time, incidence of intraoperative complications, hematological examination, and postoperative tissue healing in both groups, investigating the effectiveness of pneumatic dental elevators to provide a theoretical basis and technical reference for the clinical use of pneumatic dental elevators, aiding in its better promotion and usage in the future.\u003c/p\u003e"},{"header":"MATERIALS AND METHOD","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAnimals\u003c/h2\u003e \u003cp\u003eThe experiment was approved by the Ethics Committee on the Use and Care of Animals at Northwest A\u0026amp;F University. All of the dogs were reared, obtained, and housed in accordance with our institute\u0026rsquo;s laboratory animal requirements. The dogs were kept in cages in a feeding room with purification equipment at a temperature of 18\u0026ndash;25\u0026deg;C, humidity of 40\u0026ndash;60%, airflow value of 0.13\u0026ndash;0.18 m/s, ventilation rate of 10\u0026ndash;20 times per hour, light normal, and noise below 60 dB.\u003c/p\u003e \u003cp\u003eSix experimental dogs, weighing between 5 and 10 kg and aged between 2 and 4 years were selected and numbered 1\u0026ndash;6. They were all fed the same diet and given water, as well as immunized and dewormed. The experimental dogs were acclimated for one week before the experiment. The animals were fasted and deprived of water for 6 h before anesthesia. General anesthesia was induced with propofol (Jiabo Pharmaceutical, Qingyuan, China) and maintained with isoflurane (Ringpu, Tianjin, China) in oxygen. The physiological parameters (heart rate, mean arterial pressure, blood oxygen saturation, and respiratory rate) of the experimental animals in a stable state (three stages of anesthesia without any operation) and during the extraction were recorded by the monitor (Mindray, Shenzhen, China). Prior to the surgery, the teeth were cleaned and polished, followed by rinsing with a diluted (0.12%) chlorhexidine gluconate solution (Lircon, Dezhou, China). After surgery, the animals were deprived of water for 6 h and food for 1 d.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eExodontia using the traditional dental elevator\u003c/h2\u003e \u003cp\u003eThe mandibular first molars and maxillary first premolars of dogs numbered 1 to 3, were extracted using traditional dental elevators (Kruuse, Shanghai, China), designated as the control group. The surgical steps were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) cutting dental crown: maxillary first premolars are single-rooted teeth and do not require sectioning; mandibular first molars are double-rooted teeth, and need to be sectioned into two single-rooted parts from the root bifurcation towards the crown direction using a high-speed dental drill (Kruuse, Shanghai, China); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) loosening teeth: the blade of the elevator was wedged into the periodontal space, and the elevator handle was rotated using adjacent teeth or surrounding bone tissue as a fulcrum, to relax and break the periodontal ligament. The elevator was used to move around the tooth, repeating the above steps to loosen the tooth; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) tooth extraction: when the tooth was sufficiently loose, the neck of the tooth was grasped and gently twisted with extraction forceps (RWD, Shenzhen, China), followed by tooth extraction. The time taken for each tooth to be completely extracted was recorded; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) closure of the extraction socket: the wound was debrided and a pedicle mucogingival flap was created on the buccal side to suture without tension.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eExodontia using pneumatic dental elevator\u003c/h2\u003e \u003cp\u003eThe mandibular first molars and maxillary first premolars of dogs numbered 4\u0026ndash;6, were extracted using the pneumatic dental elevator (Runyue, Shijiazhuang, China), designated as the experimental group. The cutting crown, tooth extraction, and socket closure operations were the same as the traditional dental elevator. The methods of using the dental elevator varied, as follows: the handle was held using the pen-holding technique, and the blade was inserted into the periodontal space. The machine was turned on, and after the blade entered approximately 2 mm into the periodontal space, the angle of the blade was adjusted. The machine was turned on again, allowing the blade to penetrate deeper into the periodontal space and widen it, cutting or tearing the periodontal ligament. The above steps were repeated at multiple points to loosen the tooth. The time taken for each tooth to be completely extracted was recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIncidence of intraoperative complications\u003c/h2\u003e \u003cp\u003eThe types and incidence of intraoperative and postoperative complications were recorded. Minor intraoperative complications included root fractures, gingival tears, minor alveolar bone fractures, and root displacements; more serious intraoperative complications included jaw fractures, severe bleeding, significant tooth displacement, and damage to adjacent tissues.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eImaging examinations\u003c/h2\u003e \u003cp\u003eBefore and after the surgery, X-ray films of the surgical site were taken by a digital radiography system (Eighteeth, Changzhou, China) to observe the bone defect of the extraction socket.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHematological tests\u003c/h2\u003e \u003cp\u003eVenous blood was collected from the dogs prior to the surgery and 24 h after tooth extraction for blood routine tests (Mindray, Shenzhen, China) and serum CRP concentration assays. The changes in these results were calculated in comparison to the preoperative blood routine test results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSoft tissue healing assessment\u003c/h2\u003e \u003cp\u003eThe soft tissue healing was evaluated using the EHS at 24 h postoperatively (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and Landry's healing index at 7 d postoperatively (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), with higher scores indicating a greater degree of healing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eBone tissue recovery evaluation\u003c/h2\u003e \u003cp\u003eTissue samples from the surgical sites in the upper and lower jaws were collected at 90 d and 120 d postoperatively. The samples were fixed in 4% paraformaldehyde for 48 h, rinsed in water for 2 h, and dehydrated in 70%, 80%, and 90% gradient alcohol for 5 d. The samples were then made transparent by soaking in n-butanol for 3 d, followed by soaking in absolute ethanol twice, and then in xylene for 3 d. The samples were embedded in hydroxyethyl methacrylate embedding medium for 5\u0026ndash;10 days. The embedded samples were sectioned continuously using a hard tissue microtome, with section thicknesses of approximately 100 \u0026micro;m. The sections were then polished to a thickness of 70\u0026ndash;80 \u0026micro;m using a hard tissue grinder. Finally, the tissue sections were stained with hematoxylin-eosin (H\u0026amp;E) and toluidine blue, to observe the overall tissue repair and bone formation, respectively. The sections were examined and photographed using a fluorescence stereomicroscope and an automatic upright microscope. Three technical replicates (repeat measurements of the samples from the same animal) were performed for each sample. The captured images of the sections were processed using ImageJ to measure and calculate the percentage of trabecular bone area relative to the total area.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eExperiments were repeated at least 3 times. All data were analyzed with GraphPad Prism version 8.0.0 (GraphPad Software), and presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error of the mean. Independent samples t-test was used for statistical analysis between two groups, where \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated a significant difference and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01 indicated a highly significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative physiological parameters\u003c/h2\u003e \u003cp\u003eThe heart rate, respiratory rate, mean arterial pressure (MAP), and blood oxygen saturation of animals at three stages of anesthesia without any operation and when using tooth extraction during the experiment were recorded, and the changes in each indicator were calculated. The change in heart rate and the increase in respiratory rate of the experimental group animals was significantly lower than that of the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003eA and B, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, respectively), and there was no significant difference in the changes in MAP and blood oxygen saturation between the two groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003eC and D).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTooth extraction time\u003c/h2\u003e \u003cp\u003eWhen removing the mandibular first molar, the experimental group took significantly less time than the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e1\u003c/span\u003eE, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); when removing the maxillary first premolar, there was no significant difference in the duration of tooth extraction between the two groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIncidence of intraoperative complications\u003c/h2\u003e \u003cp\u003eIn the control group, there was a case of root fracture and two cases of severe soft tissue damage during the operation (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003eA), all involving the mandibular first molar and surrounding tissues; preoperative and postoperative X-ray examination results showed no alveolar bone fracture, jaw bone fracture, or adjacent tissue damage in both groups (data not shown). The incidence of complications during the operation in the control group was 25% (3/12), while no complications were observed in the experimental group. In addition, postoperative mandibular alveolar bone defects were present in all subjects of the control group, while only 2/3 of the teeth in the experimental group exhibited such defects (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Moreover, the extent of the defects in the experiment group was smaller compared to the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eHematological examination\u003c/h2\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003e, postoperative white blood cell counts significantly increased in both groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with the experimental group significantly lower than the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); postoperative neutrophil counts in both groups were significantly higher than before surgery but not significantly different (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003eB, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There were no significant changes in the counts of monocytes, eosinophils, basophils, and platelets in either group postoperatively (data not shown). The postoperative serum CRP concentrations of both groups exceeded the normal range, with the experimental group significantly lower than the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003eC, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative soft tissue recovery\u003c/h2\u003e \u003cp\u003ePostoperative soft tissue healing was assessed using EHS 24 h after surgery, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There was no significant difference in maxillary EHS scores between the two groups; however, the mandibular EHS scores in the experimental group were significantly higher than those in the control group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At 7 d postoperatively, the healing index of the experimental group was significantly higher than that of the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003eA, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ePostoperative soft tissue healing evaluation (24 h)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaxillary surgical site\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMandibular surgical site\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative bone tissue healing\u003c/h2\u003e \u003cp\u003eAt 30 d, 60 d, and 90 d postoperatively, there were no significant differences in the ratio of postoperative to preoperative alveolar bone height between the control group and the experimental group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eThe ratio of postoperative to preoperative alveolar bone height\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 d\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003eB, at 90 days postoperatively, H\u0026amp;E stained sections showed that trabeculae (black triangle) were observed in both groups, which were thin and interconnected in a mesh-like pattern; moreover, toluidine blue stained sections showed that both groups had osteoblasts (black arrow) on the surface of the bone trabeculae, with no signs of inflammatory infiltration in either group. At 120 days postoperatively, the H\u0026amp;E stained sections showed that the trabeculae (black triangle) in both groups were thicker than at 90 days postoperatively; toluidine blue stained sections showed a decrease in the number of osteoblasts (black arrow) on the surface of trabeculae in both groups compared to 90 days postoperatively, with no inflammatory infiltration was observed in either group. Figure\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003eC presented the quantitative analysis of the trabecular area percentage in the sections at 90 and 120 days postoperatively, revealing a significantly higher percentage in the experimental group compared to the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003eC, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSurgery can cause certain damages to animals, including intraoperative and postoperative pain (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Increased heart rate, respiratory rate, blood oxygen saturation, and blood pressure, are usually considered indicators of pain perception, therefore monitoring these changes in clinical practice can be used to assess pain levels. This study monitored the above indicators of animals during the surgical process and calculated the changes. The results showed that when using the pneumatic dental elevator for tooth extraction, the increase in heart rate and respiratory rate of animals was significantly lower than when using the traditional dental elevator. This indicates that compared to traditional dental elevators, the use of pneumatic dental elevators for tooth extraction results in lower pain perception in animals. In addition, the time taken to extract the mandibular first molar using the pneumatic dental elevator was significantly shorter than using the traditional dental elevator, and the incidence of intraoperative complications was significantly reduced. With the reduction in surgical time, the time of anesthesia also decreased, which to some extent reduces the anesthesia risk of surgery (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Therefore, using the pneumatic dental elevator not only significantly improves the efficiency of tooth extraction, but also increases safety.\u003c/p\u003e \u003cp\u003eDental surgery complications are relatively common, with minor intraoperative complications including crown/root fracture, soft tissue injury, minor alveolar bone fracture, and root displacement; more serious intraoperative complications include mandibular fracture, severe bleeding, severe tooth displacement, and damage to adjacent tissues (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The extent of soft tissue damage can be assessed visually, while the degree of bone tissue damage requires evaluation through imaging studies. Taking an oral X-ray before tooth extraction can help clinicians understand the overall condition of the tooth roots and periodontal tissues, and formulate an appropriate surgical plan (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Taking an oral X-ray after tooth extraction can determine whether the tooth has been completely removed, and can determine whether the surgery has caused damage to the periodontal hard tissues and adjacent teeth as well as the severity of the damage by comparing it with the preoperative X-ray. In this study, the incidence of complications during the operation in the control group was 25% (3/12), while no complications were observed in the experimental group. Furthermore, postoperative mandibular alveolar bone defects were present in all subjects of the control group, whereas only 2/3 of the subjects in the experimental group exhibited such defects, with the extent of the defects smaller than the control group. Therefore, using a pneumatic dental elevator can cause less damage to teeth.\u003c/p\u003e \u003cp\u003eWhen the white blood cell count, neutrophil ocunt and serum CRP concentration increases and exceeds the normal reference range, it may indicate infection or inflammation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Research by Michelsen et al. showed that serum CRP concentration can sensitively measure the differences in surgical injury severity (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The results of the blood routine tests showed that both groups had significantly elevated white blood cell count and neutrophil count after surgery, with the postoperative neutrophil count in the experimental group significantly lower than that in the control group. Both groups had postoperative serum CRP concentrations exceeding the normal range (\u0026gt;\u0026thinsp;10 mg/L). The postoperative serum CRP concentration in the control group was greater than 40 mg/L, indicating moderate systemic inflammation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and significantly higher than that in the experimental group, suggesting that the degree of intraoperative damage in the experimental group was lower than that in the control group. These results indicate that both groups had acute inflammation after surgery, but the inflammatory response in the experimental group is milder.\u003c/p\u003e \u003cp\u003eFollowing injury, gingival epithelial cells exhibit robust regenerative capacity, with migration towards the injured site commencing within hours. By the 7th day, these cells mature, culminating in the formation of a new stratum corneum (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The EHS has been specifically designed to evaluate the initial stages of healing in gingival tissues following dental procedures within 24 hours. This method takes into account three key parameters: clinical signs of re-epithelialization (CSR), clinical signs of hemostasis (CSH), and clinical signs of inflammation (CSI) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). CSR evaluates the extent to which the wound edges approximate, CSH assesses the absence of bleeding and fibrin exudate, and CSI examines the degree of redness indicating inflammation. A higher combined score indicates better healing progress (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). By the 7th day post-extraction, epithelial cells mature, forming a new stratum corneum, which is then evaluated using the healing index developed by Landry et al (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This index incorporates parameters such as tissue color reflecting gum swelling, bleeding on probing, presence of granulation tissue, margin of epithelialization, and any signs of pus, providing a comprehensive assessment of soft tissue healing at this stage. A higher score also signifies improved healing. This experiment evaluated the degree of soft tissue healing at 24 h and 7 days postoperatively, with the experimental group scoring significantly higher than the control group, indicating better soft tissue healing in the experimental group.\u003c/p\u003e \u003cp\u003eAfter tooth extraction, there is a noticeable resorption of the alveolar bone, with the width of the bone showing a more significant loss than the height, and the buccal plate resorbing more markedly than the lingual plate (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The ratio of alveolar bone height after tooth extraction compared to before extraction is an important clinical indicator. It reflects the impact of the extraction on the alveolar bone structure and the healing condition of the alveolar bone post-extraction. If the ratio is close to 1, it indicates that the alveolar bone has been well preserved during the extraction process or that the healing process is going well. In this study, it was found that there was no significant difference in the ratio of postoperative to preoperative alveolar bone height between the control group and the experimental group. Observations of osteoblasts, bone trabeculae formation, and the histological structure of bone tissue can be used to assess the degree of bone tissue healing. Morphological observation of the surgical site tissues at 90 and 120 days postoperatively revealed a greater number of osteoblasts on the bone trabecular surfaces in both groups. Osteoblasts, fibroblasts, endothelial cells, and other cells secrete various growth factors that stimulate the migration of mesenchymal stem cells, osteoblast proliferation and differentiation, as well as bone matrix synthesis, promoting bone remodeling (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Compared to the control group, the experimental group showed more new bone formation, suggesting better bone healing in the experimental group.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eUsing pneumatic dental elevators for tooth extraction reduces the degree of pain during the surgical process, takes less time, causes less damage to periodontal tissues, reduces the severity of postoperative inflammation, and promotes better tissue healing.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCONFLICT OF INTEREST\u003c/h2\u003e \u003cp\u003eThere are no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFUNDING\u003c/h2\u003e \u003cp\u003eThis work was supported by Northwest A\u0026amp;F University Doctoral Research Startup Fund (Yangling, Shaanxi, China; grant no. 2452024063).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eXF and YT wrote the main manuscript text and prepared Figs. PD and XZ formulated the experimental plan. QD and KW performed sample processing and data collection. RC and JD performed data analysis and interpretation. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGuo H, Bai X, Wang X, Qiang J, Sha T, Shi Y, Zheng K, Yang Z, Shi C. Development and regeneration of periodontal supporting tissues. Genesis (New York, NY : 2000). 2022 Sep;60(8-9):e23491. eng. Epub 2022/07/06. doi:10.1002/dvg.23491. Cited in: Pubmed; PMID 35785409.\u003c/li\u003e\n\u003cli\u003eMamoun J. Use of elevator instruments when luxating and extracting teeth in dentistry: clinical techniques. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2017 Jun;43(3):204-211. eng. Epub 2017/08/05. doi:10.5125/jkaoms.2017.43.3.204. 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Cited in: Pubmed; PMID 34043832.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pneumatic tooth elevator, traditional tooth elevator, tooth extraction, molar, tissue healing.","lastPublishedDoi":"10.21203/rs.3.rs-4740115/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4740115/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePneumatic tooth elevators are newly developed surgical instruments that utilize compressed air to drive a small, oscillating tip that can gently loosen the tooth from its socket. However, the effect of pneumatic tooth elevators in veterinary clinical practice is not yet clear. In this study, 6 dogs were used as experimental animals. and maxillary first premolars and mandibular first molars were extracted using traditional (control group) and pneumatic dental elevators (experimental group). Physiological parameters, extraction time, intraoperative complications, hematological examination, and tissue healing were compared to investigate the effect of pneumatic dental elevators. The results showed that compared to the control group, the experimental group had a smaller increase in heart rate and respiratory rate, and the time required to extract the mandibular first molar was less. The incidence of complications in the control group was 25% (3/12), while there were no complications in the experimental group. Additionally, all cases in the control group had defects in the mandibular alveolar bone, while only 2/3 of the cases in the experimental group had defects, and the degree of defect was less than that of the control group. The white blood cell count and C-reactive protein (CRP) concentration in the experimental group were significantly lower than those in the control group. The early wound healing score (EHS), soft tissue healing index, and trabecular area in the experimental group were all significantly greater than those in the control group. The above results indicate that using pneumatic dental elevators reduces the degree of pain during the surgical process, takes less time, causes less damage to periodontal tissues, reduces the severity of postoperative inflammation, and promotes better tissue healing. This study provides a theoretical basis and technical reference for the clinical application of the new type of pneumatic dental elevator, promoting its wider application.\u003c/p\u003e","manuscriptTitle":"Evaluation of the effect of a pneumatic dental elevator on tooth extraction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-16 16:10:22","doi":"10.21203/rs.3.rs-4740115/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"306dbe7e-9233-471e-9cf9-eb0e3fe5cce5","owner":[],"postedDate":"August 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-18T02:38:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-16 16:10:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4740115","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4740115","identity":"rs-4740115","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}