Category Archives: Principles of Uncomplicated Exodontia

Maxillary canine

Maxillary canine

The maxillary canine is usually the longest tooth in the mouth. The root is oblong in cross section and usually produces a bulge  called the canine eminence on the anterior surface of the maxilla. The result is that the bone over the labial aspect of he maxillary canine is usually quite thin. In spite of the thin labial bone, this tooth can be difficult to extract simply because of its long root. Additionally it is not uncommon for a segment of labial alveorar bone to fracture from the labial plate and be removed with the tooth.

The upper universal (no. 150) forceps is the preferred instrument for removing the maxillary canine. As with all extractions, the initial placement of the beaks of the forceps on the canine tooth should be as far apically as possible. The initial movement is to the buccal aspect, with return pressure to .the palatal. As the bone is expanded and the tooth mobilized, the forceps should be re positioned apically. A small amount of rotational force may be useful in expanding the tooth socket especially if the adjacent teeth are missing or have been extracted after the tooth has been well luxated it is delivered from the socket in a labial incisal direction with labial tractional forces  (fig. 7-61).

If during the luxation process with the surgeon feels a portion of  the  labial bone fracture a decision must be made concerning  the next step if the palpating finger indicates that a relatively small amount bone has fractured free and attached to the canine tooth  the extraction should continue in the usual manner with caution taken not to tear the soft tissue how ever if the palpating finger indicates that a relatively large portion of labial alveolar plate  has fractured , the surgeon should stop the’ surgical procedure. Usually the fractured profound bone  is attached to periosteum and therefore is viable the surgeon should use a thin periosteal elevator to raise a small amount of mucosa from around the tooth,down to the level of the fractured bone.

The canine tooth should then be stabilized with the extraction forceps; and the surgeon should attempt to free the fractured bone from the tooth, with the periosteal elevator as a lever to separate the bone from the tooth root. If this can be accomplished, the tooth can be ‘removed and the bone left in plate attached to the periosteum. Normal healing should occur. If the bone’ becomes detached from the periosteum during these, attempts, it should be removed, because it is probably nonvital and may actually prolong wound healing. This procedure can be used whenever alveolar bone is fractured during extraction.

Prevention of fractured labial plate is important. If during the luxation process with the forceps a normal amount of pressure has not resulted in. any movement of the tooth, the surgeon should seriously consider doing an open extraction. By reflecting a soft tissue flap and removing a small amount of bone, the surgeon may be able to remove the stubborn canine tooth without fracturing a larger amount of labial bone. By using the open’ technique, there will be an overall reduction in bone loss and in postoperative healing time .

 

Maxillary incisor teeth

Maxillary incisor teeth

The maxillary incisor teeth are extracted with the upper universal forceps (no. 150), although other forceps can be used. The maxillary incisors generally have conic roots, with the lateral ones being slightly longer and more slender. The lateral incisor is more likely also to have a distal curvature on the apical one third of the root, so this must be checked radiographically before the tooth is extracted. The alveolar bone Is thin on the labial side and heavier on the palatal side, which indicates that the major expansion of the alveolar process will be in the buccal direction. The initial .movement is slow, steady, and firm in the labial direction, which expands the crestal buccal bone. A less vigorous palatal force is then used, followed by a slow, firm, rotational force. Rotational movement should be minimized for the lateral incisor, especially if a curvature exists on the tooth. The tooth is delivered in the labialincisal  direction with a small amount of tractional force (Fig. 7-60).

Extraction of maxillary left posterior teeth. Left index finger reflects lip and cheek and supports alveolar process on buccal aspect. Thumb is positioned on palatal aspect of alveolar process and supports alveolar process. Head is steadied by this grip, and tactile information is gained regarding tooth and bone movement

Extraction of maxillary left posterior teeth. Left index finger reflects lip and cheek
and supports alveolar process on buccal aspect. Thumb is positioned on palatal aspect of alveolar
process and supports alveolar process. Head is steadied by this grip, and tactile information
is gained regarding tooth and bone movement

Maxillary Teeth

Maxillary Teeth

In the correct position for extraction of maxillary left or anterior teeth, the left index finger of the surgeon should reflect the lip and cheek tissue; the thumb should rest on the palatal alveolar process (Fig. 7-59). In this way the left hand is able to reflect the soft tissue of the cheek, stabilize the patient’s head, support the alveolar process, and provide tactile information to the surgeon regarding the progress of the extraction. When such a position is used during the extraction of a maxillary molar, the surgeon can frequently feel with the left hand the palatal root of the molar becoming free in the alveolar process before realizing it with the forceps or extracting hand. For the right side, the index finger is positioned on the palate and the thumb on the buccal aspect.

SPECIFIC TECHNIQUES FOR REMOVAL OF EACH TOOTH

SPECIFIC TECHNIQUES FOR REMOVAL
OF EACH TOOTH

This section describes specific techniques for the removal of each tooth in the mouth. In some situations several teeth are grouped together (e.g., the maxillary anterior teeth), because the technique for their removal is essentially the same.

Role of Assistant during Extraction

Role of Assistant during Extraction

For a successful outcome in any surgical procedure, it is essential to have a competent assistant. During the extraction the assistant plays a variety of important roles that contribute to making the surgical experience atraumatic, The assistant helps the surgeon visualize and gain access to the operative area by ref!e~ting the soft tissue of unobstructed view of the surgical field Even during ‘a closed extraction, the assistant can reflect the soft tissue so that the surgeon can ‘apply the instruments to loosen the soft tissue attachment and adapt the forceps to the tooth and tooth root in the most effective manner.

Another major activity of the assistant is to suction away blood, saliva and the irrigating solutions used during the surgical procedure. This prevents fluids from ‘. accumulating and makes proper visualization of the surgical field possible. Suctioning is also important for patient comfort, because most patients are unable to tolerate an accumulation of blood or other fluids in their mouths. During a surgical procedure it is almost.impossible for the assistant to suction too much.

During the extraction the assistant should also help to protect the teeth of the opposite arch, which is especially important when removing lower posterior teeth. If traction forces are necessary to remove a lower tooth, occasionally the tooth releases suddenly and the forceps strike the maxillary teeth and sometimes fracture a tooth cusp. The assistant should hold either a suction tip or a finger against the maxillary teeth to protect them from an unexpected blow.

During the extraction of mandibular teeth, the assistant may play an important role by supporting the mandible during the application of the extraction forces. A surgeon who uses the hand to reflect the soft tissue may not be able to support the mandible. If this is the case, the assistant plays an important role in stabilizing the  mandible to prevent TMJ discomfort. Most often the surgeon stabilizes the mandible, which makes this role less important for the assistant.

The assistant also provides psychologic and emotional support for the patient by helping alleviate patient anxiety during the surgery. The assistant is important in gaining the patient’s confidence and cooperation by using positive language and physical contact with the patient during the preparation and performance of the surgery. The assistant should avoid making casual,  offhand comments that may increase the patients’ anxiety and lessen their cooperation.

Role of Opposite Hand

Role of Opposite Hand

When using the forceps and elevators to luxate and remove teeth, it is important that the surgeon’s opposite hand play an active role in the procedure. For the righthanded operator, the left hand has a variety of functions. It is responsible for reflecting the soft tissues of the . cheeks, lips, and tongue to provide adequate visualization of the area of surgery. It helps to protect other teeth from the forceps, should it release suddenly from the tooth socket. It helps to stabilize the patient’s head during the extraction process. In some situations, large amounts of force are required to expand heavy alveolar bone; therefore the patient’s head requires active assistance to be held steady. The opposite hand plays an important role in supporting and stabilizing the lower jaw when mandibular teeth are being extracted. It is often necessary to apply considerable pressure to expand heavy mandibular bone, and such forces can cause discomfort and even injury to the TMJ unless a steady hand counteracts them. A bite block placed on the contralateral side is also used to help support the jaw in this situation. Finally, the opposite hand supports the alveolar process and provides tactile information to the operator concerning the expansion of the alveolar process during the luxation period. In some situations it is impossible for  the opposite hand to perform all of these functions at the same time, so the surgeon requires an assistant to help with some of them.

PROCEDURE FOR CLOSED EXTRACTION

PROCEDURE FOR CLOSED EXTRACTION

An erupted root can be extracted using one of two major techniques: (1) closed Or (2) open. The closed technique is also known as the simple.. or forceps technique. The open technique is also known as the surgical, or flap technique. This section discusses the closed or forceps extraction technique the open technique is discussed in Chapter 8.

The closed technique is the most frequently used technique and is given primary consideration for almost every extraction. The. open technique is used when the clinician believes that excessive force is necessary to remove the tooth of when a substantial amount of the crown is missing and access to the root of the tooth is difficult.

The correct technique for any situation should lead to an atraumatic extraction the wrong technique may result in an excessively traumatic extraction.

Whatever technique is chosen, 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) Used of controlled force to luxate and remove the tooth.

For the tooth to be removed from the bony socket, it is necessary to expand the alveolar bony walls to allow the tooth root an unimpeded pathway, and it is necessary to teat the periodontal ligament Fibers that hold the tooth in the bony socket. The use of elevators and forceps as levers and wedges with steadily increasing force can accomplish these two objectives.

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 firm around the. tooth with a sharp instrument, such a, the Woodson elevator or the sharp end of the no. 9  periosteal elevator (fig. 7-51). The purpose of loosening the soft tissue from the tooth is twofold. First, it allows the surgeon to ensure tbat profound anesthesia has been achieved. Wben this step has been. performed, the dentist informs the patient that the surgery is about to begin and that the first step will be to push the soft .tissue away from the tooth. A small amount of pressure is felt at this step, but no sensation of sharpness or discomfort. The surgeon then begins the soft tissue loosening procedure, gently at first and then with increasing force.

The second reason that the soft tissue is loosened is to allow the tooth-extraction forceps to be positioned more apically without interference from or impingement on the soft tissue of the gingiva. As the soft tissue is loosened away from the tooth it is slightly reflected which thereby increases the width of the gingiva sulcus and allows easy entrance of the beveled wedge tip of the forceps beaks.

If a straight elevator is to be used to luxate the tooth, ‘the Woodson elevator is also used to reflect the tooth’s adjacent gingival papilla where the streight elevator will be inserted (Fig. 7~52). This allows the elevator to be placed directly onto alveolar bone, without crushing or injuring the gingival papilla.

If center of rotation (0) is not far enough apically, it is too far occlusally, which results in excess movement of tooth apex (A). B, Excess motion of root apex caused by high center of rotation results in fracture of root apex

If center of rotation (0) is not far enough apically, it is too far occlusally,
which results in excess movement of tooth apex (A). B, Excess motion of root apex
caused by high center of rotation results in fracture of root apex

If forceps is apically seated, center of rotation t') i~displaced apically and less apical pressures are generated (A). This results in greater expansion of buccal cortex, I~s movement of apex of tooth, and therefore less chance of fracture of root (B).

If forceps is apically seated, center of rotation is displaced apically and
less apical pressures are generated (A). This results in greater expansion of buccal cortex,
I~s movement of apex of tooth, and therefore less chance of fracture of root (B).

Buccal pressure applied to tooth will expand buccocortical plate toward crestal bone, with some lingual expansion at apical end of root. ", Center of rotation.

Buccal pressure applied to tooth will expand buccocortical
plate toward crestal bone, with some lingual expansion at apical
end of root. Center of rotation.

Lingual pressure will expand linguocortical plate at erestal area and sliqhtly expand buccal bone at apical area. ", Center of rotation

Lingual pressure will expand linguocortical plate at erestal
area and slightly expand buccal bone at apical area. Center of
rotation

Rotational forces, useful for teeth with conic roots, such as maxillary incisors and mandibular premolars

Rotational forces, useful for teeth with conic roots, such
as maxillary incisors and mandibular premolars

Tractional forces are useful for final removal of toothfrom socket. They should always be small forces, because teeth are not ."pulled."

Tractional forces are useful for final removal of toothfrom
socket. They should always be small forces, because teeth are
not “pulled.”

Woodson elevator, used' to loosen gingival attachment from tooth.

Woodson elevator, used to loosen gingival attachment
from tooth.

Reflection of gingival papilla to allow straight elevator to be used to luxate tooth without injury to papilla

Reflection of gingival papilla to allow straight elevator to
be used to luxate tooth without injury to papilla

Step 2: Luxation of tile tooth with a dental elevator. The next step is to begin the luxation. of the tooth with a dental elevator, usually the straight elevator. Expansion and dilation of the alveolar bone and tearing of the periodontal ligament require that the tooth be luxated in several ways. The straight elevator is inserted perpendicular to the tooth into the interdental space, after reflection of the interdental papilla (Fig. 7-53). The elevator is then turned in such a way that the inferior portion of the blade rests’ on the alveolar bone and the superior, or occlusal, portion of the blade is turned toward the tooth being extracted .(Fig. 7-54). Strong, slow, forceful turning of the handle  moves the tooth in a posterior direction, which results in some expansion of the alveolar bone and tearing of the periodontal ligament. If the tooth is intact and in contact .with stable teeth anterior and posterior to it the amount of movement achieved with the straight elevator will be minimal. The usefulness of this step is greater if the  patient does not have a tooth posterior to the tooth being extracted or if it is broken down to an extent that the crowns do not inhibit movement of the tooth.

In certain situations the elevator can be turned in the opposite direction and more vertical displacement of the tooth will be achieved, which can possibly result in complete removal of the tooth (Fig. 7-55).

luxation of teeth with a’ straight elevator should be performed with caution. Excessive forces can damage and even displace the teeth adjacent to those being extracted. This is especially true if the adjacent tooth has a large restoration or carious lesion. It must be kept in’ mind that this is only the initial step in the extraction process, and that the forceps is the major instrument for tooth luxation and removal in most situations.

Step 3: Adaptation of the forceps to the tooth, The proper forceps is then chosen for the tooth to be extracted, The beaks of the forceps should be shaped to adapt anatomically to the tooth.apical to the cervical line, that is, to the root surface. The forceps is then seated onto the tooth so that the tips of the forceps beaks grasp the root underneath the loosened soft tissue (Flg. 7-56);- The lingual’ beak is usually seated first and then the buccal beak. Care must be taken to confirm that the tips of the forceps beaks are beneath the soft tissue and not engaging an adjacent tooth.’ Once the forceps has been positioned on the tooth, the surgeon grasps the, handles of the forceps at the very ends to maximize mechanical advantage and control (Fig. 7-57).

Small, straight elevator, inserted perpendicular to tooth after papilla has been reflected.

Small, straight elevator, inserted perpendicular to tooth
after papilla has been reflected.

 If the tooth is malopposed in such a fashion that the usual forceps cannot grasp the tooth without injury to adjacent teeth, another forceps should be employed. The maxillary root forceps can often be useful for crowded lower anterior teeth (Fig. 7-58).

The beaks of the forceps must be held parallel to the long axis of the tooth so that the forces generated by the application of pressure to the forceps handle can be delivered along the long axis of the tooth for maximaf effectiveness in dilating and  xpanding the alveolar bone. If the beaks are not parallel to the long axis of the tooth, it is increasingly likely that the tooth root will
fracture.

The forceps is then forced apically as far as possible to grasp the root of the tooth as apically as possible. This accomplishes two things First, the beaks ‘of the forceps act as wedges to dilate the crestal bone on the buccal and lingual aspects. Second, by forcing the beaks apically, the center of rotation (or fulcrum) of the forces applied to the tooth is .displaced toward the apex of the tooth, which results in greater effectiveness of bone expansion and less likelihood of fracturing the apical end of the tooth.

At this point the surgeon’s hand should be grasping the forceps firmly with the wrist locked and the arm held against the body the surgeon should be prepared to apply force with the shoulder and upper arm without any wrist pressure. The surgeon should be standing straight with the feet comfortably apart.

Step 4: Luxation-of the tooth with the forceps. The surgeon begins to luxate the tooth by using the motions – discussed earlier. The major portion of the force is directed toward the thinnest and therefore weakest bone. Thus . in the maxilla and all but the molar teeth in the mandible, the major movement is labial and buccal (i.e., toward the thinner layer of bone). The surgeon uses slow, steady.force to displace the tooth ‘buccally, The motion is deliberate and slow, and it gradually increases in force. The tooth is then moved again toward the. opposite direction with slow, deliberate, strong pressure. As the alveolar bone begins to expand, the forceps is apically reseated with a strong, deliberate motion, which causes additional expansion of the alveolar bone and , further displaces the center, of the rotation apically. Buccal and lingual pressures continue to expand the alveolar socket. For some teeth, rotational motions are then used to help expand the tooth socket and tear the periodontal ligament attachment.

Beginning surgeons have a tendency to apply inadequate pressure for insufficient amounts of time. The following three factors must be reemphasized (1) The forceps must be apically seated as far as possible and reseated periodically during the extraction (2) the forces applied in the buccal and lingual directions should be slow, deliberate pressures and not jerky wiggles and (3) the force should be held for several seconds to allow the bone time to expand. It must be remembered that teeth are not pulled rather, they are gently lifted. from the socket once the alveolar process has been sufficiently expanded.

Handle of small straight elevator, turned so that occlusal side of elevator blade is-turned toward tooth,

Handle of small straight elevator, turned so that occlusal
side of elevator blade is-turned toward tooth,

Handle of elevator, which may be turned in opposite direction to displace tooth further from socket. This can be accomplished only if no tooth is adjacent posteriorly,

Handle of elevator, which may be turned in opposite
direction to displace tooth further from socket. This can be accomplished
only if no tooth is adjacent posteriorly,

Tips of forceps beak, forced apically under soft tissue.

Tips of forceps beak, forced apically under soft tissue.

Forceps handles, held at very ends to maximize mechanical advantage and control. A, Maxillary universal forceps. B, Mandibular universal forceps ..

Forceps handles, held at very ends to maximize mechanical advantage and control.
A, Maxillary universal forceps. B, Mandibular universal forceps ..

Step 5: Removal of tile tooth from the socket. Once the alveolar bone has expanded sufficiently and the tooth has been luxated, a slight tractional force, usually directed buccally, can be used. Tractional forces should be minimized, because this is the last motion that is used once the alveolar process IS sufficiently expanded and the periodontal ligament completely severed.

It is useful to remember that luxation. of the tooth with the forceps and removal of the tooth from the bone are separate steps in the extraction. Luxation is directed toward expansion of the bone and disruption of the periodontal ligament. The tooth is hot removed from the bone until these two goals are accomplished. The novice surgeon should realize that the major role of the forceps is not to remove the tooth but rather to expand the bone so that the tooth can be removed.

For teeth that are malopposed or have unusual positions in the alveolar process, the luxation with the forceps and removal from the alveolar process will be in unusual directions. The surgeon must develop a sense for the direction the tooth wants to move and then be able to move’ it in that direction. Careful preoperative assessment and planning help to make this determination during the extraction.

forceps, too wide to grasp premolar to be extracted without luxating adjacent teeth. B, Maxillary root forceps, which can be adapted easily to tooth for extraction.

forceps, too wide to grasp premolar to be extracted without luxating adjacent
teeth. B, Maxillary root forceps, which can be adapted easily to tooth for extraction.

PRINCIPLES OF FORCEPS USE

PRINCIPLES OF FORCEPS USE

The primary instrument used to remove a tooth from the alveolar process is the extraction forceps. Although elevators may help in the luxation of a tooth, the instrument that does most of the work is the 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, and (2) removal of the tooth from the socket.

The forceps can apply five major motions to luxate the teeth and expand the bony socket: The first is apical pressure, which accomplishes two goals. Although the tooth moves in an apical direction minimally, the tooth socket is expanded by the insertion of the beaks down into the periodontal ligament space (Fig. 7-44). Thus apical pressure of the forceps on the tooth causes bony expansion. A second accomplishment of apical pressure is that the center of the tooth’s rotation is displaced apically. Because the tooth is moving in response to the force placed on it by _ the forceps, the forceps becomes the instrument of expansion. If the fulcrum is high (Fig. 7-45), 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 (Fig. 7-46) This process decreases the chance for apical root fracture.

The second major Pressure or movement applied by forceps is the buccal force. Buccal pressures result in expansion of the buccal plate, particularly at the crest of the ridge (Fig. 7-47). Although buccal pressure causes expansion forces at the crest of the ridge, it is important to remember that it also causes lingual apical pressure.

Third, lingual pressure is similar 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 (Fig. 7-48).

Fourth, rotational pressure, as the name implies, rotates the tooth, which causes some internal expansion of the tooth socket. Teeth with single, conic roots, such as the maxillary incisors, and mandibular premolars, with roots that are not curved, are most amenable to luxation by this technique (Fig. 7-49). Teeth that have other than conic roots or that have multiple roots especially if those roots are curved-are. more likely to fracture under this type of pressure.

In removal of this mandibular premolar tooth, purchase point has been placed in tooth, which creates first-class lever situation. When Crane pick is inserted into purchase-point and handle forces apically (A), tooth is elevated occlusally out of socket with buccoalveolar bone used as fulcrum (B).

In removal of this mandibular premolar tooth, purchase point has been placed in tooth, which
creates first-class lever situation. When Crane pick is inserted into purchase-point and handle forces apically
(A), tooth is elevated occlusally out of socket with buccoalveolar bone used as fulcrum (B).

Wedge can be used to expand, split, and displace portions of substance that receives it

Wedge can be used to expand, split, and displace portions
of substance that receives it

Beaks of forceps act as wedge to expand alveolar bone and displace tooth in occlusal direction

Beaks of forceps act as wedge to expand alveolar bone
and displace tooth in occlusal direction

Finally, tractional forces are useful for delivering 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 (Fig. 7-.50).

In summary, a variety of forces can be used to remove teeth. A strong apical force is always useful and should be .
applied whenever forceps is adapted ‘to the tooth. Most teeth are removed by a combination’ of buccal and lingual forces. Because maxillary buccal bone is usually thinner and the palatal bone is a thicker cortical bone, maxillary teeth are usually removed by strong buccal forces and less vigorous palatal forces. In the mandible the buccal bone is thinner from the midline posteriorly to the area of the molars. Therefore.the incisors, canines, and premolars are removed primarily as a result of strong buccal force and
less vigorous lingual pressures. The mandibular molar teeth have stronger buccal bone and usually require a stronger lingual pressure than the other teeth in the mouth. As mentioned earlier, rotational forces are useful for single-rooted,teeth that have conic’ roots and no severe curvatures at the root end. The maxillary Incisors,particularly the central incisor and mandibular premolars (especially the second premolar), are most amenable to rotational forces.

Small, straight elevator, -used as wedge to displace tooth root from its socket. Its use'in this fashion gives this elevator the nick name "shoehorn."

Small, straight elevator, -used as wedge to displace tooth
root from its socket. Its use’in this fashion gives this elevator the nick name “shoehorn.”

Triangular elevator in role of wheel-and-axle machine, used to retrieve root from socket.

Triangular elevator in role of wheel-and-axle machine,
used to retrieve root from socket.

Extraction forceps should be seated with strong apical pressure to expand crestal bone and to displace center of rotation (*) as far apically as possible

Extraction forceps should be seated with strong apical
pressure to expand crestal bone and to displace center of rotation
(*) as far apically as possible

Mechanical Principles Involved In Tooth Extraction

Mechanical Principles Involved In Tooth Extraction.

he removal of teeth from the alveolar process employs the use 01 the following mechanical principles and simple machines the lever, wedge, and wheel and axle.

Elevators are used primarily as levers. A lever is a mechanism for transmitting a modest force-with the mechanical advantages of a long lever arm and a short efector arm into a small movement against great resistance (Fig. 7-38). When an elevator is used for tooth extraction, a purchase point can be made and a crane pick can be used to elevate the tooth or a tooth root from the socket (Fig. 7-39). The small, straight elevator is frequently used to help mobilize teeth in a similar fashion, without the preparation of a purchase point.

the second machine that is useful is the wedge (Fig.7-40). It is useful in several different ways for the extraction of teeth. First the beaks of the extraction forceps are usually narrow at their tips they broaden as they go periorly. When the forceps is used, there should be a conscious effort made to force the tips of the forceps into the periodontal ligament space to expand the bone and force the tooth out of the socket (Fig. 7-11). The wedge principle is also useful when a straight elevator is used to luxate a tooth from its socket. A small elevator is forced into the periodontal ligament space, which displaces the root toward the occlusion and therefore out of the socket (Fig. 7-12).

The third machine used in tooth extraction is the wheel and axle, which is most closely identified with the triangular. or pennant-shaped, elevator. When one root of a multiple-rooted tooth is left in the alveolar process, the pennant-shaped elevator is positioned into the socket and turned. The handle then serves as the axle, and the tip of the triangular elevator acts as a wheel and engages and elevates the tooth root from the socket (Fig. 7-43).

The behind-the-patient position can be used for removal of mandibular posterior teeth. Hand is positioned under forceps for maximum control.

The behind-the-patient position can be used for
removal of mandibular posterior teeth. Hand is positioned under forceps
for maximum control.

When English style of forceps is used, a behind-the patient position is preferred.
When English style of forceps is used, a behind-the patient
position is preferred.

First-class lever transforms small force and large movement to small movement and large force.

First-class lever transforms small force and large movement
to small movement and large force.

CHAIR POSITION FOR FORCEPS EXTRACTION

CHAIR POSITION FOR FORCEPS EXTRACTION

The positions of the patient, chair, and operator are critical for successful completion of the extraction. The best position is one that is comfortable for both the patient and surgeon and allows the surgeon to have maximal control of the force that is being delivered to the patient’s tooth through the forceps. 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. The force delivered can thus be controlled in the face of sudden loss  of resistance from a root or bone fracture.

Dentists usually stand during extractions, so the positions for a standing surgeon will be described first. Modifications
that are necessary to operate in’ a seated position will be presented later.

For a maxillary extraction the chair should be tipped backward so that the maxillary occlusal plane is at an angle of about 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 (F.ig.7-20). During an operation on tile maxillary right quadrant, the patient’s head should be turned substantially toward the operator, so that ‘adequate access and visualization ‘can be achieved (fig. 7-21). For extraction of teeth in the maxillary , anterior portion of the arch, the patient should be looking  straight ahead (Fig. 7-22), The position for the maxillary left portion of the arch is similar, except that the patient’s head is turned slightly toward the operator (fig, 7-23).

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. A bite block should be used to stabilize the mandible when the extraction forceps is used. hen though the surgeon will support the jaw, the additional support provided .by the bite block will result in less stress being transmittedto the jaws. The chair should be lower than for extraction of maxilary teeth and the surgeon’s arm is inclined downward to .approximately a L.V degree angle at the elbow (Fig. 7-24), which provides a comfortable, stable position that is more controllable than the higher position. During removal of the mandibular right posterior teeth the patient’s head should be turned severely toward the surgeon to allow adequate access to the jaw, and the surgeon should maintain the proper arm and hand position (rig. 7-251. When removing teeth in the anterior region of the mandible the surgeon should rotate around to the side of till patient (Figs. 7-26 and 7-27). When operating on the left posterior mandibular region, the surgeon should stand in front of the patient, but the patient’s head should not turn quite so severely toward the surgeon (Fig. 7-28).

Patient positioned for maxillary extraction: tilted back so that maxillary occlusal plane is at about 60-degree angle to floor. Height of chair should put patient's mouth slightly below surgeon's elbow.

Patient positioned for maxillary extraction: tilted back so
that maxillary occlusal plane is at about 60-degree angle to floor.
Height of chair should put patient’s mouth slightly below surgeon’s
elbow.

Extraction of anterior maxillary teeth Patient look; straight ahead.

Extraction of anterior maxillary teeth Patient look;
straight ahead.

Extractson of teeth in maxillary right quadrant. Note that surgeon turns patients head toward self.

Extractson of teeth in maxillary right quadrant. Note
that surgeon turns patients head toward self.

Patient wifh head turned slightly toward surgeon lor extraction of maxillary left posterior teeth

Patient with head turned slightly toward surgeon for
extraction of maxillary left posterior teeth

For mandibular extractions, patient is more upright so that mandibular occlusal plane of opened mouth is parallel to floor. Height of chair is also lower to allow operator's arm to be straighter

For mandibular extractions, patient is more upright so
that mandibular occlusal plane of opened mouth is parallel to floor.
Height of chair is also lower to allow operator’s arm to be straighter

For extraction of mandibular anterior teeth, surgeon stands at side of patient, who looks straight ahead.

For extraction of mandibular anterior teeth, surgeon
stands at side of patient, who looks straight ahead.

Patient with head turned toward surgeon for removal of rgandibular right teeth.

Patient with head turned toward surgeon for removal of
rgandibular right teeth.

When English style of forceps is used for anterior mandibular teeth, -patient's head is positioned straight

When English style of forceps is used for anterior
mandibular teeth,patient’s head is positioned straight

Some surgeons prefer to approach the mandibular teeth from a posterior position. This allows the left hand of the surgeon to support the jaw better, but it requires that the forceps be held opposite the usual method and that the surgeon view the field with a more upside-down perspective. The left hand of the surgeon goes around the patient’s head and supports the jaw.The usual-behind the patient approach is seen in figures 7-29 and 7-30.

If the surgeon chooses to sit while performing extractions’ several modifications must be made. For maxillary extractions, the patient is positioned in a reclining position similar to that used when the surgeon is standing, However, the patient is not reclined quite as much therefore the maxilIary occlusal plane is not perpendicular to the floor as it is when the surgeon is standing. The patient should be lowered as far as possible so that the level of the patient’s mouth is as near as possible to the surgeon’s elbow (Fig. 7~31)..The arm anti hand position for extraction of the maxillary anterior and posterior teeth is similar to the position used for the same extractions performed while standing (Fig. 7-32).

As when the surgeon is standing, for’ extraction of teeth in the lower arch, the patient is a’ bit more upright than for extraction of maxillary teeth. The surgeon can work from the front of the patient (Figs. 7-33 and 7-34) or from behind the patient (rigs. 7-35 and 7-36). When the English style of forceps is used, the surgeon’s position is usually behind the patient (Fig. 7-.17.). It should be noted that the surgeon and . the assistant have hand- and arm’ positions similar to those used when the surgeon is in the standing Position.

For extraction of mandibular posterior 'teeth, patient turns slightly toward surgeon.

For extraction of mandibular posterior ‘teeth, patient
turns slightly toward surgeon.

Behind-the-patient approach for extraction of posterior left mandibular teeth. Hand is positioned under forceps

Behind-the-patient approach for extraction of posterior
left mandibular teeth. Hand is positioned under forceps

Behind-the-patient approach for extraction of pesterior right mandibular teeth. This allows surgeon to be in comfortable, stable position.

Behind-the-patient approach for extraction of pesterior
right mandibular teeth. This allows surgeon to be in comfortable,
stable position.

In seated position, patient is positioned as low as possible so that mouth is level with surgeon's elbow

In seated position, patient is positioned as low as possible
so that mouth is level with surgeon’s elbow

For extraction of maxillary teeth, patient is reclined back approximately 60 degrees. Hand and forceps positions are same as for standing position.

For extraction of maxillary teeth, patient is reclined back
approximately 60 degrees. Hand and forceps positions are same as
for standing position.

For removal of mandibular posterior teeth, patient's head is turned toward surgeon.

For removal of mandibular posterior teeth, patient’s
head is turned toward surgeon.

For extraction of mandibular teeth, operator's hand and arm position is similar to that used for standing position. Patient is placed more upright so that mandibular occlusal plane of open moi.th is nearly parallel to floor. Surgeon's opposite hand helps support n andible .

For extraction of mandibular teeth, operator’s hand and
arm position is similar to that used for standing position. Patient is
placed more upright so that mandibular occlusal plane of open
moi.th is nearly parallel to floor. Surgeon’s opposite hand helps support
n andible .

For removal of anterior teeth, surgeon moves to position behind patient so that mandible and alveolar process can be supported by surgeon's opposite hand.

For removal of anterior teeth, surgeon moves to position
behind patient so that mandible and alveolar process can be supported
by surgeon’s opposite hand.