Rules of using dental forceps & elevator


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Anaesthesia & Exodontia
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Rules of using dental forceps & elevator

  1. 1. ‫سبحان ال وبحمده سبحان ال العظيم‬ Principles of Exodontia Dr. Adel I Abdelhady )BDS, MSC, (Eg) Phd (USA , Eg .Oral and Maxillofacial Surgery Dept .College of Dentistry,, KSA
  2. 2. Rules of using Dental Forceps & Elevator Dr. Adel I Abdelhady )BDS, MSC, (Eg) Phd (USA , Eg .Oral and Maxillofacial Surgery Dept .College of Dentistry,, KSA
  3. 3. Vaccination of the students  Vaccination of Hepatitis B virus for the students is mandatory before starting any clinical exposure or dealing with the patients.
  4. 4. Specific Objectives and Outlines        Preparation of the patient prior dental extraction Know the proper position and stance either for the patient or for the operator Know how to prepare the dental chair for the specific tooth extraction How to select the proper forceps Know the difference between the forceps used for extraction of teeth of upper as well as lower jaw Know the different extraction movement Know how to grib the tooth using extraction forceps either for maxillary or mandibular teeth.
  5. 5. General considerations :Factors complicating dental extraction 1. Restriction by the lips and cheeks. 2. Movement of the tongue. 3. Movement of the mandible. 4. Restriction of the mouth opening 5. Communication of the mouth with the pharynx and larynx. 6. Flooding of the oral cavity with micro-organisms. 7. The related structures such as floor of the mouth, tongue, hard and soft palate. 8. The location and position of the tooth to be extracted
  6. 6. Techniques of Extraction 1- INTRA-ALVEOLAR EXTRACTION FORCEPS or CONVENTIONAL This is by using dental forceps and elevators. 2- TRANS-ALVEOLAR EXTRACTION This is by using Surgical Flaps technique with bone removal and tooth sectioning
  7. 7. CLINICAL EVALUATION OF TEETH BEFORE EXTRACTION    Access to Tooth Mobility of Tooth Condition of Crown
  8. 8. RADIOGRAPHIC EXAMINATION OF TOOTH     The relationship of the tooth to be extracted to adjacent erupted and unerupted teeth should be noted. Relationship of Associated Vital Structures Configuration of Roots Condition of Surrounding Bone
  9. 9. CHAIR POSITION FOR FORCEPS EXTRACTION   The positions of the patient, chair, and operator are critical for successful completion of the extraction. The correct position allows the surgeon to keep the arms close to the body and provides stability and support; it also allows the surgeon to keep the wrists straight enough to deliver the force with the arm and shoulder and not with the hand.
  10. 10. CHAIR POSITION FOR FORCEPS .EXTRACTION cont    For a maxillary extraction the chair should be tipped backward so that the maxillary occlusal plane is at an angle of about 45-60 degrees to the floor. The height of the chair should be such that the height of the patient's mouth is at or slightly below the operator's elbow level. During an operation on the maxillary right quadrant, the patient's head should be turned substantially toward the operator, so that adequate access and visualization can be achieved .
  11. 11. PATIENT AND SURGEON PREPARATION  Infection control is mandatory
  12. 12. Preparations of dental chair, operator and assistant
  13. 13.   For extraction of teeth in the maxillary anterior portion of the arch, the patient should be looking straight ahead. The position for the maxillary left portion of the arch is similar, except that the patient's head is turned slightly toward the operator
  14. 14.   For the extraction of mandibular teeth, the patient should be positioned in a more upright position so that when the mouth is opened widely, the occlusal plane is parallel to the floor The chair should be lower than for extraction of maxillary teeth, and the surgeon's arm is inclined downward to approximately a 120degree angle at the elbow which provides a comfortable, stable position that is more controllable than the higher position.
  15. 15. Intra-alveolar extraction Forceps Elevator • Parts of the dental forceps: A, Blades. B, Joints. C, Handles. • Requirements of the dental forceps
  16. 16. Extraction of teeth with forceps   These have two blades with sharp edges to cut the periodontal fibers. The blades are wedge-shaped to dilate the socket and are hollowed on their inner surface to fit the roots The blades are hinged which allows them to close and grasp the root the handle act as a lever which gives the operator a mechanical advantage. The farther from the blades the surgeon grasps the handles the less effort he will have to make to apply force to the tooth. 20/01/14
  17. 17.    In order to drive the forceps blade straight up the long axis of the tooth the shape of the handle is varied Lower forceps have handles at right angles to the blades Upper forceps are straight for anterior teeth and cranked ‫ ملتوية‬for the posterior one, for the upper third molars the beaks and the handle are bent.
  18. 18. Extraction of teeth with forceps   The extraction of teeth is a surgical operation based primarily on an anatomical appreciation of their attachment in the jaw. First the soft tissues of the gingival attachment and periodontal membrane are cut to separate the tooth from the bone . Next the socket is dilated by moving the root to expand its bony socket .Finally when the tooth is loose it may be drawn out of the alveolus .When completed with forceps extractions are performed in two movement. 20/01/14
  19. 19. Requirement of the Dental Forceps INTRA-ALVEOLAR EXTRACTION Dental extraction forceps has three components which is blades and handles united together by a hinge joint. 1-The serrated handles must possess a suitable size to rest comfortably in the operator’ s hand and should long enough to afford use of strong and steady extraction movements. Also it must be suitable in shape and design to suit the area of the tooth.
  20. 20. INTRA-ALVEOLAR EXTRACTION  2- The wedge shape blades must be sharp to be introduce under the free gum margin. In multirooted teeth the blades should be designed to grip the different root patterns The angulations design of the blades in relation to the joint and handles should be made to facilitate gripping of the tooth at CEJ
  21. 21.  3-The joint of the dental forceps must have free movement for easy manipulation but must be free from rolling movement Parts of dental forceps A-Blades B-Joint C-Handles
  23. 23.  • • • • • • •  • • • Upper Forceps Upper Anterior central; lateral incisors and canine teeth Upper Premolar Upper Left Molar Upper Right Molar Bayonet Forceps for upper third molar Lower Forceps Lower Anterior Lower premolar Lower molar
  24. 24. Upper forceps Anterior Premolar R. Molar Premolar Anterior Bayonet Lower forceps Molar L. Molar
  25. 25. Forceps Style American
  26. 26. English
  27. 27. Forceps design Upper forceps
  28. 28. Lower Forceps
  29. 29. Technique of Forceps Extraction 1- Position of the Operator
  30. 30. Types of Dental :Forceps .Straight e.g. 1 Upper anteriors .Curved e.g. 2 All lowers and upper posteriors
  31. 31. PRINCIPLES OF FORCEPS USE     The primary instrument used to remove a tooth from the alveolar process is the extraction forceps. The goal of forceps use is twofold: (1) expansion of the bony socket by use of the wedge-shaped beaks of the forceps and the movements of the tooth itself with the forceps, (2) removal of the tooth from the socket
  32. 32.   The forceps can apply five major motions to luxate the teeth and expand the bony socket: 1-The first is apical pressure, which accomplishes two goals the tooth socket is expanded by the insertion of the beaks down into the periodontal ligament space and causes bony expansion. A second accomplishment of apical pressure is to make the fulcrum more farther apically
  33. 33.   If the fulcrum is high a larger amount of force is placed on the apical region of the tooth, which increases the chance of fracturing the root end. If the beaks of the forceps are forced into the periodontal ligament space, the center of rotation is moved apically, which results in greater movement of the expansion forces at the crest of the ridge and less force moving the apex of the tooth lingually. This process decreases the chance for apical root fracture.
  34. 34.   2-The second major pressure 2or movement applied by forceps is the buccal force. Buccal pressures result in expansion of the buccal plate, particularly at the crest of the ridge 3-Third, lingual pressure is 3similar to the concept of buccal pressure but is aimed at expanding the linguocrestal bone and, at the same time, avoiding excessive pressures on the buccal apical bone
  35. 35.   4-Fourth, rotational pressure, as the name 4implies, rotates the tooth, which causes some internal expansion of the tooth socket. Teeth with single, conical roots, such as the maxillary incisors, and mandibular premolars 5-Finally, tractional forces are useful for 5delivering the tooth from the socket once adequate bony expansion is achieved. Tractional forces should be limited to the final portion of the extraction process and should be gentle
  36. 36. Grip of the- 2 extraction forceps Wright Wrong Wright Wrong Wrong
  37. 37. Application of the Forceps ( (Grip of the tooth -3
  38. 38. Proper function and Position of Left Hand- 4
  39. 39. Mechanical principles of forceps extraction Expansion of socket walls Wedging
  40. 40. Extraction movements
  41. 41. PROCEDURE FOR CLOSED EXTRACTION     The three fundamental requirements for a good extraction remain the same: (1) adequate access and visualization of the field of surgery, (2) an unimpeded pathway for the removal of the tooth, and (3) the use of controlled force to luxate and remove the tooth.
  42. 42. Five general steps make up the closed-extraction procedure   Step 1: Loosening of soft tissue attachment from the tooth. The first step in removing a tooth by the closed extraction technique is to loosen the soft tissue from around the tooth with a sharp instrument, Step 2: Adaptation of the forceps to the tooth. The proper forceps is then chosen for the tooth to be extracted and the forceps is then seated onto the tooth t so that the tips of the forceps beaks grasp the root underneath the loosened soft tissue (Fig. 7-56). The lingual beak is usually seated first and then the buccal beak.
  43. 43. ‫سبحان ال وبحمده سبحان ال العظيم‬ Principles of Exodontia Lec. # 4 Dr. Adel I Abdelhady )BDS, MSC, (Egypt) PhD (USA , Egypt .Oral and Maxillofacial Surgery Dept .College of Dentistry, KSA 20/01/14
  44. 44. Dental Elevators 20/01/14
  45. 45. Dental Elevators Parts of Elevators: 1-Blade 2-Shank 3-Handle  20/01/14
  46. 46. :Classification •According to Form. •According to Use. Different Forms of Elevators
  47. 47. Elevators Classification  I-According to use: 1-Elevators designed to remove the entire tooth, straight elevators, hospital pattern and winter elevator 2-Elevators designed to remove roots broken off at the gingival line e.g. Apexo elevator , Coupland and lido lavien elevators 3-Elevators designed to remove roots broken off half way to the apex e.g. curved elevator hospital pattern, winter elevator and Apexo elevator 20/01/14
  48. 48. Dental Elevators Classification II-According to Form: 1-Straight elevator S,M,L 2-Curved right and left 3-Angulated right and left 4-Cross bar “ handle at right angle to the shank”  20/01/14
  49. 49. Types of Dental :Elevators .Straight e.g. 1 Copland's .Curved e.g. 2 Cryer’s 20/01/14
  50. 50. Root Elevators  Used to loosen and frequently remove teeth and roots.  a small straight elevator  a large straight elevator 20/01/14
  51. 51. Dental Elevator ”Cross bar “winter Hospital pattern Straight and curved Curved apexo 20/01/14
  52. 52. Choice of elevators Choice of elevators according to: • • • • Remaining tooth structure Space available Availability and position of solid fulcrum Direction of the required movement 20/01/14
  53. 53. Characteristics • • • • • Has no joints Needs a fulcrum to work Has to be wedged between bone and tooth Exerts less directional force on the tooth Different sizes and shapes 20/01/14
  54. 54. Indications of use • • • • • Breaking down the periodontal attachment Luxation or removal of full tooth Luxation and removal of remaining roots Bone removal Mucoperiosteal elevation 20/01/14
  55. 55. Mechanical Principles  To obtain maximum mechanical advantage of the elevator the fulcrum should be near the point of resistance and the effort arm should be longer than resistance arm (Principle of class I levers ) 20/01/14
  56. 56. Rules of Use of Elevators VIP • • • • • • 1-Palm grip and finger guard 2-Don’t use the neighbouring tooth as a fulcrum 3-Don’t use the buccal or lingual plate of bone as a fulcrum 4-Use the left hand for reflection, guard and support 5-Take care of the surrounding vital structures 6-Follow respectfully, root curvature 20/01/14
  57. 57. Handling and Application of the Elevator
  58. 58. Principles of Use of Elevator VIP • • • Wedge principle: straight elevator Lever principle: Copland elevator, straight elev. Axel and Wheel principle: Cryer’s elevator 20/01/14
  59. 59. Principles of Use of Elevator Wedge Principle  Some elevators are designed primarily to be used as a wedge e.g. Apexo ,and coupland. This elevators are forced between the root of the tooth and the investing bony tissue parallel to the long axis of the tooth 20/01/14
  60. 60. Principles of Use of Elevator Lever Principle:  On applying this principle the elevator is a lever of the first class the position of the fulcrum is between the effort and resistance in order to obtain a mechanical advantage in a lever of the first class the effort arm on one side of the fulcrum, must be longer than the resistance arm 20/01/14
  61. 61. Principles of Use of Elevator Wheel and Axle Principle  The wheel and axle is a simple machine the effort is applied to the circumference of a wheel which turn the axle so as to raise a weight. It could be used as a sole work principle in removing the teeth, it is also used in conjunction with a wedge or lever principles 20/01/14
  62. 62. Wheel & Axle Wedging
  63. 63. Use of Elevators in Extraction of Teeth .Parts of Elevator :Work Principles  Levering.  Wedging.  Wheel and Axle principle.
  64. 64. Danger in the Use of Elevators 1-Loosening or extracting the adjacent teeth  2-Fracture the alveolar process or fracturing the mandible  3-Penetrating the maxillary antrum or forcing the root into the antrum  4-Forcing a root a root of a mandibular molar through lingual plate of the mandible  5-Damage of soft tissues by slipping of the tip of the elevator  20/01/14
  65. 65. Elevation of teeth Wedge elevator between tooth and bone at neck of tooth and rotate handle with slight twisting, quarter-turn movement Observe for tooth movement Do not use excessive force •Crown fracture •Loosen adjacent teeth As tooth loosens, move elevator more into bone towards root end 20/01/14
  66. 66. Elevation of teeth    Uses leverage at a mechanical advantage point used to luxate tooth in alveolar socket Movement of tooth expands alveolar bone to allow tooth to be removed Start with smaller elevator and move to larger as tooth luxates 20/01/14
  67. 67. Principles of Extraction of Maxillary and Mandibular Teeth
  68. 68. Anatomical Considerations The Upper Anterior Central incisor Lateral incisor Canine
  69. 69. The Upper Posteriors First Premolar First Molar Second Premolar Second Molar Third Molar
  70. 70. The Lower Teeth Incisors Canine Premolars
  71. 71. First Molar Second Molar Third Molar
  72. 72. Extraction of maxillary molars
  73. 73. Extraction of mandibular 1st & 2nd molars
  74. 74. The combined use of forceps and elevators The supporting Hand The jaws should be adequately supported by free hand of the operator this particularly important in the lower jaw. the other function of supporting hand is retraction of the cheek, tongue and lip .This done by placing the finger and thumb one on each side of the gum on the buccal and lingual or palatal aspects of the tooth ,and also the operator is able to feel that the blades of the forceps are under the m.m. and the watching finger can feel any slipping of the forceps or any tendency of the adjacent tooth to move 20/01/14
  75. 75. Extraction of Deciduous Teeth In general deciduous teeth are much easier to extract than the permanent ones But some factors may complicate their extraction: 1-Small mouth of the children patient 2-Permanent premolars are enclosed within the roots of their predecessors , deciduous molars have no root mass and caries often invades roots making it difficult to grip them  20/01/14
  76. 76. Extraction of Deciduous Teeth 3-Pediatric forceps should be used 4-Care must be taken not to place the beaks of forceps deep down on the root of D. teeth because great possibility of removing the partially formed permanent teeth. 20/01/14
  77. 77. Hazard of Extraction of Primary teeth  When this inadvertently happens, the partially formed tooth should be carefully freed from the primary roots and replaced in the alveolus , the soft tissues are then sutured over the alveolus to hold the bone and the tooth in position 20/01/14
  78. 78. Modifications for extraction of primary teeth • • Thin diverged roots Resorbed roots 20/01/14
  79. 79. Modifications for extraction of primary teeth • • • • Successors Inferior alveolar nerve Resilient bone Restricted access 20/01/14
  80. 80. Point to remember in extraction of teeth   Never refer to the extraction of tooth as a “simple extraction”. You may find yourself in the embarrassing position of trying to explain to the patient why this simple extraction taking so much time and effort Anticipate breakage by knowing all reason why root and crown break. Forewarn the patient of the possibility of breakage or fracture 20/01/14
  81. 81. Mechanical principles involved in tooth extractions • • 20/01/14 Removal of bone surrounding the root Sectioning the tooth
  82. 82. Policy for leaving root fragments Benefits bone removal Maxillary sinus Tissue spaces Nerve injury Risks Small size <5 mm Very deeply seated No pathosis Inform the patient Follow up 20/01/14
  83. 83. Removal of Fractured Root Fractured root should be removed at the time of extraction because it may cause the following complication: 1-Large roots in the alveolus will be localized source of inflammation 2-It may cause residual infection 3-RR may act as a mechanical irritant and set up an inflammatory reaction which may give rise to neuralgic pain of obscure origin  20/01/14
  84. 84. Reason of Root Breakage 1-Faulty application of instruments or extraction movements, wrong pattern forceps on a particular tooth may cause its breakage. Improper grip , inadequate extraction movements. Sudden or jerky extraction movement, gripping of the crown too superficially and not at CEJ 20/01/14
  85. 85. Reason of Root Breakage 1-Pulpless teeth, badly decayed, teeth with abnormal root pattern or Hypercementosis 3-Excessive density of the surrounding bone due condensing osteitis , or isolated tooth and in old age patient 4-Lake of perfect control of instrument or interference from the patient 20/01/14
  86. 86. Removal of Broken Roots of Maxillary Molars  Another technique is first to separate the fused roots with drill in the form of “ Y “ shape and then remove them individually by mean of forceps or by Warwick James curved elevator between the separated roots. 20/01/14
  87. 87. Removal of broken single rooted teeth     This includes the maxillary incisors and canines and mandibular incisors, canines and premolars: Removal of Roots Broken at the Gingival Margin: A-These root may be extracted with forceps , with careful adaptation of the beaks under the gingival margin B-Straight Apexo elevator or Coupland .The angulated Apexo elevator used to remove mandibular single rooted teeth apply moderate force distal as will as mesial of the root till complete delivery of the RR 20/01/14
  88. 88. Removal of the root broken halfway of the apex  Generally , these are the cases which require the reflection of mucoperiosteal flap and removal of buccal and lingual alveolar bone what we call it TRANS-ALVEOLAR SURGICAL EXTRACTION 20/01/14
  89. 89. Removal of Roots of Upper and Lower Molars 1-Removal of Broken Root of Mandibular Molars : 1-When both roots are fractured at the gingival line , the root trunk is still present a lower premolar forceps can be used, its beaks should be inserted as far under the gingival margin  20/01/14
  90. 90. Removal of Roots of Upper and Lower Molars  2-The other technique for removal of such roots is a drill used to separate the roots after this Apexo elevator may be used to loosen the mesial root by inserting it into a space between the lamia dura and the surface of the root from the mesial and distal surfaces until loosening of the root occur . The other root could extracted by using Winter or Cryer elevators 20/01/14
  91. 91. Extraction of teeth    Extraction of teeth related to a malignant tumors Extraction of teeth related to a line of fracture Extraction of teeth in a patient received radiotherapy