INSTRUMENTATION

B A S I C O R A L S U R G E RY
CONTENTS:

I. Holding the Mouth Open

II. Suctioning
III. Holding Towels and Drapes in position
IV. Irrigating
V. Extracting Teeth
PART I: HOLDING THE MOUTH OPEN
(I) HOLDING THE MOUTH OPEN

When performing extractions of mandibular teeth, it is necessary to support the mandible to

prevent stress on the temporomandibular joint (TMJ).

Appliances:
a) Bite Block
b) Molt Mouth Prop (side-action Mouth Prop)
(A) BITE BLOCKS

The bite block is a soft, rubberlike block on which the patient can rest his or her teeth.
The patient opens the mouth to a comfortably wide position, the rubber bite block is inserted,
and the block holds the mouth in the desired position without patient effort.
Bite blocks come in several sizes to fit variously sized patients and produce varying degrees of
opening.
Should the surgeon need the mouth to be opened wider using any size of bite block, the
patient must open his or her mouth more widely and the bite block must be positioned more
to the posterior of the mouth.
(B) MOLT MOUTH PROP

This mouth prop has a ratchet-type action, opening the mouth wider as the handle is closed.
This type of mouth prop should be used with caution because great pressure can be applied to
teeth and the TMJ, and injury may occur with injudicious use.
It is useful in patients who are deeply sedated or have mild forms of trismus.
Whenever a bite block or side-action mouth prop is used, the surgeon should take care to
avoid opening the patients mouth too widely because it may cause stress on the TMJ.
It is a good idea to remove the prop periodically and allow the patient to move the jaw and
rest the muscles for a short time.
PART II: SUCTIONING
SUCTIONING

To provide adequate visualization, blood, saliva, and irrigating solutions must be suctioned from
the operative site.
The surgical suction is one that has a smaller orifice than the type used in general dentistry to
more rapidly evacuate fluids from the surgical site to maintain adequate visualization.
Many of these suctions are designed with several orifices so that the soft tissue will not
become aspirated into the suction hole and cause tissue injury.
FRASER SUCTION

The Fraser suction has a hole in the handle portion that can be covered with a fingertip as
needed.
When hard tissue is being cut under copious irrigation, the hole is covered so that the solution
is removed rapidly.
When soft tissue is being suctioned, the hole can be left uncovered to prevent tissue injury or
soft tissue obstruction of the suction tip
PART III: HOLDING TOWELS &
DRAPES IN POSITION
HOLDING TOWELS & DRAPES IN
POSITION
When drapes are placed around a patient, they can be held together with a towel clip .
This instrument has a:
locking handle,
finger and thumb rings.
The action ends of the towel clip can be sharp or blunt.
Those with curved points penetrate the towels and drapes.
PART IV: IRRIGATING
IRRIGATING

The irrigation cools the bur and prevents bone-damaging heat buildup.
The irrigation also increases the efficiency of the bur by washing away bone chips from the
flutes of the bur and by providing a certain amount of lubrication.
A large plastic syringe with a blunt 18-gauge needle is commonly used for irrigation.
Although the syringe is disposable, it can be sterilized multiple times before it is discarded.
The needle should be blunt and smooth so that it does not damage soft tissue, and it should
be angled for more efficient direction of the irrigating stream
PART V: EXTRACTING TEETH
EXTRACTING TEETH
One of the most important instruments used in the extraction procedure is the dental
elevator.
These instruments are used to luxate (loosen) teeth from surrounding bone.
Loosening teeth before the application of the dental forceps makes extractions easier.
By elevating teeth before the application of the forceps, the clinician can minimize the
incidence of broken crowns, roots, and bone.
Finally, luxation of teeth before forceps application facilitates the removal of a broken root
should it occur because prior elevator use is likely to have loosened the root in the dental
socket.
In addition to their role in loosening teeth from surrounding bone, dental elevators are also
used to expand alveolar bone.
Finally, elevators are used to remove broken or surgically sectioned roots from their sockets.
EXTRACTING TEETH

Dental Elevators
Types of Elevators
Periotomes
Extraction Forceps
a) Forceps Components
b) Maxillary Forceps
c) Mandibular Forceps
(1) DENTAL ELEVATORS

The three major components of the elevator are the

(a) handle
(b) shank
(c) blade
(A) HANDLE

The handle of the elevator is usually of generous size, so it can be held comfortably in the
hand to apply substantial, but controlled, force.
In some situations, cross-bar or T-bar handles are used.
These instruments must be used with great caution because they can generate an excessive
amount of force
(B) SHANK

The shank of the elevator simply connects the handle to the working end, or blade, of the
elevator.
The shank is generally of substantial size and is strong enough to transmit the force from the
handle to the blade.
(C) BLADE

The blade of the elevator is the working tip of the elevator and is used to transmit the force
to the tooth, bone, or both.
(2) TYPES OF ELEVATORS

The biggest variation in the type of elevator is in the shape and size of the blade.
The three basic types of elevators are
a) Straight type,
b) Triangle (or pennant-shape) type
c) Pick type.
(A) STRAIGHT TYPE ELEVATOR

The straight elevator is the most commonly used elevator to luxate teeth
The blade of the straight elevator has a concave surface on one side that is placed toward the
tooth to be elevated
The small straight elevator, No. 301, is frequently used for beginning the luxation of an
erupted tooth before application of the forceps
Larger straight elevators are used to displace roots from their sockets and are also used to
luxate teeth that are more widely spaced or once a smaller-sized straight elevator becomes
less effective.
The most commonly used large straight elevator is the No. 34S, but the No. 46 and the No. 77R
are also used occasionally.
(A) STRAIGHT TYPE ELEVATOR

The shape of the blade of the straight elevator can be angled from the shank, allowing this
instrument to be used in the more posterior aspects of the mouth.
Two examples of the angled-shank elevator with a blade similar to the straight elevator are the
Miller elevator and the Potts elevator.
(B) TRIANGULAR ELEVATOR

The second most commonly used type of elevator is the triangular elevator
These elevators are provided in pairs:
a left and a right.
The triangular elevator is most useful when a broken root remains in the tooth socket and the
adjacent socket is empty.
(B) TRIANGULAR ELEVATOR

The tip of the triangular elevator is placed into the socket, with the shank of the elevator
resting on the buccal plate of bone.
The elevator is then turned in a wheel-and-axle rotation, with the sharp tip of the elevator
engaging the cementum of the remaining distal root; the elevator is then turned, and the root
is delivered.
Triangular elevators come in a variety of types and angulations, but the Cryer elevator is the
most common type
(C) PICK-TYPE ELEVATOR

The third type of elevator that is used with some frequency is the pick-type elevator.
This type of elevator is used to remove roots.
The heavy version of the pick is the Crane pick
The second type of pick is the root-tip pick or the apex elevator
i. CRANE PICK

This instrument is used as a lever to elevate a broken root from the tooth socket.
Usually, it is necessary to drill a hole with a bur (purchase point) approximately 3 mm deep
into the root just at the bony crest.
The tip of the pick is then inserted into the hole, and with the buccal plate of bone as a
fulcrum, the root is elevated from the tooth socket.
Occasionally, the sharp point can be used without preparing a purchase point by engaging the
cementum or the furcation of the tooth.
ii. ROOT TIP PICK

The root-tip pick is a delicate instrument that is used to tease small root tips from their
sockets.
Should not be used as a wheel-and axle or lever type of elevator such as the Cryer elevator or
the Crane pick.
The root tip pick is used to tease the very small root end of a tooth by inserting the tip into the
periodontal ligament space between the root tip and the socket wall.
(3) PERIOTOMES

Periotomes are instruments used to extract teeth while preserving the anatomy of the tooths
socket.
It is used to sever some of the periodontal ligaments of the tooth to facilitate its removal.
There are varying types of periotomes with different blade shapes
(3) PERIOTOMES

The tip of the periotome blade is inserted into the periodontal ligament space and advanced
using pressure in the apical direction along the long axis of the tooth.
It is advanced about 2 to 3 millimeters (mm) and then removed and reinserted into an
adjacent accessible site.
The process is continued around the tooth, gradually advancing the depth of the periotome tip
while progressing apically.
Once sufficient severance of periodontal ligaments has been accomplished, the tooth is
removed by using a dental elevator, extraction forceps, or both, taking care to avoid excessive
expansion or fracture of bone.
(4) EXTRACTION FORCEPS

The extraction forceps are instruments used for removing the tooth from alveolar bone.
Ideally, forceps are used to lift elevator-luxated teeth from their sockets, rather than to pull
teeth from their sockets.
They also can help to expand bone when properly used. Forceps are designed in many styles
and configurations to adapt to the variety of teeth for which they are used.
(i) FORCEPS COMPONENTS

The basic components of dental extraction forceps are

the handle,
hinge, and
beaks
(1) HANDLES

The handles are usually of adequate size to be used comfortably and to deliver sufficient
pressure and leverage to remove the required tooth
The handles of the forceps are held differently, depending on the position of the tooth to be
removed.
Maxillary forceps are held with the palm underneath the forceps so that the beak is directed in
a superior direction. The forceps used for removal of mandibular teeth are held with the palm
on top of the forceps so that the beak is pointed down toward teeth
The handles of the forceps are usually straight, but some may be curved.
(2) HINGE

The hinge of the forceps, like the shank of the elevator, is merely a mechanism for connecting
the handle to the beak.
The hinge transfers and concentrates the force applied to the handles to the beak.
The usual American type of forceps has a hinge in a horizontal direction and is used as has
been described. The English preference is for a vertical hinge and a corresponding vertically
positioned handle
Thus, the English-style handle and hinge are used with the hand held in a vertical direction as
opposed to a horizontal direction
(3) BEAK

The beaks of the extraction forceps are the source of the greatest variation among forceps.
The beak is designed to adapt to the tooth root near the junction of the crown and root.
The beaks of the forceps are designed to be adapted to the root structure of the tooth and not
to the crown of the tooth.
The design variation is such that the tips of the beaks will adapt closely to the various root
formations, improving the surgeons control of forces on the root and decreasing the chances
of a root fracture.
The more closely the beaks of the forceps adapt to the tooth roots, the more efficient is the
extraction and the lower is the chance for undesired outcomes.
(3) BEAK
(Width Of The Beak)
Some forceps beaks are narrow because their primary use is to remove narrow teeth such as
incisor teeth.
Other forceps beaks are broader because the teeth they are designed to remove are
substantially wider.
(ii) MAXILLARY FORCEPS

The removal of maxillary teeth requires the use of instruments designed for single-rooted
teeth and for teeth with three roots.
After proper elevation, single-rooted maxillary teeth are usually removed with maxillary
universal forceps, usually No. 150
NO. 150

The No. 150 forceps are slightly S-shaped when viewed from the side and are essentially
straight when viewed from above.
The beaks of the forceps curve to meet only at the tip.
The slight curve of the No. 150 allows the operator to comfortably reach not only incisors but
also premolars.
The beaks of the No. 150 forceps come in a style that has been modified slightly to form the
No. 150A forceps
NO. 150A

The No. 150A is useful for maxillary premolar teeth and should not be used for incisors
because of its poor adaptation to the roots of incisors.
NO. 150 & NO. 1

In addition to the No. 150 forceps, straight forceps are also available.
The No. 1 forceps, which can be used for maxillary incisors and canines, are easier to use
compared with the No. 150 for upper incisors.
Left & Right

Maxillary molar teeth are three-rooted teeth, with a single palatal root and a buccal
bifurcation.
Therefore, forceps that are specifically adapted to fit maxillary molars must have a smooth,
concave surface for the palatal root and a beak with a pointed design that will fit into the
buccal bifurcation.
This requires that the molar forceps come in pairs: a left and a right.
Additionally, the maxillary molar forceps should be offset so that the surgeon can reach the
posterior aspect of the mouth and remain in the correct position.
NO.53 (RIGHT & LEFT)

The most commonly used molar forceps are the No. 53 right and left
These forceps are designed to fit anatomically around the palatal beak, and the pointed buccal
beak fits into the buccal bifurcation.
The beak is offset to allow for good surgeon positioning.
NO.88 (RIGHT & LEFT)

A design variation is shown in the No. 88 right and left forceps, which have a longer, more
accentuated, pointed beak formation
They are particularly useful for maxillary molars with crowns that are severely carious.
The major disadvantage is that they crush crestal alveolar bone, and when used on intact
teeth without due caution, fracture of large amounts of buccal alveolar bone may occur.
On occasion, maxillary second molars and erupted third molars have a single conical root. In
this situation, forceps with broad, smooth beaks that are offset from the handle can be useful.
NO. 210S & NO.65

The No. 210S forceps exemplify this design

Another design variation is shown in the offset molar forceps with very narrow beaks.
These forceps are used primarily to remove broken maxillary molar roots but can be used for
the removal of narrow premolars and for lower incisors.
These forceps, the No. 65, are also known as root-tip forceps
NO. 150 & NO.150S

A smaller version of the No. 150, the No. 150S, is useful for removing primary teeth. These
forceps adapt well to all maxillary primary teeth and can be used as universal primary tooth
forceps.
(iii) MANDIBULAR FORCEPS

Extraction of mandibular teeth requires forceps that can be used for single-rooted teeth for
the incisors, canines, and premolars, as well as for two-rooted teeth for the molars.
The forceps most commonly used for the single-rooted teeth are the lower universal forceps,
or the No. 151
NO. 151

These forceps have handles similar in shape to the No. 150, but the beaks are pointed
inferiorly for lower teeth.
The beaks are smooth and narrow and meet only at the tip.
This allows the beaks to fit near the cervical line of the tooth to grasp the root.
NO. 151A

The No. 151A forceps have been modified slightly for mandibular premolar teeth
These forceps should not be used for other lower teeth because their form prevents
adaptation to the roots of teeth.
Great force can be generated with these forceps.
Unless great care is exercised, the incidence of root fracture is higher with this instrument.
Mandibular molars are bifurcated, two-rooted teeth that allow the use of forceps that
anatomically adapt to the tooth.
Because the bifurcation is on the buccal and the lingual sides, only a single molar forceps are
necessary for the both sides, in contradistinction to the maxilla, for which a right- and left-
paired molar forceps set is required.
NO. 17

Useful lower molar forceps are the No. 17

These forceps are usually straight-handled, and the beaks are set obliquely downward.
The beaks have pointed tips in the center to be set into the bifurcation of lower molar teeth.
The remainder of the beak adapts well to the sides of the furcation.
Because of the pointed tips, the No. 17 forceps cannot be used for molar teeth, which have
fused, conical roots.
For this purpose, the No. 151 forceps are used.
NO. 87

A major design variation in lower molar forceps is the No. 87, the so-called cowhorn forceps
These instruments are designed with two pointed, heavy beaks that enter the bifurcation of
lower molars.
After the forceps are seated into the correct position, usually while gently pumping the
handles up and down, the tooth is actually elevated by squeezing the handles of the forceps
together tightly.
As the beaks are squeezed into the bifurcation, they use the buccal and lingual cortical plates
as fulcrums, and the tooth can be literally squeezed out of the socket.
NO. 151 & NO. 151S

The No. 151 is also adapted for primary teeth.

The No. 151S is the same general design as the No. 151 but is scaled down to adapt to primary
teeth.
These forceps are adequate for the removal of all primary mandibular teeth
THANK YOU
PRESENTED BY:

RAMJEET Luvish
201002152
(+86)139-6889-1690
luvish@dr.com