Surgical instruments in oral surgery

1. Surgical instruments in
oral surgery
Presented by –Dr Tejal R Ragji

2. INTRODUCTION
• Surgeons have access to a variety of surgical instruments that are
designed to help them in treatment of abnormalities
• This presentation deals primarily with a description of instruments
and their uses in various ways.
• Armamentaria have evolved for the ease of surgeon, shortening
on-table time, widening the surgical field, increase visibility,
minimizing trauma to surgical areas, etc.

3. OBJECTIVES
 The major objectives of armamentarium used in the oral
maxillofacial surgery are :
 Optimal Surgical Field
 Optimal Visibility
 Decreased Strain of the Surgeon.

13. DIAGNOSTIC INSTRUMENTS
MOUTH MIRRORS
• Based on material:
(i) Stainless steel
(ii) Plastic (Plastic mirrors are disposable).
• Based on size:
• No. 3, No. 4, No. 5 (most commonly used are no. 4 and no. 5)

14. DENTAL PROBES & EXPLORERS
Probes: Used to measure the depth of periodontal pockets or sulci.
Explorers: Used to detect dental caries in tooth grooves and pits.
Tweezer-Used for holding and transferring the cotton wool pellets,
cotton wool rolls, wedges and articulation paper from the tray to the oral
cavity and back.

15. INSTRUMENTS FOR GAINING SURGICAL
ASEPSIS
CHEATLE FORCEPS
• It is a long angulated instrument that is used
for
picking up sterile instruments from a tray or
linen
from the drum.
• Stored in a container containing an antiseptic
solution
like savlon.
• The solution must be changed everyday.

16. SWAB HOLDER
• An instrument with long blades, expanded at
the ends forming an oblong tip with central
fenestration and transverse serrations.
• To hold a swab and clean the area of
operation.
• To swab the throat, when there are profuse
secretions in an unconscious patient.
• To press on the tonsillar bed to arrest
haemorrhage.
• To hold tongue and give anterior traction and
thus preventing tongue fall and airway
obstruction.

17. TOWEL CLIP
• Two types
Pinchter type (Jones)
Forceps type (Beckhaus)
• Jones type has spring joint whereas Beckhaus has
locking handles.
• Tip of both instruments curves towards each other,
pointed and
overlaps each other which penetrate drapes.
• Used to hold drapes, stabilize suction tubes, motor
cables etc.

18. INSTRUMENTS USED FOR GAINING
SURGICAL ACCESS
SCALPEL
• Two parts– Blade and Blade handle
• Bard Parker Blade handle :
• Various sizes of handles
• Most commonly used handle is no 3
• Handle has slot for blade.
• Blade should be held with the help of
needle holder or an artery forcep while
fitting the blade to handle.
• Use-pengrip .

19. BLADES
BLADES-Different nos
• No. 10 – for making skin incision.
• No. 11 – for stab incision (e.g. to drain an
abscess)
• No. 12 – Mucogingival procedures
• No. 15 for I/o surgery

20. DISSECTING SCISSORS
• For soft tissue dissection in deeper layer.
• Sharp pointed for dissection and blunt pointed for
bandage or dressing cutting.
• Side cutting edge to cut the tissues.
• Types:1.iris or metzanum scissor
(pointed)
2.Mayo’s dissecting scissor
(curved & straight)
• Sterilization : Autoclave

21. MOUTH PROP
• Two types : Rubber, Metal
• To keep the mouth open during surgery GA
• In surgery  LA, Prolong procedure in mouth.
• During epileptic attack, to avoid injury to
tongue.
• Trismus
Vertical block having a concave surface on either of its
ends to fit the maxillary and mandibular teeth.

22. FERGUSON MOUTH GAG
• Keep the mouth open in a patient under
GA, during surgeries of the oral cavity,
tonsils and pharynx.
• Flat blades with serration which rest on
the occlusal surfaces of teeth.
• Handle has catch that is fixed at the
required opening.
Uses :1.To open the mouth
forcefully.
2.For exercise after
TMJ ankylosis
surgery.

23. Heisters & Doyen Janson mouth gag

24. INSTRUMENTS USED FOR RETRACTIONS
SKIN HOOKS-A thin long instrument with a
delicate pointed curved tip, which engages
tissue.
• Types
• Single prong – Gillies
• Double prong - Kilner
• Uses –
• To hold and retract skin edges during
cutting, dissection and suturing.
• To retract small amount of soft tissues.
• .

25. NERVE HOOK-
• A small instrument with a broad curve at the tip, tip is relatively blunt.
• Used in neurectomy procedures for nerve identification and in nerve repositioning
procedures.
VEIN HOOK-
• A small instrument with broad curved blade (concave from inside) with smooth
edge, which encircles the vessel.
• Used to retract vessels during dissection (especially for major vessels during neck
dissection

26. RETRACTORS
LANGENBACKS RETRACTORS
• Long handle and ‘L’ shaped blade.
• Difference sized and blade width :
Single ended and double ended
• Uses :
• To retract the soft tissues
• To retract incision edges
• To allow proper exposure to deep structures

27. C- SHAPED RETRACTORS
• Long handle double ended retractor
• Blade is ‘C’ shaped
• Mostly used in abdominal surgeries.

28. CAT’S PAW RETRACTOR
• Instrument resembles a cat’s paw.
• Thin metallic double ended / single
ended
instrument.
• Blade has prongs that are curved as
tip.
• Double ended – other and broad
curved blade.
• To retract small amount of soft
tissue.
Disadvantage :
• Excessive force may lead to
perforation / tear in the flap

29. OBWEGESSORS RAMUS RETRACTOR
• Similar to Langenback’s Retractor except
edges of retracting blades forked.
Forming a ‘V’ shaped notch to engage
anterior border of the ramus of mandible.
Uses :
• To retract soft tissue along the ant.
border of the ramus during sag split or
ramus osteotomy.
• To retract the tissues during
coroncidectomy.

30. AUSTIN’S RETRACTOR
• Short right angled retractor used for
retracting cheek ,tongue and
mucoperiosteal flap.
• Its working end is forked.

31. CONDYLE RETRACTORS
• Special retractors – double ended
• Similar appearance to tongue depressor
• Narrower blade.
• Tip ‘C’ shaped hook.
(Instrument slipped under the ankylosed mass to retract and protect the medial
soft tissue during TMJ surgery.)
• It has a finger grip at the middle of the handle to hold the retractor in position.

32. CHANNEL RETRACTOR

33. Weider’s retractor,Minnesota,Copper
malleable retractors

34. TONGUE DEPRESSOR
• ‘L’ shaped with broad, smooth blade to depress
or retract the tongue.
Uses :
• To depress the tongue during endotracheal
intubation and extubation.
• For inspection or oral cavity, tonsils and
pharyngeal wall.
• To retract tongue during surgery in oral cavity.
• To retract the cheek.

35. Wards 2 sided cheek retractor

36. INSTRUMENTS FOR REFLECTING FLAPS
PERIOSTEAL ELEVATOR(molts nos 9)
Double ended broad flat end on one side and sharp
pointed triangular on other side.
USES-
POINTED END –Release dental papilla around teeth
BROAD END –Elevating mucoperiosteal flap from bone.
-Can be used as soft tissue retractor

37. Methods of reflecting the periosteum
Prying motion :
• Pointed end of the instrument is inserted firmly under the interdental
papilla and the tissue is pried from its bed.
Push stroke :
• Wide end of the instrument is kept at 45 degree to the surface and
repeated thrusts are made.
• The flap will split and tear if excessive force is applied to the
mucoperiosteum.
Pull Stroke :
• Also called as Scrape stroke and most likely to tear periosteum.

38. PERIOSTEAL STRIPPERS
• A straight instrument with a handle and a blade with sharp
working tip.
• Comes in various shapes and sizes of handle and blade.
• Curve, angle and blade width combine to elevate periosteum in
quicker and easier fashion.
• Light in weight.
• Used in “push” stroke.

39. HOWARTH ELEVATOR
• Broad end – one side flat and
• Sharpened other side The Pointed end is used to
• release the dental papilla between the teeth.
• Broad end is used for elevating the
• mucoperiosteal flat from the bone.
• Broad end as a soft tissue retractor

40. MOON’S PROBE
• Thin flat instrument with small working tip at right angle to the handle.
• Tip is narrow and blunt.
Uses :
• Elevate mucoperiosteum around the tooth prior to extraction.

41. SUCTION TIPS
• To maintain a clean field by sucking away blood, flushing
solutions, debris, cystic fluid, pus and secretions.
• A stylet is provided to clean the lumen if there is clogging
• Straight / angulated
• No 3 and 4 are commonly used
• Yankauer – rigid hollow tube made up of metal or disposable
plastic with a curve at the distal end to facilitate removal of thick
secretions.

42. SUCTION TUBING

43. INSTRUMENTS USED FOR HOLDING
TISSUES DURING SURGERY
ARTERY FORCEPS
• These are hinged (locking) forceps
having relatively long delicate beaks
and unidirectional transverse
serrations on the blades.
• Can be
• straight / curved
• large / medium / small
• Mosquito are small curved artery
forceps which have smaller finer tips

44. Uses
• To achieve hemostasis by catching blood vessels (by crushing /
ligating / cauterizing)
• To hold the ends of ligatures.
• To drain an abscess ( by Hilton’s method).
• As tissue forceps for holding subcutaneous tissue and
aponeurosis (but not skin or nerves).
• To pick up necrotic tissues, granulation tissues, foreign bodies,
tooth / root / bone fragments

45. KOCHER’S TOOTHED ARTERY FORCEP
• Similar to a long heavy artery forcep
but it has toothed tips.
Uses
• Specially designed to hold the coronoid
process during coronidectomy
procedures.
• Can be used like other bone holding
forceps for stabilization of bony
fragments.
• TOOTHED ARTERY FORCEP

46. ADSON’S TISSUE HOLDING FORCEP
• Delicate forceps, used to hold tissues
during process of dissection /
suturing.
• Two types
• Plain / non toothed- No tooth at
tips, have serrations on inner
aspect of tip to aid in grip, used to
hold delicate structures.
• Toothed – Having teeth at the tips
used to hold tough structures like
skin, coarse muscle and fascia.

47. • Can be of different length
• 4/6/8 inch, used according to need.
• Microadson forcep (Used for precise and
fine handling of the soft tissue)
• Always held in pen grip

48. BABCOCK’S TISSUE FORCEP
• Instrument with broad flared blades
with fenestrations and without teeth.
• More delicate and less traumatic than
Allie’s forcep.
• Used to hold enlarged lymph nodes or
any glandular tissue or appendix

49. LANE’S FORCEP
• It is a long & stout instruments with sharp teeth on the blades
• It is used to hold tough structure like the skin, coarse muscles…

50. ALLIS TISSUE HOLDING FORCEP
• A forceps with locking handle, blades have
delicate teeth.
• Uses
• To hold and retract tissues (generally for tissues that
will be excised).
• To provide tension during tissue dissection.
• Should never be used to hold the skin directly.
• Held in the same way as needle holder.

51. CROCODILE BONE HOLDING FORCEP
• Have long handles as compared to beaks.
• Beaks have toothed margin to allow a good grip on
the bone.
• Has a catch to stabilize the instrument in required
position.
• Used to hold the bony fragments during manipulation
(fracture reduction and fixation / osteotomy /
resection procedures).
• When it comes without catch in the handle, called as
Sequestrum holding forcep, used to hold
sequestrum.

52. INSTRUMENTS USED FOR BONE REMOVAL
BONE RONGEUR FORCEP
• This forcep has curved handles with
spring action.
• The tip of the blade is angulated
forward towards the handle and has a
concave inner surface.
• The beaks are sharp.
• They can be
• Both side and end cutting
• Only side cutting (Blumenthal)

53. • Uses
• To nibble sharp bony margins following extraction of teeth or
surgical procedures.
• To peel of thinned out bone present over cystic or tumorous
pathologies.
• To trim sharp bony edges during alveoloplasty procedures.

54. BONE CUTTER
• Similar to Ronger forceps as far as working
principle is concerned, but more sturdy than
Ronger, shape of the blade is different and
have a side cutting action only.
• Uses
• To cut sharp bony margins following
extractions or surgical procedures.
• To cut sharp ridge projections during
alveoloplasty procedures.

55. MILLER COLBOURN BONE FILE
• To smoothen sharp bony margin present in
surgical field .
• Double ended one end curved working end
and other end is oval.
• Working end has horizontal serration.
Uses-Pull stroke
Push stroke causes burnishing and
crushing of bone).

56. CHISEL
• Uni bevelled for cutting bone
• Rounded on square handle
• Long flat working tip
• Working edge – bevel on one side ,
sharp and flat
• Different width of blade :
Mostly 3 mm and 5 mm wide chisels are
used to split the bone in controlled
fashion.
• Length- Eastman pattern – 7½inches.
8½ inches

57. OSTEOTOME
• Similar to chisel but --- bibeveled.
• It splits bone rather than cutting or chipping it.
Uses
• Various osteotomy procedures.
• Removal / Recontouring of bone.
• Biopsy of bony lesions

58. MALLET
• Similar to hammer, made up of steel / lead /
wood.
• Used for giving controlled taps on the chisel /
osteotome / bone gouge.
• To be effective the mallet should be used with a
loose free swinging movements of the wrist.
• Usually a 6 inch mallet is used in oral surgical
procedures.
• Teflon coated mallet imparts less shock to the
patient and it is less noisy.

59. BONE GOUGE
• It has a round handle and a blade that has
sharp working tip that is concave on inner
side.
• Working tip is half round and has a long
working area.
Uses
• To make a window in anterior border of
maxillary sinus.(in Caldwell Luc)
• To remove cancellous bone graft material /
irregular pieces of bone.

60. GIGLI’S WIRE SAW
• It has three components
1. Wire saw
• It is made by twisting a few pieces of wire
together so that it acquires a sharp barbed
cutting edge.
2. Handles
• At the end of the wire there is a ring to which
the hook of the handles can be fitted.
3. Introducer
• When moved to and fro along its long axis, it
cuts the bone.
• Used in mandiblectomy procedures.

61. Micromotor straight Handpiece & Burs
• It is a quicker method of bone removal.
• The handpiece should have relatively high
speed (35-40000 rpm) and torque which
allows rapid bone removal and efficient
sectioning of teeth.
• Burs are rotary instruments that cut the
bone made up of stainless steel / carbide
and available in different shapes and
length.

62. • Sharp carbide burs remove cortical bone efficiently, burs such
as No.557 / No. 703 fissure bur or No. 8 round bur are used.
Uses
• To aid in bone removal or splitting the tooth during surgical
removal of tooth.
• To round of sharp margins after extractions / minor surgical
procedures and during alveoloplasty.
• To make bony window for access to cystic cavities.
• To release bony ankylosis.
• To perform osteotomy cuts.
• To perform resection of maxilla / mandible.

63. SURGICAL SAW
• It gives ease of cutting bone with precision because of different shape /
movements of saw.
• Unit consists of
• Regulator, foot control and cable.
• Hand piece
• Electric powered
• Pneumatic powered (uses compressed air at 90 – 110 psi pressure)

64. • In handpieces speed of 10,000 – 1 lakh cpm can be
achieved.
• Different kinds of saws available for various type of
osteotomy.
• Saggital saw moves side to side (5 - 6° arc), used
for wedge / transverse osteotomy.
• Oscillating saw oscillates (5 - 6° arc), used for
curved / straight osteotomy.
• Reciprocating saw moves to and fro (2.4mm), used
for short / long osteotomy.

65. INSTRUMENTS USED FOR WOUND
DEBRIDEMENT
LUCAS CURETTE
• An exploratory instrument with spoon shaped working tip, used to scrape
soft tissues from bony defects.
• The working end may be in the plain as the shank or at an angulation for
adequate access.
• It can be single / double ended.
• Always held in “thumb and palm” grasp and used in “pull (scrape)”
stroke.
Uses
• To remove tooth particles / debris / infected clot from extraction
site.
• To enucleate cyst / dental granulomas / intra osseous tumours / cystic
neoplasms.
• To remove small sequestra in non healing sockets.

66. VOLKMANN’S BONE SCOOP
• Similar to curette but concavity of the working edge is
more pronounced.
Uses
• To collect the contents from sinus tract / fistula /
chronic abscess cavity.
• To scrape bony cavities due to cystic / tumorous /
osteomyelitic lesions.
• To scoop out cancellous bone for grafting
procedures.
• To introduce graft material or antiseptic powder
into the surgical area.

67. LISTERS SINUS FORCEP
• It has long narrow blades which are serrated
transversely for only ½ an inch at the tip.
• Tip is rounded and bulbous.
• Instrument does not have a catch.
Uses
• To open an abscess by Hilton’s method.
• To dissect out sinus / fistulous tract in
soft tissues.
• To hold a small piece of gauze between
blades to clean a cavity.

68. DRAINS
PENROSE DRAIN
• A simple rubber tube which opens at both ends.
• One end is inserted in the cavity and the other is left out
on the skin and secured with sutures.
• Can be used for drainage of abscess cavities / hematomas.
Disadvantages
• Cannot drain against gravity, secretions cannot be
measured.
• Silicone Special Penrose Drain Tube:
• 5 mm -25 mm
• 300 mm

69. CORRUGATED RUBBER DRAIN
• A sheet of red rubber with corrugations on the
surface.
• One end is inserted in the cavity and the other is left
out on the skin and secured with sutures.
• Multiple holes are made in the drain to prevent the
drain from getting obstructed.
• Used as a drain following abscess drainage.
Disadvantages
• Cannot drain against gravity, secretions cannot be
measured and chances of infection are more.

70. CLOSED WOUND SUCTION SYSTEM
 It is a suction drain which has following parts
- Suction bag
-Tubing system
-Clamp

71. INSTRUMENTS USED FOR SUTURING
MAYO HEGAR NEEDLE HOLDER
• Stainless steel instrument.
• Straight, stout instrument with shorter
working tip.
• Blade is shorter and stronger than hemostats.
• The working tip : Cross hatched serrations
with a single vertical serration to grip the
needle.
• The handle has a catch.
• Usually a six or eight inch needle holder is
mostly used.
• Sterilization : Autoclave , Boiling for ½ hr.

72. SUTURE CUTTING SCISSORS
• For cutting the suture ends.
• Can be straight or curved and angulated or non
angulated.
• Angulation at the joint or at tip to facilitate
access to the posterior – area of oral cavity.
• Long delicate handles and short cutting edges.

73. INSTRUMENTS FOR MANAGEMENT OF
FRACTURES/OSTEOTOMIES
HAYTONS WILLIAMS FORCEPS
• 2 widely divergent curved beaks that engage the maxilla behind
the tuberosity.
• Used for mid – palatal fractures.

74. ROWE’S MAXILLARY DISIMPACTION
FORCEPS
• Pair of this instrument for disimpacting maxilla in
LeFort fractures.
• Consists of a straight unpadded blade and a curved
padded blade.
• The unpadded blade is passed up a nostril and
padded blade grips the palate.
• The operator stands behind the patient and
manipulates the fragment into position.

75. ASCHE’S NASAL SEPTUM FORCEP
• Used to reduce and align fractures of the nasal
septum.
• Blades are passed on either side of the septum and
vomer and perpendicular plate of ethmoid bone.

76. WALSHAM’S NASAL BONE FORCEP
• For reduction of nasal fractures
• It has 2 blades – small blade is inserted into the nose and larger is applied
externally to grip the side of the nose up to the medial canthus and parallel to
frontal process of maxilla

77. BRISTOW’S ELEVATOR
• Flat instrument of sufficient rigidity and
inserted into the same plane to reduce
zygomatic arch fracture.
• Rowe’s modification – through Gille’s
temporal approach.
• The instrument has a blade and oval
handle similar to Bristow’s pattern as well
as a lifting handle which is attached by a
strong hinge with a positive stop near the
origin of the other handle.

78. MODIFIED BRISTOW’S ELEVATOR

79. NASAL SEPTUM OSTEOTOME
• It is used to fracture the anterior nasal spine
and separate the nasal septum from maxilla
during LeFort I or premaxillary osteotomy
procedures.
• The instrument has a thin, flat blade with a
sharp edge. This edge has a slit that engages
the anterior nasal spine.

80. SMITH SPREADER
• It has 3 blades that are separated by spring action when the handles are
compressed.
• Used to separate bony fragments after completion of the osteotomy cuts mainly
used to check separation of fragments during downward fracture of maxilla / BSSO
procedure.

81. BONE AWL
• Long slender instrument provided with an eyelet at tip through
which the wires are pushed in for transosseous wiring.
• Used for placement of circum-mandibular wiring or can be passed
around the zygomatic arch/ piriform as in maxillary suspension
procedures.

82. BONE PLATING SYSTEM
• Consist of bone plates, monocortical screw, screw holder, plate
bending forceps and screw driver.
• Used for open reduction and fixation of fractures.
• The bone plates come in different sizes depending upon the
thickness and size of the hole for the screw. They can be 1.5 mm,
2mm, 2.5 mm can be used for fixation of mandibular fractures.
• They come in variety of shapes such as “L”, “X”, “Y” and straight
etc.
• The screw are of different length and diameter depending upon
thickness of the cortical bone into which they are fixed.

84. INSTRUMENTS USED FOR EXTRACTION
• COUPLAND ELEVATOR

85. APEXO ELEVATOR

86. CRYERS ELEVATOR

87. CROSSBAR ELEVATOR

88. WARWICK JAMES

89. MAXILLARY ANTERIOR FORCEP

90. MAXILLARY PREMOLAR FORCEP

91. MAXILLARY MOLAR FORCEP

92. MAXILLARY COWHORN FORCEP

93. BAYONET FORCEP

94. MAXILLARY THIRD MOLAR FORCEP

95. MANDIBULAR ANTERIOR FORCEP

96. MANDIBULAR PREMOLAR FORCEP

97. MANDIBULAR MOLAR FORCEP

98. MANDIBULAR COWHORN FORCEP

99. MANDIBULAR THIRD MOLAR FORCEP

100. REFERENCES
• Textbook of oral and maxillofacial surgery – Neelima A Malik
• Peterson’s Contemporary Oral & Maxillofacial surgery – James
Hupp, Edward Ellis
• Rowe & William’s Maxillofacial injuries
• Textbook of Oral and Maxillofacial Surgery – Daniel M Laskin
• Internet

101. THANK YOU