O R A L S U R G E R Y

Dental Update – January/February 2001 41

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

described should be applicable in relatively well defined but commonly occurring

situations. The two techniques involve the unconventional use of conventional dental

extraction forceps, with the aim of facilitating removal of the retained roots of certain

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

hybrid procedures.

Dent Update 2001; 28: 41-44

Clinical Relevance: Unconventional methods of use of extraction forceps may prevent

the need for raising a mucoperiosteal flap.

O R A L S U R G E R Y

N. Malden, BDS (Lond.), FDS (Glas.),Specialist in Surgical Dentistry, AssociateSpecialist in Oral Surgery, Edinburgh DentalInstitute, Edinburgh.

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

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 1This technique is recommended for

removal of retained roots in the upper

and lower incisors, canine and

premolar regions. The following

criteria must be met:

● 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.

The ProcedureThis technique may be broken down

into four distinct stages.

Stage 1

Lift the gingival margin from the

lingual and buccal aspects of the socket

bone with an elevator (a No. 1

Coupland chisel is the author’s choice).

Stage 2

Guide the fine root forceps down to the

position shown in Figure 1, and check

carefully to ensure the beaks are within

the soft tissues.

Stage 3

Close forceps and remove tooth/root

with bone using appropriate

movements – lingual-labial for lower

incisors, rotations for roots with a

conical shape (Figure 2).

Surgical Forceps TechniquesNICK MALDEN

M

Figure 1. Guide the root forceps down to theposition shown.

Figure 2. A small portion of labial bone may bediscovered within the beaks of the forceps.

42 Dental Update – January/February 2001

O R A L S U R G E R Y

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.

● 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

in an attempt to ‘chase’ retained

apices, could unduly damage

lingual/palatal bone).

● Over-enthusiastic use of the

technique could also increase the

likelihood of dislodgement of roots

into the antrum.

REMOVAL OF LOWER FIRSTMOLARGenerally, 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.

Removal of Retained RootsIf 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

effectively. The appropriate elevator is

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).

Figure 3. Cowhorns forceps, left and rightCryer’s elevators and Coupland chisel.

Figure 5. The forceps may well be fully closedbefore the tooth can be delivered.

Figure 4. Conventional application of Cowhornsforceps to extract a lower first molar. The buccalgroove, if present, can be a helpful guide to theposition of the bifurcation.

Figure 6. The areas where a No. 1 Couplandchisel can be used to exert considerableelevating force.

Figure 7. The appropriate elevator is placedinto the empty socket, the handle coming out at45o to the occlusal plane.

Figure 8. The inter-radicular bone dividing thetwo roots should be removed.

O R A L S U R G E R Y

Dental Update – January/February 2001 43

TECHNIQUE 2Although 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).

Stage 2: Place the buccal beak onto

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

begin to move, remove forceps and

return to conventional positioning

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).

DISCUSSIONThe 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.

SUMMARYOver 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 9. Once the intervening bone has beenremoved, attempt to engage the root andelevate it.

Figure 10. The lingual beak of the forceps isplaced in the conventional position but thebuccal beak should be placed onto mucosa andpierced down to rest on the outer aspect of thebuccal bone.

Figure 11. The buccal beak of forceps restingon the buccal plate of bone.

Figure 12. Controlled downward pressure mustbe exerted on the forceps to prevent the buccalbeak of the forceps slipping up the bone.

Figure 13. Return forceps to the conventionalposition before delivering the tooth.

Figure 14. If this technique is performedcorrectly only a small buccal puncture woundwill be produced and no sutures will be needed.

44 Dental Update – January/February 2001

O R A L S U R G E R Y

without the use of a mallet and can

avoid recourse to a conventional

surgical approach.

CONCLUSIONThe 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.

ACKNOWLEDGEMENTS

I would like to thank Margaret Ferrier for her help inthe production of this manuscript and Mr R.D.Brown for permission to use his material.

REFERENCES

1. The Management of Patients with 3rd MolarTeeth. Report of a working party convenedby the Faculty of Dental Surgery, RoyalCollege of Surgeons of England, London:Royal College of Surgeons of England, 19976(2).

2. The removal of roots. In: Seward GR, Morris M,McGowan DA, eds. Killey & Kays Outline of OralSurgery Part 1. Bristol: I.O.P. Publications Ltd.,1987: pp.48–51.

3. Moore JR, Gilbe GV, eds. Operations on theteeth. 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.

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

ABSTRACTS 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

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