FORCEPS

Maxillary

#1, #99-C = Anterior

#150 = PMs, conical shaped molars; root fragments, sectioned molars
#150A = specifically PM
#150S = primary teeth

#88R/L, 89, 90 = 1st and 2nd Molars (trifurcated roots); can be used w/ excessive
caries or large restorations
#53R/L = 1st and 2nd Molars (trifurcated roots); pointed beak, dont use w/
excessive caries, large restoration, brittle endo teeth

#210S = 3rd molars; shorter beaks than #53 cuz 3rds are usually shorter
#286 = Root fragments

Mandibular

#74, 74-N, 74-extra-N = incisors and root tips aka ASH

#151 = PMs and root tips; can be used for anteriors and 3rds too
#151A = specifically PM
#151S = primary teeth
#203 = similar to 151(A), thinner beaks; better than 151 for incisors, root tips

#23 (Cowhorn) = most popular; squeeze molar out of socket; buccal-lingual

movement
#17 = bifurcated 1st and 2nd molars; will NOT adapt to conical-rooted molars
#222 = 3rds, conical shaped 2nds

ELEVATORS

Inclined plane and Wheel & Axle

o displacement, wheel/axle, lever action
displacement = insert into PDL space to dislodge root tip
do NOT do in close proximity to MX sinus

Purchase Point
o #41 - Crane Pick

handiest, and most dangerous

usually used w/ Purchase point
wheel/axle

Very small root tips

o Apex elevator
o displacement

Root tips adjacent empty socket

o #30-31 Cryer
fxn w/ or w/out Purchase point
ex: after md 1st molar after distal root has been extracted
must stay sharp
wheel/axle

Larger root fragments by displacement effect

o #34-S or #46 (looks like a larger #301)
possibly most commonly used elevator
#34S is WIDER than #46
main use = displacement of single roots
sometimes lever action

Small root tips, intial luxation when larger elevator too big
o #301, 302, 303
like 34s and 46 but smaller
used for smaller roots
displacement
sometimes lever action

#73/74 (Miller), Potts elevator

o impacted 3rd molars
o placed at cervical line of MB and forced toward palate
o Potts
has the t-bar for increased force
o wheel/axle

MISC Instruments

#5 Rongeurs
o alveoplasty, remove large amounts of bone
o cuts rather than pinches
major alveoplasty

o side cutting
#4 Rongeurs
o minor alveoplasty
o PINCHES, doesnt cut
o side and end-cutting
surgical mallet is used w/ #2 bibevel or #52 monobevel chisel
o splite teeth or remove bone
#52 Monobevel chisel
o remove bone w/ hand pressure only
impaction surgery
o used w/ surgical mallet sometimes
#2 Bibevel chisel
o split teeth
molt/lucas curettes
o used for enucleation of small cysts or granulation tissue
#12 bone file
o PULL stroke
#9 Molt/ Hopkins
o periosteal elevator
o reflect mucoperiosteum
o occassionaly retractors
Kelly 6 curved
Bard-Parker #11
o I&D
BP #12
o tuberosity
BP 15
o std blade

ASSESSMENT

Pre-Surgical Assessment
o 4 = WORST situation for all categories of extraction, makes extracting
HARDER
o Tooth Mobility (is BACKWARDS compared to class)
4 = ANKYLOSED
3 = no mobility (no ankylosing)
2 = normal mobility (Class I or II)
1 = greater than normal (Class III)

REMOVAL OF TEETH

Bone
o MX

o MD

bone is thicker everywhere on the palatal so more pressure/force

directing buccally, and deliever teeth to buccal
CANINES
should be surgically removed, buccal plate will easily
fracture
rotation w/ MORE buccal-palatal movement
st
1 PM
ONLY tooth to be removed with TRACTION alone
excessive buccal-lingual = fracture of one of the root
2nd PM
ovoid root allows some rotation; primarily buccal-lingual
movement
1st molar/2nd molar
thin buccal bone and frequently fenestrated
use #53 R/L, or #89-90 (88 r/l)
o #53 NOT used w/ heavy caries/large
restoration/endo treated
periodontally involved = #150
buccal-lingual movements and traction
o emphasis to buccal
rd
3 molar
use #210-S
possibly use #73-74 Miller or Potts elevator if impacted
Root tips
#286 forceps
use ROTATION and Traction
Primary Teeth
#150-S
movements
o labial palatal rotary reverse rotary
extract in path of least resistance

bone is thicker on buccal everywhere ANTERIOR to molars

Molar region buccal is equal to or greater than lingual bone
thickness

Anterior Incisor/Canine region

generally thin bone
however may be a little thicker over the canine root
surgical ext
Anterior
#74 or #203
beaks as far apically as possible
labial-lingual, rotation/traction
PM
#151(A) or #74
bone thinner labially
buccal-lingual, rotation, traction
1st/2nd Molars
distal root = stronger
bone thickness is variable depending on mylohyoid and
external oblique ridge
o 1st molar buccal = lingual
o 2nd molar buccal > lingual
use #23 (cowhorn) or #17
delievery to the LINGUAL
rd
3 molars
#23 if bifurcated, #222 if not
delievery to LINGUAL
Root tips
#151, 74, or elevators 34-S/46 (similar to 301), #30-31
(cryer)
Primary
#151-S
buccal lingual stronger buccal stronger lingual
least resistance rotary slightly when solid resistance not
felt

Shape of roots
o Anteriors have conical roots so you can emphasize rotational movements
o Molars have bifurcations/trifurcations so stress buccal-lingual movement

FLAPS

Mucoperiosteal flaps
o broad base
if error is made in flap design, make it TOO BIG rather than too
small

 post-op pain related to amount of bone removal, not flap size

o repositioned and suture over solid bone; margin of flap at least 5mm from
margins of bony defect
o full thickness

Envelope Flap
o full thickness flap
o horizontal incision
no vertical incisions
CAN be included if needed/required
o flap of choice for most surgical procedures
o extended two teeth mesial, one tooth distal
o includes interdental papilla
o ex: ext 1st molar
from premolar to distal of 2nd molar
interdental papilla between first premolar and canine also reflected
Envelope + 1 vertical incision
o 2nd most useful flap
o incision extends from 1 tooth distal to one tooth mesial
Envelope + 2 VI
o Rectangular flap
Curved Flap/Semi-lunar flap
o dont involve gingival sulcus
o ideal for periapical endo surgery or retrieval of small root tips
Pedicle flap
o close oro-antral communication
o greatly increased potential for necrosis and rejection since they must
contain adequate blood flow to support the flap
Md flaps
o direct buccal incision in 2nd molar region UPWARDS towards crest of
ridge
prevent injuring facial artery/vein
Full thickness
o generally flaps in OS are full thickness
o easier to reflect and preserve the periosteum
o use sharp end of periosteal elevator to pry interdental papilla free first
Split Thickness
o when you want to increase attached gingiva
Sutures
o placed to hold tissue in position (NOT to stretch or pull tissue)
o should NOT close incision tightly unless needed to do so

o
o
o
o

if marginal tissue blanches, too tight

needle should pass from unattached to attached tissue
placed minimum of 3mm from flap margins
Minimal tension 4-O gut is sufficient

MOST IMPACTED 3RD MOLARS ARE IN LINGUAL VERSION

> PDL, > Follicle Width = more bone movement possible, easier extraction
crown size & shape much more significant in horizontally impacted 3rds
purchase point most commonly at MB aspect so that buccal bone can act as
fulrcum for crane or cryer
o 2nd common = distal root aspect; section tooth, remove distal and then
remove the mesial after
do NOT use forceps to extract impacted teeth
o elevators yes (#34-S, #30-31)

vertical impaction
o cut bone to point just below the crest of contour
o poor visibility
o more difficult than MA or horizontal
horizontal
o cut bone 4mm distal to cervical line exposing distal root
o more difficult than MA
mesioangular impaction
o purchase point most commonly at MB aspect so that buccal bone can act
as fulrcum for crane or cryer
o least difficult ext
distoangular impaction
o very poor visability
o remove bone mesiobuccal aspect 4mm beneath cervical line
o most difficult extractions
most used radiographic views
o intraoral PA
o pano