O R A L S U R G E ROY R A L S U R G E RY

Surgical Forceps Techniques

NICK MALDEN

Stage 1
Abstract: This paper considers two new elevator and dental forceps techniques for the
atraumatic removal of teeth to avoid a surgical procedure where possible. The techniques Lift the gingival margin from the
described should be applicable in relatively well defined but commonly occurring lingual and buccal aspects of the socket
situations. The two techniques involve the unconventional use of conventional dental bone with an elevator (a No. 1
extraction forceps, with the aim of facilitating removal of the retained roots of certain Coupland chisel is the author’s choice).
teeth: the first for incisors, canines and premolars and the second for lower first molars.
The term ‘surgical forceps technique’ is tentatively put forward as a description of these Stage 2
hybrid procedures. Guide the fine root forceps down to the
position shown in Figure 1, and check
Dent Update 2001; 28: 41-44
carefully to ensure the beaks are within
Clinical Relevance: Unconventional methods of use of extraction forceps may prevent the soft tissues.
the need for raising a mucoperiosteal flap.
Stage 3
Close forceps and remove tooth/root
with bone using appropriate

M ultiple extractions of permanent

teeth still make up a large
proportion of the workload of units
providing dentoalveolar surgery. Full,
or almost full, clearances of the
dentition are still being regularly
performed and the continued option of
general anaesthesia is a welcome
adjunct for managing these often very
anxious patients.
With the move towards intravenous
sedation and away from general
anaesthesia in the management of
patients for removal of symptomatic
wisdom teeth,1 the author’s general
anaesthesia lists are more commonly
containing multiple extraction cases.
Another patient group that regularly
undergoes the removal of permanent
teeth are children having permanent
first molars removed, again under
general anaesthesia.
The techniques described in this
article will be of merit in the treatment
of patients regardless of whether they
are being treated under general
movements – lingual-labial for lower
incisors, rotations for roots with a
conical shape (Figure 2).
anaesthesia – which cannot be said
about some commonly accepted
techniques that involve the use of a
surgical mallet such as tapping a
Coupland chisel along the periodontal
space to expand the socket.
TECHNIQUE 1
This technique is recommended for
removal of retained roots in the upper
and lower incisors, canine and
premolar regions. The following
criteria must be met: Figure 1. Guide the root forceps down to the
position shown.
● the pre-extraction assessment does
not preclude the use of a forceps
technique;
● the labial bone would be sacrificed
anyway as the result of a
conventional surgical removal.

N. Malden, BDS (Lond.), FDS (Glas.),

Specialist in Surgical Dentistry, Associate
Specialist in Oral Surgery, Edinburgh Dental
Institute, Edinburgh.
The Procedure
This technique may be broken down Figure 2. A small portion of labial bone may be
into four distinct stages. discovered within the beaks of the forceps.

Dental Update – January/February 2001 41

 O R A L S U R G E RY

● May reduce likelihood of roots

being pushed into the antrum.

Disadvantages
● Demands more care.
● If used carelessly may cause
unnecessary damage to soft and
hard tissues (for example, if used
Figure 3. Cowhorns forceps, left and right in an attempt to ‘chase’ retained Figure 6. The areas where a No. 1 Coupland
Cryer’s elevators and Coupland chisel. apices, could unduly damage chisel can be used to exert considerable
lingual/palatal bone). elevating force.
● Over-enthusiastic use of the
technique could also increase the
likelihood of dislodgement of roots
into the antrum.

REMOVAL OF LOWER FIRST

Figure 4. Conventional application of Cowhorns
forceps to extract a lower first molar. The buccal
groove, if present, can be a helpful guide to the
position of the bifurcation.
Stage 4
The mobility of one or both adjacent
papillae should be assessed: if the
papillae are ‘detached’ they are best
sutured. Vertical tears involving the
gingival margin are not an inevitable
consequence of this technique and do
not necessarily benefit from suturing if
they occur.
Advantages
● Quick and atraumatic, sutures not
always being required.
● Only basic instrumentation is
employed.
MOLAR
Generally, this is performed using the
conventional Cowhorns technique.
Instruments used are the Cowhorns
extraction forceps, No. 1 Coupland
chisel and Cryer’s left and right
elevators (Figure 3).
Stage 1: Guide the beaks into the
bifurcation (Figure 4).
Stage 2: Use a standard figure-of-
eight or buccolingual movement to
extract the tooth. The forceps may
well be fully closed before the
tooth becomes mobile (Figure 5).
However, if the bifurcation fractures
coronally then this technique is
ineffective. The presence of a thick
buccal plate of bone precludes the use
of the first surgical forceps technique,
and the use of elevators may be one
method of avoiding conventional
surgical removal.
Figure 7. The appropriate elevator is placed
into the empty socket, the handle coming out at
45o to the occlusal plane.
placed into the empty socket, the
handle coming out at 45o to the
occlusal plane (Figure 7).
Stage 1: The aim is to remove the
inter-radicular bone which divides
the two roots (Figure 8). The heel
of the elevator can rest on bone or
the adjacent tooth surface
(remember to check the condition
of any tooth you lean on before
doing so).
Stage 2: Once some inter-radicular
bone has been removed, attempt to
engage the retained root and
elevate with a rotation movement
similar to that in Stage 1 (Figure
9).

Removal of Retained Roots

Figure 5. The forceps may well be fully closed
before the tooth can be delivered.
If both roots remain, with a fracture at the
bifurcation, then elevators may be
effective in delivering the roots (areas
where a Coupland No. 1 could be used to
exert considerable force on retained roots
of a lower first molar are described in
standard texts;2,3 see Figure 6).
Should only one root remain then
Cryer’s elevators can be used very Figure 8. The inter-radicular bone dividing the
effectively. The appropriate elevator is two roots should be removed.

42 Dental Update – January/February 2001

 O R A L S U R G E RY

Stage 2: Place the buccal beak onto

Figure 9. Once the intervening bone has been
removed, attempt to engage the root and
elevate it.
mucosa and pierce down to rest on
the outer aspect of the buccal bone
(Figures 10 and 11).
Stage 3: Carefully close forceps,
using downward pressure to
prevent the buccal beak slipping
coronally up the buccal bone
(Figure 12).
Stage 4: As soon as the retained roots Figure 12. Controlled downward pressure must
begin to move, remove forceps and be exerted on the forceps to prevent the buccal
return to conventional positioning beak of the forceps slipping up the bone.
of forceps to deliver the roots
(Figure 13).

If this technique is performed

successfully only a small puncture
wound will be left buccally and no
sutures will be necessary (Figure 14).

DISCUSSION Figure 13. Return forceps to the conventional

Figure 10. The lingual beak of the forceps is
placed in the conventional position but the
buccal beak should be placed onto mucosa and
pierced down to rest on the outer aspect of the
buccal bone.
TECHNIQUE 2
Although this technique can be used to
advantage in cases where the crown of
the first molar is broken down buccally
or lingually, it really comes into its own
in the removal of retained lower first
molar roots where there is no fracture of
the bifurcation.
A conventional cowhorn technique
should first be attempted. If this fails
follow the following stages:
Stage 1: Place lingual beak of forceps
in conventional position (Figure
10).
Figure 11. The buccal beak of forceps resting
on the buccal plate of bone.
The development of techniques for
extracting teeth without resorting to
surgery is a natural progression for
operators performing extractions
regularly. The motivation to develop
these techniques is, in the author’s
view, purely one of the pursuit of
efficiency.
It may be argued that these
techniques involve using instruments
for purposes for which they were not
designed and that the techniques are
short cuts, which could cause
otherwise avoidable hard and soft
tissue damage. The author makes no
apology for apparently promoting the
‘misuse’ of instruments if they are
suited to the task. As regards
avoidable tissue damage, the surgical
wound produced is different from that
produced as a consequence of the
conventional surgical approach but
these techniques, when applied
successfully, produce less damage than
the conventional technique.
Because these techniques follow on
from standard forceps extraction
procedures and should be brought into
play only once these have failed, some
degree of extraction experience and
skill is a prerequisite. Teaching of
these techniques is therefore
inappropriate in an undergraduate
curriculum.
position before delivering the tooth.
SUMMARY
Over the years many techniques have
been developed to facilitate the
removal of teeth. A number of
techniques in common usage before the
introduction of handpieces involved the
use of surgical mallets, and some can
still be found in contemporary oral
surgery texts. Indeed, some still have
their applications in the unconscious
patient (e.g. broken instrument
technique).4
The conscious patient is likely to find
the use of specialized forceps,
elevators and luxators more acceptable
than the use of a mallet. The techniques
described here expedite extraction
Figure 14. If this technique is performed
correctly only a small buccal puncture wound
will be produced and no sutures will be needed.

Dental Update – January/February 2001 43

 O R A L S U R G E RY

without the use of a mallet and can
avoid recourse to a conventional
surgical approach.
CONCLUSION
The ability to raise a mucoperiosteal
flap, remove buccal or labial bone,
elevate any retained roots and then
suture back the mucoperiosteal flap is
valuable when extractions do not
proceed smoothly.
This paper presents the
unconventional use of extraction
forceps in an effort to avoid resorting
to such an invasive procedure. The
methods explained are safe and
expedient ways of removing retained
roots in certain situations.
The term surgical forceps technique
is put forward as an appropriate
description of these procedures, in
which dental forceps are used in such
an unconventional manner.
A CKNOWLEDGEMENTS
I would like to thank Margaret Ferrier for her help in
the production of this manuscript and Mr R.D.
Brown for permission to use his material.
REFERENCES
1. The Management of Patients with 3rd Molar
Teeth. Report of a working party convened
by the Faculty of Dental Surgery, Royal
College of Surgeons of England, London:
Royal College of Surgeons of England, 1997
6(2).
2. The removal of roots. In: Seward GR, Morris M,
McGowan DA, eds. Killey & Kays Outline of Oral
Surgery Part 1. Bristol: I.O.P. Publications Ltd.,
1987: pp.48–51.
3. Moore JR, Gilbe GV, eds. Operations on the
teeth. In: Textbook of Oral Surgery. Oxford/
London: Blackwell Scientific Publications, 1985:
pp.315–339.
4. Broken Instrument Technique. In: Howe GL.
Minor Oral Surgery. Bristol: Wright, 1985:
p.102.

ABSTRACTS
DO YOU BOND YOUR AMALGAM
RESTORATIONS?
Marginal Microleakage in Bonded
Amalgam Restorations: A Combined In
Vivo and In Vitro Study. R. Di Lenarda,
M. Cadanero, G. Gregorig and E.
Dorigo. Journal of Adhesive Dentistry
2000; 2: 223–228.
Amalgam is still used for over 80% of
all restorations in posterior teeth, in
spite of the known lack of adhesion to
tooth tissue. The resultant penetration of
oral fluids and bacteria can lead to
sensitivity, pulpal irritation and
secondary caries.
These authors selected teeth
scheduled for extraction and placed
cervical amalgam restorations sealed
with Scotchbond Plus, together with
unsealed controls. The extracted teeth
were stained and examined
microscopically for evidence of
microleakage. Of the bonded amalgams,
80% showed no evidence of
microleakage at the enamel margin,
while all the unsealed cavities showed
complete dye penetration. The sealed
restorations, however, did show
evidence of dye penetration at the
cervical margin where there was no
enamel.
The authors recommend that, although
further long-term investigations are
required, early indications would suggest
that all amalgam restorations should be
bonded.
PROBLEMS WITH COMPLETE
UPPER DENTURE WEARERS?
The Effectiveness of Palate-less Versus
Complete Palatal Coverage Dentures. R.
Akeel, M. Assery and S. Al-Dalgan.
European Journal of Prosthodontics
and Restorative Dentistry 2000; 8 (2):
63–66.
Ten edentulous patients who were to be
fitted with new maxillary and
mandibular complete dentures were
selected for this study. The maxillary
denture was carefully duplicated to
produce the same denture but with no
palatal coverage. Analysis of the biting
forces were carried out, together with
chewing tests. No significant differences
were found between the dentures,
although some of the patients actually
reported better mastication with the
experimental dentures. Furthermore,
eight of the patients found the palate-
less dentures more comfortable.
The authors conclude that, whilst
more extensive investigations are
indicated, this could certainly form an
acceptable treatment modality.
Peter Carrotte
Glasgow Dental School

COVER PICTURES SUBSCRIPTIONS –

REDUCED RATES
Do you have an interesting and striking colour picture with a dental
connection, which may be suitable for printing on the front cover? Please note we do have reduced rate
Send your transparencies to: subscriptions for a range of readers
Students £29
The Executive Editor, Dental Update, VDPs £45
George Warman Publications (UK) Ltd, Unit 2, Riverview Business Park,
Walnut Tree Close, Guildford, Surrey GU1 4UX. Retired GDPs £45
Call 01752 312140
Payment of £75 will be made on publication. for more details.

44 Dental Update – January/February 2001