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Full text of "Contemporary Oral and Maxillofacial Surgery,4th Ed Part II Principle of Exodontia"

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Principles of Exodontia 

7 or most people, dentists, and laypeople alike, the term oral surgery 
usually implies the removal of a tooth. The atraumatic extraction of 
a tooth is a procedure that requires finesse, knowledge, and skill on 
the part of the surgeon. The purpose of this section is to present the princi- 
ples of exodontia, as well as the instrumentation, techniques, and manage- 
ment of patients who are undergoing extraction surgery. 

Chapter 6 presents the armamentarium commonly used for office oral sur- 
gical procedures. The basic instrumentation and their fundamental applica- 
tions to their surgical purposes are discussed. Many variations of the instru- 
ments presented here are available. 

Chapter 7 presents the basic aspects of how to remove an erupted tooth 
atraumatically. The preoperative assessment and preparation of the patient 
are briefly discussed. The position of the patient in the chair and the position 
of the surgeon, the surgeon's hands, and the dental assistant for the removal 
of each tooth are discussed. The armamentarium and movements necessary 
to extract each tooth are discussed in detail. 

Chapter 8 presents the basic aspects of managing complicated extractions. 
Complicated extractions primarily refer to retrieving tooth roots and teeth 
that are likely to fracture or, for some other reason, have an obstacle to extrac- 
tion. In these situations, surgical removal of bone or surgical sectioning of the 
tooth is required. 

Chapter 9 presents the fundamental aspects of management of impacted 
teeth. The rationale for timely removal of impacted teeth is presented in the ini- 
tial portion of the chapter. Classifying and determining the degree of difficulty 
of the impaction follow. Last, a brief description of the basic surgical techniques 
required to remove impacted third molars is provided. 

Chapter 10 presents the techniques for managing the patient during the 
postoperative period. This chapter discusses postoperative instructions that 
should be given to the patient, as well as postoperative medications. 

Chapter 1 1 presents the common surgical complications that are encoun- 
tered in the removal of teeth. Emphasis is placed on anticipating complica- 
tions and taking measures to prevent or minimize them. 

Last, Chapter 12 discusses the medical and legal considerations involved in 
basic exodontia. An important portion of this chapter discusses the concept 
.of informed consent for the patient. 


for Basic Oral Surgery 


Larry j. Peterson 

— =«*• 

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Chapter outline 



Rongeur Forceps 

Chisel and Mallet 

Bone File 

Bur and Handpiece 


Needle Holder 


Suture Material 








Maxillary Forceps 

Mandibular Forceps 

/■ T ** he purpose of this chapter is to introduce the 

^ f instrumentation required to perform routine 

J- oral surgical procedures. These instruments 

are used for a wide variety of purposes, 

including both soft tissue and hard tissue procedures. 

This chapter deals primarily with a description of the 

instruments; subsequent chapters discuss the actual 

use of the instruments in the variety of ways for which 

they are intended. 


Most surgical procedures begin with an incision. The 
instrument for making an incision is the scalpel, which is 
composed of a handle and a disposable, sterile sharp 
blade. The most commonly used handle is the no. 3 han- 
dle, but occasionally the longer, more slender no. 7 han- 
dle will be used (Fig. 6-1). The tip of the scalpel handle is 
prepared to receive a variety of differently shaped scalpel 
blades that can be inserted onto a slotted receiver. 


Atmmnentanum for Bask Oral Surgery 



FIG. 6-1 Scalpels are composed of handle and sharp, disposable blade. Scalpel no. 7 handle with no. 
15 blade (top) and scalpel with more commonly used no. 3 handle (bottom). 

FIG. 6-2 Scalpel blades used in oral surgery include no. 15 (middle left), no. 12 (middle right), no. 
11 (lower left), and no. 10 (lower right). No. 3 scalpel handle is above. 

The most commonly used scalpel blade for intraoral 
surgery is the no. 15 blade (Fig. 6-2). It is relatively small 
and can be used to make incisions around teeth and 
through mucoperiosteum. It is similar in shape to the 
larger no. 10 blade, which is used for large skin incisions. 
Other commonly used blades for intraoral surgery are the 
no. 11 blade and the no. 12 blade. The no. 11 blade is a 
sharp-pointed blade that is used primarily for making 
small stab incisions, such as for incising an abscess. The 
hooked no. 12 blade is useful for mucogingival proce- 

dures in which incisions must be made on the posterior 
aspect of teeth or in the maxillary tuberosity area. 

The scalpel blade is carefully loaded onto the handle 
with a needle holder to avoid lacerating the operator's fin- 
gers. The blade is held on the superior edge, where it is 
reinforced with a small rib, and the handle is held so that 
the male portion of the fitting is pointing upward (Fig. 6-3, 
A), The knife blade is then slid onto the handle until it 
clicks into position (Fig. 6-3, B). The knife is unloaded in a 
similar fashion. The needle holder grasps the most proxi- 


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i'riiuiphs of Exoiiofitki 

FIG. 6-3 A, When loading scalpel blade, surgeon holds blade in needle holder and handle, with male 
portion of fitting pointing upward. B, Blade is then slid into handle until it clicks into place. C, To 
remove blade, the surgeon uses needle holder to grasp proximal end of blade and lifts it to 
disengage it from fitting. D, Blade is then slid off handle. 


mal end of the blade (Fig. 6-3, C) and lifts it to disengage it 
from the male fitting. It is then slid off the knife handle in 
the opposite direction (Fig. 6-3, D). The used blade is dis- 
carded into a proper rigid-sided "sharps" container. 

When using the scalpel to make an incision, the sur- 
geon holds it in the pen grasp (Fig. 6-4) to allow maximal 
control of the blade as the incision is made. Mobile tissue 
should be held firmly to stabilize it so that as the incision 
is made, the blade will incise, not displace, the mucosa. 
When a mucoperiosteal incision is made, the knife 
should be pressed down firmly so that the incision pene- 
trates the mucosa and periosteum with the same stroke. 

Scalpel blades are designed for single-patient use. They 
are dulled very easily when they come into contact with 
hard tissue such as bone and teeth. If several incisions 
through mucoperiosteum to bone are required, it may be 
necessary to use a second blade during a single operation. 
It is important to remember that dull blades do not make 
clean, sharp incisions in soft tissue and therefore should 
be replaced when they become dull. 


After an incision through mucoperiosteum has been made, 
the mucosa and periosteum should be reflected from the 
underlying bone in a single layer with a periosteal elevator. 

The instrument that is most commonly used is the no. 9 
Molt periosteal elevator (Fig. 6-5, A). This instrument has a 
sharp, pointed end and a broader fiat end. The pointed end 
is used to reflect dental papillae from between teeth, and 
the broad end is used for elevating the tissue from the bone. 

Some surgeons prefer to use round-ended Molt 
periosteal elevators. This type of periosteal elevator can 
be single-ended (Fig. 6-5, B) or double-ended (Fig. 6-5, C 
and D). The cutting edge of the Molt periosteal elevator is 
thin and sharp, resulting in a clean separation of the 
periosteum from the bone. 

The periosteal elevator can be used to reflect soft tissue 
by three methods: First, the pointed end can be used in a 
prying motion to elevate soft tissue. This is most com- 
monly used when elevating a dental papilla from 
between teeth. The second method is the push stroke, in 
which the broad end of the instrument is slid underneath 
the flap, separating the periosteum from the underlying 
bone. This is the most efficient stroke and results in the 
cleanest reflection of the periosteum. The third method is 
a pull, or scrape, stroke. This is occasionally useful in 
some areas but tends to shred or tear the periosteum 
unless it is done carefully. 

The periosteal elevator can also be used as a retractor. 
Once the periosteum has been elevated, the broad blade of 
the periosteal elevator is pressed against the bone, with the 
mucoperiosteal flap elevated into its reflected position. 

Armamentarium for Basic Oral Surgery 




FIG. 6-4 Scalpel is held in pen grasp to allow maximal control. 

When teeth are to be extracted, the soft tissue attach- 
ment around the tooth must be released from the tooth. 
The instrument most commonly used for this is the no. 
1 Woodson periosteal elevator (Fig. 6-6). This instru- 
ment is relatively small and delicate and can be used to 
loosen the soft tissue via the gingival sulcus. The point- 
ed end of the no. 9 periosteal elevator can also be used 
for this purpose. 



It is critical to have good vision and good access to per- 
form good surgery. To this end, a variety of retractors 
have been designed to retract the cheeks, tongue, and 
mucoperiosteal flaps. 

The two most popular cheek retractors are (1) the 
right-angle Austin retractor (Fig. 6-7) and (2) the offset 
broad Minnesota retractor (Fig. 6-8). Both of these retrac- 
tors can retract the cheek and a mucoperiosteal flap 
simultaneously. Before the flap is created, the retractor is 
held loosely in the cheek, and once the flap is reflected 
the retractor is placed on the bone and is then used to 
retract the flap. 

In addition to the Austin and Minnesota retractors, 
other retractors are designed more specifically to reflect 
soft tissue flaps. The Seldin retractor is typical of this kind 
(Fig. 6-9). Although this retractor may look similar to a 
periosteal elevator, the leading edge is not sharp but 
rather is dull and should not be used to reflect muco- 
periosteum. The periostea! elevator is often used as the 
primary instrument to retract soft tissue. Once the flap 
has been reflected, the periosteal elevator is positioned on 
bone and held there to reflect the tissue. 

The instrument most commonly used to retract the 
tongue is the mouth mirror. This is usually part of every 
basic setup, because it has both the usual use and use as 
a tongue retractor. The Weider tongue retractor is a broad, 
heart-shaped retractor that is serrated on one side so that 

it can more firmly engage the tongue and retract it medi- 
ally and anteriorly (Fig. 6-10). When this retractor is used, 
care must be taken not to position it so far posteriorly 
that it causes gagging (Fig. 6-11). 

The towel clip can be used to hold the tongue. When 
a biopsy procedure is to be performed on the posterior 
aspect of the tongue, the most positive way to control the 
tongue is by holding the anterior tongue with a towel 
clip. Local anesthesia must be profound where the clip is 


When incisions are made through tissue, small arteries 
and veins are incised, causing bleeding that may require 
more than simple pressure to control. When this is nec- 
essary, an instrument called a hemostat is used (Fig. 6-12, 
A). Hemostats come in a variety of shapes, may be rela- 
tively small and delicate or larger, and are either straight 
or curved. The hemostat most commonly used in oral 
surgery is a curved hemostat (Fig. 6-12, B). 

The hemostat has a relatively long, delicate beak, used 
to grasp tissue, and a locking handle. The locking mech- 
anism allows the surgeon to clamp the hemostat onto a 
vessel and then let go of the instrument, which will 
remain clamped onto the tissue. 

In addition to its use as an instrument for controlling 
bleeding, the hemostat is especially useful in oral surgery 
to remove granulation tissue from tooth sockets and to 
pick up small root tips, pieces of calculus, fragments of 
amalgam restorations, and any other small particles that 
have dropped into the mouth or wound area. 


In performing soft tissue surgery it is frequently necessary 
to stabilize soft tissue flaps to pass a suture needle. Tissue 
forceps most commonly used for this purpose are the 



Principles ofExodontia 

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FIG. 6-5 A, No. 9 Molt periosteal elevator is most commonly used in oral surgery. B, A single-ended Molt 
periosteal elevator with a sharp round end may be used to elevate the mucoperiosteum. C and D, The dou- 
ble-ended Molt periosteal elevator has a large and small end to provide the surgeon the appropriate-size 
end for the specific task. 

Armamentarium f&r Basic Oral Surgery 



FIG. 6-6 No. 1 Woodson periosteal elevator is used to loosen soft tissue from teeth before extraction. 


FIG. 6-7 Austin retractor is a right-angle retractor that can be used 
to retract cheek, tongue, or flaps. 

FIG. 6-8 Minnesota retractor is an offset retractor used for retrac- 
tion of cheeks and flaps. 

FIG. 6-9 Periosteal elevators such as Woodson and no. 9 Molt are useful to retract flaps. Seldin retrac- 
tor (top) is broader instrument that provides broader retraction and increased visualization. 



Principles of Ewdontia 

■ . ■_■.-. -/. 


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FIG. 6-10 Weider retractor is a large retractor designed to retract 
tongue. Serrated surface helps to engage tongue so that it can be 
held securely. 

FIG. 6-1 1 Weider retractor is used to hold tongue away from sur- 
gical field. Austin retractor is used to retract cheek, 


FIG. 6-12 A, Hemostats (top view) used in oral surgery. B, Curved hemostat (side view). 

Armamentarium for Basic Oral Surgery 




FIG. 6-13 A, Small, delicate Adson tissue forceps are used to gently stabilize soft tissue for suturing 
or dissection. B, The Stillies pickup is longer than the Adson pickup and is used to handle tissue in the 
more posterior aspect of the mouth. C, The college pliers is an angled forceps that is used for picking 
up small objects in the mouth or from the Mayo tray stand. 

Adson forceps (pickups) (Fig. 6-13, A). These are delicate 
forceps with small teeth, which can be used to gently 
hold tissue and thereby stabilize it. When this instrument 
is used, care should be taken not to grasp the tissue too 
tightly, thereby crushing it. Adson forceps are also avail- 
able without teeth. 

When working in the posterior part of the mouth, the 
Adson forceps may be too short. A longer forceps that has 
similar shape is the Stillies forceps. This forceps is usually 
7 to 9 inches long and can easily grasp tissue in the pos- 
terior part of the mouth and still leave enough of the 
instrument protruding beyond the lips for the surgeon to 
control it (Fig. 6-13, B). 

Occasionally, it is more convenient to have an angled 
forceps. Such a forceps is the college, or cotton, forceps 
(Fig. 6-13, C). Although this forceps is not especially use- 
ful for handling tissue, it is an excellent instrument for 
picking up small fragments of tooth, amalgam, or other 
foreign material and for placing or removing gauze packs. 
This instrument is commonly used in tray systems. 

In some types of surgery, especially when removing 
larger amounts of fibrous tissue, such as in an epulis fis- 
suratum, forceps with locking handles and teeth that will 
grip the tissue firmly are necessary. In this situation the 
Allis tissue forceps are used (Fig. 6-14, A and B). The lock- 
ing handle allows the forceps to be placed in the proper 
position and then to be held by an assistant to provide 
the necessary tension for proper dissection of the tissue. 
The Allis forceps should never be used on tissue that is to 
be left in the mouth, because they cause a relatively large 
amount of tissue destruction as a result of crushing injury 
(Fig. 6-14, C). 

Russian tissue forceps are large, round-ended tissue 
forceps (Fig. 6-15, A) that are most useful in oral surgery 
to pick up teeth that have been elevated from their sock- 
ets (Fig. 6-15, B). The round end allows a positive grip on 
a tooth or tooth fragment so that it is not likely to slip 
out of the instrument's grip, as commonly occurs with 
the hemostat. The Russian forceps are also useful for plac- 
ing gauze in the mouth when the surgeon is isolating a 
particular area for surgery. 


FIG. 6-14 A, Allis tissue forceps are useful for grasping and hold- 
ing tissue that will be excised. B, Allis forceps are held in same fash- 
ion as needle holder. C, Comparison of Adson beaks (right) with Allis 
beaks (left) shows difference in their design and use. 



Princ ipi $& of Exadtm tia 


FIG. 6-15 A, Russian tissue forceps are round-ended pickups. B, Russian forceps are especially useful for 
grasping teeth that are loose in the mouth. 


Rongeur Forceps 

The instrument most commonly used for removing bone 
is the rongeur forceps. This instrument has sharp blades 
that are squeezed together by the handles, cutting or 
pinching through the bone. Rongeur forceps have a leaf 
spring between the handle so that when hand pressure is 
released, the instrument will open. This allows the surgeon 
to make repeated cuts of bone without manually reopen- 
ing the instrument (Fig, 6-16, A). The two major designs 
for rongeur forceps are (1) a side-cutting forceps and (2) the 
side-cutting and end-cutting forceps (Fig. 6-16, B). 

The side-cutting and end-cutting forceps (Blumenthal 
rongeurs) are more practical for most dentoalveolar sur- 
gical procedures that require bone removal. Because they 
are end-cutting, these forceps can be inserted into sockets 
for removal of interradicular bone, but they can also be 
used to remove sharp edges of bone. Rongeurs can be 
used to remove large amounts of bone efficiently and 
quickly. Because rongeurs are relatively delicate instru- 
ments, the surgeon should not use the forceps to remove 
large amounts of bone in single bites. Rather, smaller 
amounts of bone should be removed in each of multiple 
bites. Likewise, the rongeurs should not be used to 
remove teeth, because this practice will quickly dull and 
destroy the instrument. Rongeurs are usually quite 
expensive, so care should be taken to keep them in work- 
ing order. 

Chisel and Mallet 

One of the obvious methods of bone removal is to use a 
surgical chisel and mallet (Fig. 6-17, A-C). Bone is usually 
removed with a monobevel chisel, and teeth are usually 
sectioned with a bibevel chisel. The success of chisel use 
depends on the sharpness of the instrument. Therefore it 
is necessary to sharpen the chisel before it is sterilized for 

the next patient. Some chisels have carbide tips and can 
be used more than once between sharpenings. A mallet 
with a nylon facing imparts less shock to the patient, is 
less noisy, and is therefore recommended. 

Bone File 

Final smoothing of bone before suturing the muco- 
periosteal flap back into position is usually performed 
with a small bone file (Fig. 6-18, A). The bone file is usu- 
ally a double-ended instrument with a small and large 
end. It cannot be used efficiently for removal of large 
amounts of bone; therefore it is used only for final 
smoothing. The teeth of the bone file are arranged in such 
a fashion that they remove bone only on a pull stroke (Fig. 
6-18, B). Pushing the bone file results only in burnishing 
and crushing the bone and should be avoided. 

Bur and Handpiece 

A final method for removing bone is with a bur and hand- 
piece. This is the technique that most surgeons use when 
removing bone for surgical removal of teeth. Relatively 
high-speed handpieces with sharp carbide burs remove 
cortical bone efficiently. Burs such as a no. 557 or no. 703 
fissure bur or a no. 8 round bur are used. When large 
amounts of bone must be removed, such as in torus reduc- 
tion, a large bone bur that resembles an acrylic bur is used. 
The handpiece that is used must be completely steril- 
izable in a steam autoclave. When a handpiece is pur- 
chased, the manufacturer's specifications must be 
checked carefully to ensure that this is possible. The 
handpiece should have relatively high speed and torque 
(Fig. 6-19). This allows the bone removal to be done rap- 
idly and allows efficient sectioning of teeth. The hand- 
piece must not exhaust air into the operative field as do 
dental drills. Most high-speed turbine drills used for rou- 
tine restorative dentistry must not be used. The reason is 

Armamentarium for Basic Oral Surgery 



FIG. 6-16 A, Rongeurs are bone-cutting forceps that have spring-loaded handles. B, Blumenthal 
rongeurs are combination end-cutting and side-cutting blades. They are preferred for oral surgery pro- 

that the air exhausted into the wound may be forced into 
deeper tissue planes and produce tissue emphysema, a 
potentially dangerous occurrence. 


The periapical curette is an angled, double-ended instru- 
ment used to remove soft tissue from bony defects {Fig. 6- 
20). The principal use is to remove granulomas or small 
cysts from periapical lesions, but it is also used to remove 
small amounts of granulation tissue debris from the 
tooth socket. The periapical curette is distinctly different 
from the periodontal curette in design and function. 


Once a surgical procedure has been completed, the 
mucoperiosteal flap is returned to its original position 
and held in place by sutures. The needle holder is the 
instrument used to place the sutures. 

Needle Holder 

The needle holder is an instrument with a locking handle 
and a short, stout beak. For intraoral placement of 
sutures, a 6-inch (15-cm) needle holder is usually recom- 
mended (Fig. 6-21). The beak of the needle holder is 
shorter and stronger than the beak of the hemostat (Fig. 
6-22, A). The face of the beak of the needle holder is 
crosshatched to permit a positive grasp of the suture nee- 
dle and suture. The hemostat has parallel grooves on the 
face of the beaks, thereby decreasing the control over 
needle and suture. Therefore the hemostat should not be 
used for suturing (Fig. 6-22, B). 

To properly control the locking handles and to direct 
the relatively long needle holder, the surgeon must hold 
the instrument in the proper fashion (Fig. 6-23). The 
thumb and ring finger are inserted through the rings. The 
index finger is held along the length of the needle hold- 
er to steady and direct it. The second finger aids in con- 
trolling the locking mechanism. The index finger should 
not be put through the finger ring, because this will result 
in dramatic decrease in control. 



Principles of Exodontia 

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FIG. 6-1 7 A, Surgical chisel and mallet can be used for removing bone and sectioning teeth. 

B, Additional chisels are straight unibevel chisel, curved unibevel chisel, or straight bibeve! chisel. 

C, A close-up view of the chisel working end shows the bibevel end, the straight unibevel end, and 
the curved unibevel end. 

Anmumntarium for Hasic Oral Surgery 




FIG. 6-18 A, Double-ended bone file is used for smoothing small, sharp edges or spicules of bone. B, 
Teeth of bone file are effective only in pull stroke. 

FIG. 6-19 Typical moderate-speed, high-torque, sterilizable hand piece with 703 bur. 

FIG. 6-20 Periapical curette is a double-ended, spoon-shaped instrument used to remove soft tissue 
from bony defects. 



Prit idpkii of Ex odon tia 

FIG. 6-21 Needle holder has locking handle and short, stout beak. 



FIG. 6-22 A, Hemostat (top) has longer, thinner beak compared with needle holder (bottom) and 
therefore should not be used for suturing. B, Face of shorter beak of needle holder is crosshatched to 
ensure positive grip on needle (left). Face of hemostat has parallel grooves that do not allow a firm 
grip on needle (right). 

Armamentarium for Basic Oral Surgery 



FIG. 6-23 Needle holder is held by using thumb and ring finger in rings (top) and first and second 
finger to control instrument (bottom). 


The needle used in closing mucosal incisions is usually a 
small half-circle or three eighths-circle suture needle. It is 
curved to allow the needle to pass through a limited 
space, where a straight needle could not reach. Suture 
needles come in a large variety of shapes, from very small 
to very large (Fig. 6-24, A). The tips of suture needles are 
either tapered, such as a sewing needle, or they have tri- 
angular tips that allow them to be cutting needles (Fig. 6- 
24, B). A cutting needle will pass through mucoperios- 
teum more easily than the tapered needle. The cutting 
portion of the needle extends about one third the length 
of the needle, and the remaining portion of the needle is 
round. The suture can be threaded through the eye of the 
needle or can be purchased already swaged on by the 
manufacturer (Fig. 6-24, C). if the dentist chooses to load 
his or her own needles for the sake of economy, needles 
that have eyes (like those in typical sewing needles) must 
be used. If the dentist chooses to use the disposable nee- 
dles, then the suture will be swaged onto the needle. Nee- 
dles that have eyes are larger at the tip and may cause 

slightly increased tissue injury compared with the 
swaged-on needles. 

The curved needle is held approximately two thirds of 
the distance between the tip and the end of the needle 
(Fig. 6-25). This allows enough of the needle to be 
exposed to pass through the tissue, while allowing the 
needle holder to grasp the needle in its strong portion to 
prevent bending of the needle. Techniques for placing 
sutures are discussed in Chapter 8. 

Suture Material 

Many types of suture materials are available. The materi- 
als are classified by size, resorbability, and whether or not 
they are monofilament or polyfilament. 

The size of suture is designated by a series of zeros. The 
size most commonly used in the suturing of oral mucosa 
is 3-0 (000). A larger size suture would be 2-0, or 0. Smaller 
sizes would be 4-0, 5-0, and 6-0 sutures. Sutures of very 
fine size, such as 6-0, are usually used in conspicuous 
places on the skin, such as the face, because smaller 



Pit f iclp les of Exodontia 



FIG. 6-24 A, Comparison of needles used in oral surgery. Top is P- 
3 needle, which is usually 4-0 size suture. Middle is F5-2 needle, and 
bottom is X-1. All are cutting needles. B, Tip of needle used to suture 
mucoperiosteum is triangular in cross section to make it a cutting 
needle. C, Suture may be threaded through needle eye or can be 
purchased already swaged onto needle. 

FIG. 6-25 Needle holder grasps curved needle two thirds of the 
distance from tip of needle. 

sutures usually cause less scarring. Sutures of size 3-0 are 
large enough to prevent tearing through mucosa, are 
strong enough to withstand the tension placed on them 
intraorally, and are strong enough for easy knot tying 
with a needle holder. 

Sutures may be resorbable or nonresorbable. Nonre- 
sorbable suture materials include such types as silk, 
nylon, and stainless steel. The most commonly used non- 
resorbable suture in the oral cavity is silk. Nylon and 
stainless steel are rarely used in the mouth. Resorbable 
sutures are primarily made of gut. Although the term 
catgut is often used to designate this type of suture, gut 
actually is derived from the serosal surface of sheep intes- 
tines. Plain catgut resorbs relatively quickly in the oral 
cavity, rarely lasting longer than 5 days. Gut that has 
been treated by tanning solutions (chromic acid) and is 
therefore called chromic gut lasts longer — up to 10 to 12 
days. Several synthetic resorbable sutures are also avail- 
able. These are materials that are long chains of polymers 
braided into suture material. Examples are poly gly colic 
acid and poly lactic acid. These materials are slowly 
resorbed, taking up to 4 weeks before they are resorbed. 
Such long-lasting resorbable sutures are rarely indicated 
in the oral cavity. 

Finally, sutures are classified based on whether or not 
they are monofilament or polyfilament. Monofilament 
sutures are sutures such as both plain and chromic gut, 
nylon, and stainless steel. Polyfilament sutures are silk, 
polyglycolic acid, and polylactic acid. Sutures that are 
made of braided material are easy to handle and tie and 
rarely come untied. The cut ends are usually soft and 
nonirritating to the tongue and surrounding soft tissues. 
However, because of the multiple filaments, they tend to 
"wick" oral fluids along the suture to the underlying tis- 
sues. This wicking action may carry bacteria along with 
the saliva. Monofilament sutures do not cause this wick- 

Armamaitarmm for Untie Om! Surgery 


FIG. 6-26 Suture scissors have long handles and short blades. Blades may be angled slightly in either 
of two directions. 

FIG. 6-27 Suture scissors should be held in same fashion as needle holder. 

ing action but may be more difficult to tie, tend to come 
untied, and are stiffer and therefore more irritating to the 
tongue and soft tissues. 

The most commonly used suture for the oral cavity is 3- 
black silk. The size 3-0 has the appropriate amount of 
strength; the polyfilament nature of the silk makes it easy 
to tie and easily tolerated by the patient's soft tissues. The 
black color makes the suture easy to see when the patient 
returns for suture removal. Sutures that are holding mucosa 
together usually stay no longer than 5 to 7 days, so the 
wicking action is of little clinical importance. (Techniques 
for suturing and knot tying are presented in Chapter 8.) 


The final instruments necessary for placing sutures are 
suture scissors (Fig. 6-26). Suture scissors usually have rel- 
atively long handles and thumb and finger rings. They 
are held in the same way as the needle holder. The suture 
scissors usually have short cutting edges, because their 
soie purpose is to cut sutures (Fig. 6-27). The most com- 
monly used suture scissors are the Dean scissors. These 
have slightly curved handles and serrated blades that 
make cutting sutures easier. 

An additional type of scissors is designed for soft tissue. 
The two major types of tissue scissors are (1) the Iris scis- 



Principles of Exodontta 

FIG. 6-28 Soft tissue scissors are of two designs: Iris scissors (top) are small, sharp-pointed scissors. 
Metzenbaum scissors (bottom) are longer, delicate, blunt-nosed scissors. 



- ;; , 

--j i--.>. •! '■'■ ■. JTiaJiaVii'r^'- J ^ lr ^ fc - r4V^_. 


. .-i.-i-.r. 






.FIG. 6-29 A, Rubber bite block is used to hold mouth open in position chosen by patient. B, The 
sides of the bite block are corrugated to provide a surface for the teeth to engage. 

sors and (2) the Metzenbaum scissors (Fig. 6-28). The Iris 
scissors are small, sharp-pointed delicate tools used for fine 
work. The Metzenbaum scissors are blunt-nosed scissors 
used for undermining soft tissue, as well as for cutting. Tis- 
sue scissors such as the Iris or Metzenbaum scissors should 
not be used to cut sutures, because the suture material will 
dull the edges of the blades and make them less effective 
for cutting tissue. The exception is when removing very 
fine sutures placed in skin incisions in the face. Scissors 
with thin, pointed tips such as an Iris may be useful. 


When performing extractions of mandibular teeth, it is 
necessary to support the mandible to prevent stress on 
the temporomandibular joints (TMJs). By having the 
patient's jaw supported on a bite block, the joints will be 
protected. The bite block is just what the name implies 
(Fig. 6-29, A and B). It is a rubber block on which the 
patient can rest the teeth. The patient opens the mouth 
to a comfortably wide position, and the rubber bite block 
is inserted, which holds the mouth in the desired posi- 

.: . : 

Armamentarium for Bask Oral l Surgery ■ CHAP TEH 6 93 

FIG. 6-30 Side-action, or Molt, mouth prop can be used to open patient's mouth when patient is 
unable to cooperate, such as during sedation. 

tion. Should the surgeon need the mouth to open wider, 
the patient must open widely and the bite block must be 
positioned more to the posterior of the mouth. 

The side-action mouth prop or Molt mouth prop (Fig. 6- 
30) can be used by the operator to open the mouth wider 
if necessary. 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 the teeth and TMJ, and injury 
may occur with injudicious use. This type of mouth prop 
is useful in patients who are deeply sedated. 

Whenever a bite block or side-action mouth prop is 
used, the surgeon should take care to avoid opening the 
mouth too widely, because it may cause stress on the jaw 
joint. Occasionally, this may result in stretch injury to 
the joint, necessitating additional treatment. When long 
procedures are being performed, it is a good idea to peri- 
odically remove the prop and allow the patient to move 
the jaw and rest the muscles for a short time. 


To provide adequate visualization, blood, saliva, and irri- 
gating 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 so that the tooth 
sockets can be suctioned in case a root tip is fractured and 
adequate visualization is necessary. Many of these suc- 
tions are designed with several orifices so that the soft tis- 
sue will not become aspirated into the suction hole and 
cause tissue injury (Fig. 6-31, A). 

The Fraser suction has a hole in the handle portion 
that can be covered as the requirement dictates. 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 is uncovered to 
prevent tissue injury (Fig. 6-31, B). 



The transfer forceps are heavy forceps used to move 
instruments from one sterile area to another (Fig. 6-32, 
A). These forceps are usually right-angled forceps with 
heavy jaws, so instruments such as extraction forceps can 
be moved from one area to another and small items can 
be handled without dropping them (Fig. 6-32, B and C). 
The transfer forceps are stored in a container that is usu- 
ally filled with a bactericidal solution, such as glutaralde- 
hyde. The container must be emptied and new solution 
placed at least every other day. The container should be 
thoroughly washed and autoclaved at least once per 



When drapes are placed around a patient, they must be 
held together with a towel clip (Fig. 6-33). This instru- 
ment has a locking handle and finger and thumb rings. 
The action ends of the towel clip are sharp, curved points 
that penetrate the towels and drapes. When this instru- 



Principles of Exodontia 


FIG. 6-31 A, Typical surgical suction has small-diameter tip. B, Fraser suction tip has blade in handle 
to allow operator more control over amount of suction power. Suction tip has hole in side to prevent 
tissue injury caused by excess suction pressure. Wire stylet is used to clean tip when bone or tooth par- 
ticles plug suction. 

ment is used, the operator must take extreme caution not 
to pinch the patient's underlying skin. 


When a handpiece and bur are used to remove bone, it is 
essential that the area be irrigated with a steady stream of 
irrigating solution, usually sterile saline. The irrigation cools 
the bur and prevents bone-damaging heat buildup. The irri- 
gation also increases the efficiency of the bur by washing 
away bone chips from the flutes of the bur and by provid- 
ing a certain amount of lubrication. In addition, once a sur- 
gical procedure is completed and before the mucoperiosteal 
flap is sutured back into position, the surgical field should 
be irrigated thoroughly with saline. A large plastic syringe 
with a blunt 18-gauge needle is used for irrigation purpos- 
es. Although the syringe is disposable, it can be sterilized 
multiple times before it must be 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 (Fig. 6-34, A and B). 


One of the most important instruments used in the extrac- 
tion procedure is the dental elevator. These instruments are 
used to luxate teeth (loosen them) from the surrounding 

bone. Loosening teeth before the application of the dental 
forceps can frequently make a difficult extraction easier. By 
luxating the teeth before the application of the forceps, the 
clinician can minimize the incidence of broken roots and 
teeth. Finally, luxation of teeth before forceps application 
facilitates the removal of a broken root should it occur, 
because the root will be loose in the dental socket. In addi- 
tion to their role in loosening teeth from the surrounding 
bone, dental elevators are also used to expand alveolar 
bone. By expanding the buccocortical plate of bone, the 
surgeon facilitates the removal of a tooth that has a limit- 
ed and somewhat obstructed path for removal. Finally, ele- 
vators are used to remove broken or surgically sectioned 
roots from their sockets. Elevators are designed with spe- 
cific shapes to facilitate the removal of roots from sockets. 


The three major components of the elevator are the han- 
dle, shank, and blade (Fig. 6-35). The handle of the ele- 
vator is usually of generous size, so it can be held com- 
fortably in the hand to apply substantial but controlled 
force. The application of specifically applied force is crit- 
ical in the proper use of dental elevators. In some situa- 
tions, crossbar or T-bar handles are used. These instru- 
ments must be used with caution, because they can 
generate a very large amount of force (Fig. 6-36). 

Armamentarium for Bask Oral Wifi$&fy 




FIG. 6-32 A, Transfer forceps are used to move sterile instruments from one sterile area to another. 

B, These forceps are sturdy enough to move instruments without fear of loosing grip on them. 

C, Transfer forceps can also be used to handle small items, such as anesthetic cartridges. 

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. 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. 


The biggest variation in the type of elevator is in the 
shape and size of the blade. The three basic types of ele- 
vators are (1) the straight or gouge type; (2) the triangle 
or pennant- shape type; and (3) the pick type. The straight 
or gouge type elevator is the most commonly used eleva- 
tor to luxate teeth (Fig. 6-37, A). The blade of the straight 
elevator has a concave surface on one side so that it can 
be used in the same fashion as a shoehorn (Fig. 6-37, B 
and Q. The small straight elevator, no. 301, is frequently 
used for beginning the luxation of an erupted tooth, 
before application of the forceps (Fig. 6-38). The larger 
straight elevator is used to displace roots from their sock- 
ets and is also used to luxate teeth that are more widely 
spaced. The most commonly used large straight elevator 
is the no. 34S, but the no. 46 and no. 77R are also occa- 
sionally used. 

FIG. 6-33 Towel clip is used to hold drapes in position. Sharp points 
penetrate towels, and locking handles maintain drape in position. 
Towel clamps with nonpenetrating action are also available. 

The shape of the biade 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 simi- 
lar to the straight elevator are the Miller elevator and the 
Potts elevator. 



iYindpks ofExodatitiii 


FIG. 6-34 A, Bulb or regular syringes may be used to carry irrigation solution to operative site. B, The 
self-ioaded syringe is spring-loaded to allow filling simply by releasing the plunger. 

FIG. 6-35 The major components of an elevator are the handle, shank, and blade. 

The second most commonly used elevator is the trian- 
gular or pennant- shaped elevator (Fig. 6-39). These eleva- 
tors are provided in pairs: a left and a right. The triangle- 
shaped elevator is most useful when a broken root 
remains in the tooth socket and the adjacent socket is 
empty. A typical example would be when a mandibular 
first molar is fractured, leaving the distai root in the socket 
but the mesial root removed with the crown. The tip of 

the triangle-shaped elevator is placed into the socket, 
with the shank of the elevator resting on the buccal plate 
of bone. It is then turned in a wheel-and-axle type of 
rotation, with the sharp tip of the elevator engaging the 
cementum of the remaining distal root; the elevator is 
then turned and the root delivered. Triangle-shaped ele- 
vators come in a variety of types and angulations, but the 
Cryer is the most common type. 

Armunmiturmm for Bask Oral Smgwy 



FIG. 6-36 Crossbar handle is used on certain elevators. This type of handle can generate large 
amounts of force and therefore must be used with caution. 


FIG. 6-37 A, Straight elevator is most commonly used elevator. B and C, Blade of straight elevator is 
concave on its working side. 

The third type of elevator that is used with some fre- 
quency is the pick-type elevator. This type of elevator is 
used to remove roots. The heavy version of the pick is the 
Crane pick (Fig. 6-40). This instrument is used as a lever 
to elevate a broken root from the tooth socket. It is usu- 
ally necessary to drill a hole with a bur, approximately 3 
mm deep into the root. The tip of the pick is then insert- 
ed into the hole, and, with the buccal plate of bone as a 
fulcrum, the root is elevated from the tooth socket. Occa- 
sionally the sharp point can be used without preparing a 
purchase point by engaging the cementum of the tooth. 

The second type of pick is the root tip pick, or apex ele- 
vator (Fig. 6-41). The root tip pick is a delicate instrument 

that is used to tease small root tips from their sockets. It 
must be emphasized that this is a thin instrument and 
cannot be used as a wheel-and-axle or lever type of eleva- 
tor like the Cryer elevator or the Crane pick. The root tip 
pick is used to tease the very small root end of a tooth. 


The instruments that come to mind when thinking of the 
removal of a tooth are the extraction forceps. These 
instruments are used for removing the tooth from the 
alveolar bone. They are designed in many styles and con- 
figurations to adapt to the variety of teeth for which they 



Principles of Ekodantia 

FIG. 6-38 Blade of small straight elevator is about half the width of a large straight elevator. 

FIG. 6-39 Triangular-shaped elevators (Cryer) are pairs of instruments and are therefore used for spe- 
cific roots. 

FIG. 6-40 Crane pick is a heavy instrument used to elevate whole roots or even teeth after purchase 
point has been prepared with bur. 

ArmammUiriuni for Bask Oral Surgery 



FIG. 6-41 Delicate root tip pick is used to tease small root tip fragments from socket. 

FIG. 6-42 Basic components of extraction forceps. 

are used. Each basic design offers a multiplicity of varia- 
tions to coincide with individual operator preferences. 
This section deals with the basic fundamental designs 
and touches on several of the variations. 


The basic components of dental extraction forceps are the 
handle, hinge, and beaks (Fig. 6-42). The handles are usu- 
ally of adequate size to be handled comfortably and deliv- 
er sufficient pressure and leverage to remove the required 
tooth. The handles have a serrated surface to allow a pos- 
itive grip and prevent slippage. 

The handles of the forceps are held differently, de- 
pending 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 
(Fig. 6-43). 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 the teeth (Fig. 6-44). 
The handles of the forceps are usually straight but may be 
curved. This provides the operator with a sense of "better 
fit" (Fig. 6-45). 

The hinge of the forceps, like the shank of the elevator, 
is mereiy a mechanism for connecting the handle to the 
beak. The hinge transfers and concentrates the force 
applied to the handles to the beak. One distinct difference 

in styles does exist: The usual American type of forceps has 
a hinge in a horizontal direction and is used as has been 
described (see Figs. 6-42 and 6-43). The English preference 
is for a vertical hinge and corresponding vertically posi- 
tioned handle (Fig. 6-46, A). Thus the English style handle 
and hinge are used with the hand held in a vertical direc- 
tion as opposed to a horizontal direction (Fig. 6-46, B). 

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 at the junction of the 
crown and root. It is important to remember that 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, 
in a sense then, different beaks are designed for single- 
rooted teeth, two-rooted teeth, and three-rooted teeth. 
The design variation is such that the tips of the beaks will 
adapt closely to the various root formations, decreasing 
the chance for root fracture. The more closely the beak of 
the forceps adapts to the tooth roots, the more efficient 
will be the extraction and the less chance for untoward 

A final design variation is in the width of the beak. 
Some forceps are narrow, because their primary use is to 
remove narrow teeth, such as incisor teeth. Other forceps 
are somewhat broader, because the teeth they are 
designed to remove are substantially wider, such as lower 
molar teeth. Forceps designed to remove a lower incisor 

v-iv.; ■: 

100 PART II 

Priticipk'S of Exot famia 

FIG. 6-43 Forceps used to remove maxillary teeth are held with palm under handle. 

FIG. 6-44 A, Forceps used to remove mandibular teeth are held with palm on top of forceps. 
B, Firmer grip for delivering greater amounts of rotational force can be achieved by moving thumb 
around and under handle. 

FIG. 6-45 Straight handles are usually preferred, but curved handles are preferred by 
some surgeons. 

Armamentarium for Basic Oral Surgery 



FIG. 6-46 A, English style of forceps have hinge in vertical direction. B, English style of forceps are held 
in vertical direction. 


can be used to remove a lower molar, but the beaks are so 
narrow that they will be inefficient for that application. 
Similarly the broader molar forceps would not adapt to 
the narrow space allowed by the narrow lower incisor and 
therefore could not be used in that situation. 

The beaks of the forceps are angled so that they can be 
placed parallel to the long axis of the tooth, with the han- 
dle in a comfortable position. Therefore the beaks of max- 
illary forceps are usually parallel to the handles. Maxillary 
molar forceps are offset in a bayonet fashion to allow the 
operator to comfortably reach the posterior aspect of the 
mouth and yet keep the beaks parallel to the long axis of 
the tooth. The beak of mandibular forceps is usually set 
perpendicular to the handles, which allows the surgeon 
to reach the lower teeth and maintain a comfortable, 
controlled position. 

Maxillary Forceps 

The removal of maxillary teeth requires the use of instru- 
ments designed for single-rooted teeth and for teeth 
with three roots. The maxillary incisors, canine teeth, 
and premolar teeth are all considered to be single-rooted 
teeth. The maxillary first premolar frequently has a 
bifurcated root, but because this occurs in the apical one 
third, it has no influence on the design of the forceps. 
The maxillary molars are usually trifurcated and there- 
fore require extraction forceps, which will adapt to that 

The single-rooted maxillary teeth are usually removed 
with maxillary universal forceps, usually no. 150 (Fig. 6- 
47). The no. 150 forceps are slightly curved 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 reach not only the incisors, but 
also the bicuspids in a comfortable fashion. The beak of 
the no. 150 forceps has been modified slightly to form 
the no. 150A forceps (Fig. 6-48). The no. 150A is useful 
for the maxillary premolar teeth and should not be used 
for the incisors, because their adaptation to the roots of 
the incisors is poor. 

In addition to the no. 150 forceps, straight forceps are 
also available. The no. 1 (Fig. 6-49), which can be used for 
maxillary incisors and canines, are slightly easier to use 
than the no. 150 for incisors. 

The maxillary molar teeth are three-rooted teeth with a 
single palatal root and a buccal bifurcation. Therefore for- 
ceps that are adapted to fit the 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 on the buccal beak. This requires that the 
molar forceps come in pairs: a left and a right. Additional- 
ly, the molar forceps should be offset so that the operator 
can reach the posterior aspect of the mouth and remain in 
the correct position. The most commonly used molar for- 
ceps are the no. 53 right and left (Fig. 6-50). These forceps 
are designed to fit anatomically around the palatal beak, 
and the pointed buccal beak fits into the buccal bifurca- 
tion. The beak is offset to allow for good positioning. 

A design variation is shown in the no. 88 right and left 
forceps, which have a longer, more accentuated, pointed 
beak formation (Fig. 6-51). These forceps are known as 
upper cowhorn forceps. They are particularly useful for 
maxillary molars whose crowns are severely decayed. The 
sharply pointed beaks may reach deeper into the trifurca- 
tion to sound dentin. The major disadvantage is that they 
crush alveolar bone, and when used on intact teeth with- 
out due caution, fracture of large amounts of buccal alve- 
olar bone may occur. 

On occasion, maxillary second molars and erupted 
third molars have a single conically shaped root. In this 
situation, forceps with broad, smooth beaks that are off- 
set from the handie can be useful. The no. 21 OS forceps 
exemplify this design (Fig. 6-52). Another design varia- 
tion is shown in the offset molar forceps with very nar- 
row beaks. These are used primarily to remove broken 
maxillary molar roots but can be used for removal of nar- 
row premolars and for lower incisors. These forceps, the 
no. 286, are also known as root tip forceps (Fig. 6-53). 

A smaller version of the no. 150, the no. 150S, is use- 
ful for removing primary teeth (Fig. 6-54). These adapt 
well to all maxillary primary teeth and can be used as uni- 
versal primary tooth forceps. 

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 (Fig. 

Text continued on page 105 

102 PART II ■ principles ofBxodomhi 

FIG. 6-47 A, Superior view of no. 150 forceps. B, Side view of no. 150 forceps. C and D, No. 150 
forceps adapted to maxillary central incisor. 

Armamentarium for Husk Unit Surgery 




FIG. 6-48 A, Superior view of no. 1 50A forceps. B, No. 1 50A forceps have parallel beaks that do not 
touch in distinction from 1 50 forceps beak. C, Adaptation of no. 150A forceps to maxillary premolar. 

FIG. 6-49 A, Superior view of the no. 1 forceps. B, Side view of the no. 1 forceps. C, No. 1 forceps adapted to incisor. 

104 PART Jl 

Principles of Exodvntia 

FIG. 6-50 A, Superior view of the no. 53L forceps. B, Side view of no. 53L forceps. 
C, Right, No. 53L; left, no. 53R. D and E, No. 531 adapted to maxillary molar. 

ArmartJWTtitriimi for Bask Oral Surgery 





FIG. 6-51 A, Superior view of no. 88L forceps, B, Side view of no. 88L forceps. C, No. 88R adapted to maxillary molar. 

FIG. 6-52 A, Superior view of no. 21 OS forceps. B, Side view of no. 21 OS forceps. C, No. 21 OS adapted to maxillary molar. 

6-55). These have handles similar in shape to the no. 150, 
but the beaks are pointed inferiorly for the lower teeth. The 
beaks are smooth and relatively narrow and meet only at 
the tip. This allows the beaks to fit at the cervical line of 
the tooth and grasp the root. 

The no. 151 A forceps have been modified slightly for 
mandibular premolar teeth (Fig. 6-56). They should not 
be used for other lower teeth, because their form prevents 
adaptation to the roots of the teeth. 

The English style of vertical-hinge forceps is used occa- 
sionally for the single-rooted teeth in the mandible (Fig. 

6-57). Great force can be generated with these forceps; 
unless care is used, the incidence of root fracture is high 
with this instrument. Therefore it is rarely used by the 
beginning surgeon. 

The mandibular molars are bifurcated, two-rooted 
teeth that allow the use of forceps that anatomically 
adapt to the tooth. Because the bifurcation is on both the 
buccal and the lingual sides, only single molar forceps are 
necessary for the left and right, in contradistinction to 
the maxilla, with which a right- and left-paired molar for- 
ceps set is required. 

106 PART II 

Principles of Exorfontia 


FIG. 6-53 A, Superior view of no. 286 forceps. B, Side view of no. 286 forceps. C, No. 286 adapted to broken root. 

FIG. 6-54 No. 150S (bottom) is smaller 
version of no. 1 50 forceps (top) and is 
used for primary teeth. 

The most useful lower molar forceps are the no. 17 
(Fig. 6-58). These forceps are usually straight-handled, 
and the beaks are set obliquely downward. The beaks 
have bilateral pointed tips in the center to adapt into 
the bifurcation of the molar teeth. The remainder of the 
beak adapts well to the bifurcation. Because of the 
pointed tips, the no. 17 forceps cannot be used for 
molar teeth, which have fused, conically shaped roots. 
For this purpose the no. 222 forceps are useful (Fig. 6- 
59). They are similar in design to the no. 17, but the 
beaks are shorter and do not have pointed tips to pre- 

vent them from being used. The most common tooth 
for which the no. 222 is useful is the erupted mandibu- 
lar third molar. 

The major design variation in lower molar forceps is 
the no. 23, the so-called cowhorn forceps (Fig. 6-60). 
These instruments are designed with two pointed heavy 
beaks that enter into the bifurcation of the lower molar. 
After the forceps are seated into the correct position, the 
tooth is elevated by squeezing the handles of the forceps 
together tightly. The beaks are squeezed into the bifurca- 
tion, using the buccal and lingual cortical plates as ful- 

Armamentarium for Bask Oral Surgery 




FIC. 6-55 A, Superior view of no. 151 forceps. B, Side view of no. 151 forceps. C and D, No. 1 51 
forceps adapted to mandibular incisor. 


FIG. 6-56 A, No. 151 A forceps have beaks that jre parallel and do not adapt 
well to roots of most teeth in contradistinction to the no. 151 forceps beaks. 
B, No. 151 A forceps adapted to a lower premolar tooth. The lack of close adap- 
tation of tips of beak to root of tooth is visualized. 

crums, and the tooth is literally squeezed out of the sock- 
et. As with the English style of forceps, improper use of 
cowhorn forceps can result in an increase in the inci- 
dence of untoward effects, such as fractures of the alveo- 
lar bone. The beginning surgeon should use cowhorn for- 
ceps with caution. 

The no. 151 is also adapted for primary teeth. The no. 
15 IS is the same general design as the no. 151 but is 
scaled down to adapt to the primary teeth. A single pair 
of forceps is adequate for removal of all primary 
mandibular teeth (Fig. 6-61). 


Many surgeons find it practical to use the "tray" method 
to assemble instruments. Standard sets of instruments are 
packaged together, sterilized, and unwrapped at surgery. 
The typical basic extraction pack includes a local anes- 
thesia syringe, a needle, a local anesthesia cartridge, a 
Woodson elevator, a periapical curette, a small and large 
straight elevator, a pair of college pliers, a curved hemo- 
stat, a towel clip, an Austin retractor, a suction, and gauze 
(Fig. 6-62). The required forceps would be added to this 

Text continued on page 110 

108 PART II 

/ Ymciples of Exudon tin 

FIG. 6-57 A, Side view of English style of forceps. B, Forceps adapted to lower premolar 

FIG. 6-58 A, Superior view of 
no. 1 7 molar forceps. B, Side view 
of no. 1 7 molar forceps. C and D, 
No. 1 7 forceps adapted to lower 

Anmunetitarium for Basic Dial Swfgeif 



FIG. 6-59 A, Side view of no. 222 forceps. B, No. 222 forceps adapted to lower third molar. 


FIG. 6-60 A, Superior view of cowhorn no. 23 forceps. B, Side view of cowhorn forceps. C and D, Cow- 
horn forceps adapted to lower molar tooth. 

110 PART Tl 

Principles of 'Exodontla 

FIG. 6-61 No. 1 51 S (bottom) is the smaller version of no. 151 (top,) and is used to extract primary teeth. 

FIG. 6-62 Typical basic extraction tray. 

A tray used for surgical extractions would include the 
items from the basic extraction tray plus a needle holder 
and suture, a pair of suture scissors, a periosteal elevator, 
a blade handle and blade, Adson tissue forceps, a bone 
file, a tongue retractor, a root tip pick, Russian tissue for- 
ceps, a pair of Cryer elevators, a rongeur, and a handpiece 
and bur (Fig. 6-63). These instruments permit incision 
and reflection of soft tissue, removal of bone, sectioning 

of teeth, retrieval of roots, debridement of the wound, 
and suturing of the soft tissue. 

The biopsy tray includes the basic tray, plus a blade 
handle and blade, needle holder and suture, suture scis- 
sors, Metzenbaum scissors, Allis tissue forceps, Adson tis- 
sue forceps, and curved hemostat (Fig. 6-64). These 
instruments permit incision and dissection of a soft tissue 
specimen and closure of the wound with sutures. 

Armamentarium for Basic Oral Surgery 


FIG. 6-63 Surgical extraction tray adds necessary instrumentation to reflect soft tissue flaps, remove 
bone, section teeth, retrieve roots, and suture flaps back into position. 

FIG. 6-64 Biopsy tray adds equipment necessary to remove soft tissue specimen and suture wound 

The postoperative tray has the necessary instruments 
to irrigate the surgical site and remove sutures (Fig. 6-65). 
It usually includes scissors, college pliers, irrigation 
syringe, applicator sticks, gauze, and suction. 

The instruments may be placed on a flat tray, wrapped 
with sterilization paper, and sterilized. When ready for 

use, the tray is taken to the operatory, opened, and the 
instruments used from the tray. This system requires a 
rather large autoclave to accommodate the tray. 

Alternately, metal cassettes can be used instead of a 
tray. They are more compact but must also be wrapped in 
sterilization paper (see Fig. 5-6). 

112 PART II 

Principles of Exodonfia 

FIG. 6-65 Postoperative tray includes instruments necessary to remove sutures and irrigate mouth. 

The appendix includes prices for the instruments listed 
for these trays. A casual review of the cost of the surgical 
instruments will reflect why the surgeon and staff should 
make every effort to take good care of instruments. 


Brown RP: Knotting technique and suture materials, Brl Surg 
79:300, 1992. 

Edlich RF, Thacker JG, McGregor W: Past, present, and future 
for surgical needles and needle holders, Am J Surg 166:522,1993. 

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