Instruments and extraction of the anterior group
Forceps curved on the edge (less commonly on the flat) with thin, converging beaks are used for manipulations on the mandible.
- Incisors: extracted relatively easily due to short roots and thin socket walls. Standard technique is applied.
- Canines: luxation is difficult due to a long root and thickened bone. Forceps with wider beaks are required. Main movements include rocking in the labial and lingual directions with the addition of gentle rotation.
- Premolars: roots are shorter, but the socket edges are thick, which often prevents deep insertion of the forceps under the gingiva. The beaks are applied to the edges of the socket, and luxation is performed in the buccolingual direction with permissible gentle rotational movements.
Specifics of lower molar extraction
The thick cortical layer of the alveolar process in the posterior regions makes classical forceps placement problematic — the beaks slip. Forceps are used only when the socket edges have resorbed due to chronic inflammation. In other cases, the primary instrument is the elevator.
- Separated roots: luxated first in the lingual, then in the buccal direction.
- Preserved interradicular septum: wide forceps are applied. As a result, both roots are extracted at once, or the septum breaks and the roots are removed sequentially.
- Impossibility of forceps placement: the interradicular septum is sectioned with a fissure bur in the vestibulolingual direction, after which the roots are extracted using an angled elevator.
Extraction of wisdom teeth always begins with radiography to assess the topography and number of roots. In case of anomalies, surgical bone-cutting with a dental drill is used.
Elevator technique
Elevators are indispensable for deeply positioned roots or a high risk of mucosal trauma with forceps. Before instrument insertion, the circular ligament of the tooth must be detached.
- Angled elevator: used for separated molar roots. The beak is inserted with its concave side facing the root into the periodontal space. The instrument acts as a wedge, displacing the root. The remaining second root is extracted through the empty socket of the first — either by fracturing the septum or by luxating the root into the free space.
- Lecluse bayonet elevator: used for third (less frequently second) molars. The pointed end is inserted between the 2nd and 3rd molars, with the flat part facing the extracted tooth. Upon rotation, the instrument pushes the tooth upward and posteriorly. Important: it is strictly forbidden to use the 2nd molar for support if the 1st molar is missing.
- Straight elevator: used for lower "eights" and dystopic teeth using a technique similar to that of the bayonet elevator (insertion from the buccal side with rotational-advancing movements).
Bone-cutting procedure (surgical access)
Indicated for root tip fractures, hypercementosis, curvatures, or complete coverage of the root by bone.
An arcuate or angular mucoperiosteal flap is formed on the vestibular side and elevated with a periosteal elevator. The edges of the flap must overlap the bone defect area by at least 0.5–1 cm.
Using a straight handpiece and a fissure bur (strictly with irrigation!), the outer wall of the socket is removed. For the dense bone of lower molars, the perforation technique is used: the contour of the bone block is drilled out with a round bur, the holes are connected with a fissure bur, and the fragment is removed. After exposing the root, it is luxated with a straight elevator.
The wound undergoes curettage, and sharp edges are smoothed with a bur. Bone debris collected during the process is mixed with autogenous blood or biomaterials and placed into the socket to prevent atrophy. The flap is fixed with sutures.
Briefly: answers to topical questions
What specific types of forceps are used for the extraction of lower premolars?
Cowhorn forceps are used for the extraction of lower premolars.
- Cowhorn forceps curved on the edge — standard instrument whose beaks are oriented to the handles at an obtuse angle or at a 90° angle.
- Cowhorn forceps curved on the flat — used in cases of restricted mouth opening.
- Forceps with narrow, thin, and converging beaks — used for extracting the roots of lower premolars.
The beaks of surgical forceps for premolars fall into the narrow category.
What complications can occur when working with the Lecluse elevator?
Using the Lecluse bayonet elevator can lead to severe traumatic and obstructive complications.
- Fracture of the mandibular body — occurs in the angle of the jaw due to the significant force exerted by the instrument.
- Aspiration of the luxated tooth — entry of the tooth into the pharynx or trachea if it is not supported by the fingers of the left hand.
- Fracture of the lingual wall of the alveolus — may lead to the displacement of the tooth root into the soft tissues.
To prevent fractures, it is forbidden to use the second molar as a fulcrum if the first is missing.
Which nerves must be anesthetized for the painless extraction of lower molars?
Three nerves must be anesthetized for the painless extraction of lower molars.
- Inferior alveolar nerve — provides innervation to all mandibular teeth of the corresponding half and the bone tissue of the alveolar part.
- Lingual nerve — innervates the mucous membrane of the alveolar part on the lingual side and the sublingual region.
- Buccal nerve — additionally innervates the mucous membrane of the alveolar part on the vestibular side (from the middle of the second premolar to the middle of the second molar).
Simultaneous blockade of these nerves is achieved by conducting torus anesthesia.
Lecluse's rule: "Support on two." The second molar cannot be used as a fulcrum for the bayonet elevator if the first molar is missing — there is a high risk of luxating the abutment tooth.
Class and exam questions
Why are mandibular molar roots rarely extracted with forceps?
Due to the significant thickness of the alveolar process bone tissue. It is impossible to advance the forceps blades beneath the gingiva as they will slip, which is why surgeons prefer to use elevators.
How to extract the second root of a molar if the first has already been removed?
The beak of the angled elevator is inserted into the empty socket of the extracted root. By a rotational movement, either the interradicular septum is destroyed or the remaining root is luxated into the resulting empty space.
Why is irrigation necessary when cutting the socket wall with a bur?
Irrigation is critically important to prevent thermal burn and bone tissue necrosis during preparation with fissure or round burs.
What else to study on this topic
- Technique of maxillary tooth extraction and palatal roots
- Protocol for bone defect augmentation with autogenous bone chips
- Preparations for medical socket packing (Collapol, Alvogyl)
- Chronology of normal socket healing by secondary intention
- Mucosal treatment and wound suturing
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Other topics in "Chapter 14. Tooth Extraction"
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